Superagonistic CD28 antibody induces donor-specific tolerance in rat renal allografts

The ultimate goal of organ transplantation is to establish graft tolerance where CD4+CD25+FOXP3+ regulatory T (Treg) cells play an important role. We examined whether a superagonistic monoclonal antibody specific for CD28 (CD28 SA), which expands Treg cells in vivo, would prevent acute rejection and induce tolerance using our established rat acute renal allograft model (Wistar to Lewis). In the untreated or mouse IgG-treated recipients, graft function significantly deteriorated with marked destruction of renal tissue, and all rats died by 13 days with severe azotemia. In contrast, 90% of recipients treated with CD28 SA survived over 100 days, and 70% survived with well-preserved graft function until graft recovery at 180 days. Analysis by flow cytometry and immunohistochemistry demonstrated that CD28 SA induced marked infiltration of FOXP3+ Treg cells into the allografts. Furthermore, these long-surviving recipients showed donor-specific tolerance, accepting secondary (donor-matched) Wistar cardiac allografts, but acutely rejecting third-party BN allografts. We further demonstrated that adoptive transfer of CD4+CD25+ Treg cells, purified from CD28 SA-treated Lewis rats, significantly prolonged allograft survival and succeeded in inducing donor-specific tolerance. In conclusion, CD28 SA treatment successfully induces donor-specific tolerance with the involvement of Treg cells, and thus the therapeutic value of this approach warrants further investigation and preclinical studies.

Transcription factor Ets-1 is essential for mesangial matrix remodeling

Most advanced glomerular diseases are characterized by abnormal extracellular matrix (ECM) accumulation in the glomeruli, and matrix metalloproteinases (MMPs) play a pivotal role in ECM remodeling in various glomerular diseases. The proto-oncogene, ets-1, is a transcription factor regulating the expression of various matrix proteinases, including MMP-1, MMP-3, and MMP-9. The goal of the present study was to characterize the role of Ets-1 in the progression of glomerular diseases. Overexpression of Ets-1 in cultured mesangial cells prevented transforming growth factor (TGF)-beta-induced inhibition of DNA-binding activity and TGF-beta-induced type I collagen production. In addition, exogenous Ets-1 abolished TGF-beta-induced collagen gel contraction. The in vivo transfection of the ets-1 gene into nephritic kidney resulted in the increases in glomerular MMP-1, MMP-3, and MMP-9 mRNA, decreases in mesangial ECM deposition, and attenuation of fibronectin extradomain A (EDA) and type I collagen expression. In contrast, knockdown of Ets-1 in glomeruli resulted in severe ECM deposition in diseased glomeruli. In conclusion, Ets-1 promotes degradation of ECM proteins and is critical for integral glomerular reorganization.

Exploring RNA interference as a therapeutic strategy for renal disease

The short synthetic interfering RNA duplexes (siRNAs) can selectively suppress gene expression in somatic mammalian cells without nonselective toxic effects of double-stranded RNA (dsRNA). However, a selective in vivo delivery of siRNA transfer has not been reported in kidney. Here, we investigated whether injection of synthetic siRNAs via renal artery followed by electroporation could be effective and therapeutic in silencing specific gene in glomerulus. We investigated the effect of siRNA in rat cultured mesangial cells (MCs) and showed that siRNA sequence-specific suppression of transgene expression was over a 1000-fold more potent than that by antisense oligodeoxynucleotide (ASODN). Transfection of siRNA targeting luciferase into rat kidneys significantly inhibited expression of a cotransfected luciferase expression vector in vivo. The delivery of siRNA targeting enhanced green fluorescent protein (EGFP) in the transgenic 'green' rat reduced endogenous EGFP expression, mainly in glomerular MCs. Furthermore, RNAi targeting against TGF-beta1 significantly suppressed TGF-beta1 mRNA and protein expression, thereby ameliorated the progression of matrix expansion in experimental glomerulonephritis. In addition, vector-based RNAi also inhibited TGF-beta1 expression in vitro and in vivo. In conclusion, siRNA-directed TGF-beta1 silencing may be of therapeutic value in the prevention and treatment of fibrotic diseases.

Electroporation-mediated HGF gene transfection protected the kidney against graft injury

The annual rate of kidney graft loss caused by chronic allograft nephropathy (CAN) has not improved over the past decade. Recent reports suggest that acute renal ischemia results in development of CAN. The goal of the present study was to assess the renoprotective potential and safety of hepatocyte growth factor (HGF) gene transfer using a porcine kidney transplant warm ischemia injury model. Following left porcine kidney removal, 10 min of warm ischemic injury was intentionally induced. Next, the HGF expression vector or vehicle was infused into the renal artery with the renal vein clamped ex vivo, and electric pulses were discharged using bathtub-type electrodes. Kidney grafts were then transplanted after removing the right kidney. Histopathological examination of vehicle-transfected kidney transplant revealed initial tubular injury followed by tubulointerstitial fibrosis. In contrast, HGF-transfected kidneys showed no initial tubular damage and no interstitial fibrosis at 6 months post-transplant. We conclude that electroporation-mediated ex vivo HGF gene transfection protects the kidney against graft injury in a porcine model.

Papillary carcinoma of the thyroid with distant metastases to the cerebrum: a case report

Cerebral metastases from papillary carcinoma of the thyroid are a very uncommon condition, but such metastases behave more aggressively and show poor prognosis. These metastases almost always involve concomitant lung or bone metastases which may be the first metastatic sites. Here we report a 53-year-old man with diffuse goiter and cervical lymphadenopathy who developed symptoms of elevated intracranial pressure. Computed tomography demonstrated ring-enhanced lesions showing a severe mass effect in the right cerebrum and a nodule in the right thyroid gland accompanied by swollen lymph nodes. Biopsied specimens of the thyroid nodule demonstrated malignant cells of papillary carcinoma. Surgical excision of the metastatic brain lesions was followed by total thyroidectomy with regional lymphadenectomy. Histological examinations confirmed that the patient had cerebral metastases from papillary carcinoma of the thyroid without other distant metastasis. Neurological abnormality disappeared after surgery and treatment with radioactive iodine (131I) and oral thyroxine were initiated thereafter. This case suggests that the thyroid gland is potentially a primary source of metastatic brain carcinoma. Moreover, early detection of cerebral metastases is crucial because these metastatic lesions can be life threatening, in contrast to the relatively less severe clinical course of this malignancy unless it is associated with any distant metastasis.

Distinct expression of two types of Xenopus Patched genes during early embryogenesis and hindlimb development

Patched (Ptc) is a putative twelve transmembrane domain protein that is both a Hedgehog (Hh) receptor and transcriptional target of Hh. In this study, we isolated Xenopus Ptc cDNAs, Ptc-1 and Ptc-2, and carried out comparative analyses on their expression patterns. The putative Ptc-2 protein has a long C-terminal extension that has similarities in both length and sequence to those of Ptc-1 proteins in mouse, chick and human. In both early embryogenesis and hindlimb development, Ptc-2 expression is restricted to cells that receive a Hh signal, a pattern similar to that of Gli-1. Ptc-1, however, shows a broader distribution, mainly non-overlapping with that of Ptc-2. Despite the difference in their expression patterns, both are induced in animal cap explants synergistically by Shh and Noggin, showing a conserved regulation in their activation mechanisms.

Conserved and divergent expression of T-box genes Tbx2-Tbx5 in Xenopus

We report here the identification of four members of T-box family genes, Xltbx2-Xltbx5, in Xenopus. Two of them are probable pseudovariant genes of XTbx5 and ET, a putative Xenopus ortholog of Tbx3. We compared their expression patterns in both embryos and limbs. In embryos, expression of Xltbx2 and Xltbx3 showed novel diversities, such as Xltbx2 in the neural crest cells and Xltbx3 in the ventral spinal cord, together with mutual similarities in the following regions: dorsal retina, proctoderm, lateral line organ, cement gland and cranial ganglia. The patterns in limbs were highly conserved with mouse and chick orthologs, including the limb-type specific expression of Xltbx4 and Xltbx5. In addition, RT-PCR analysis showed that they are expressed weakly even in adult limbs as previously reported in the newt.

[The three-dimensional CT angiography findings of ruptured aneurysms hardly detectable by repeated cerebral angiography]

We reported three cases of cerebral aneurysms hardly detectable by cerebral angiography, but easily detected by three-dimensional CT angiography (3D-CTA). These cases were ruptured aneurysms with subarachnoid hemorrhage. After detection of subarachnoid hemorrhage on CT scan, cerebral angiography was performed at first, but aneurysms were not detected. Subsequently 3D-CTA was carried out, and aneurysms were detected. In all cases, cerebral angiography was repeated, after the aneurysms had been found by 3D-CTA. This time aneurysms were all detected by cerebral angiography, but each case needed photographs from special direction. The aneurysms were small by usual cerebral angiography and they were almost invisible behind the artery near which they existed. 3D-CTA was very useful for detection of small aneurysms, but small perforating arteries around the aneurysms were invisible by 3D-CTA. To find these perforating arteries, cerebral angiography was needed.

The early expression control of Xepsin by nonaxial and planar posteriorizing signals in Xenopus epidermis

The control mechanism of the anteroposterior axis specification in Xenopus epidermis was studied by comparing the expression of a novel anterior marker, Xepsin, with that of a panepidermal marker, type I keratin. Xepsin mRNA, which encodes a novel Xenopus serine protease, is transcribed zygotically with the expression peak in neurula stages. In normal development, its expression is limited to the anterior and anterior-dorsal portions within epidermis during neurula and tailbud stages, respectively. In UV-irradiated ventralized embryos (dorsoanterior index, DAI 0 and 1), an expression boundary for Xepsin is apparently formed within the epidermis. In contrast, Xepsin expression was observed throughout the epidermis in LiCl-treated dorsalized embryos (DAI 10), as seen from an expression pattern indistinguishable from that of type I keratin. These data suggest that posteriorizing signals which suppress the transcription of Xepsin are present in nonaxial regions and absent in the anterior dorsal mesoderm. That posteriorizing signals were present in nonaxial regions was also supported by a conjugation experiment in which Xepsin expression was suppressed in ectodermal explants conjugated with lateral or ventral marginal zone. Moreover, the partly suppressed expression of Xepsin in the epidermal region of exogastrulae indicates that the signals may travel horizontally within the plane of the epidermis. We also present data showing that both treatment with retinoic acid and the overexpression of a constitutively active form of a retinoic acid receptor caused the suppression of Xepsin mRNA transcription, suggesting that anterior-posterior patterning in the central nervous system and in the epidermis may share common endogenous factors, i.e. , retinoids, in the Xenopus embryo.

Expression of five novel T-box genes and brachyury during embryogenesis, and in developing and regenerating limbs and tails of newts

Several T-box genes are considered to play important roles in developing limbs, tails and neural retinae. Five novel T-box genes in the Japanese newt were isolated and their expression was analyzed, together with another T-box gene of brachyury, during embryogenesis and in the developing and regenerating limbs and tail. Four are designated CpTbx2, CpTbx3, CpTbx6R and CpEomesodermin based on molecular phylogenetic analyses, and the other is named CpUbiqT from its ubiquitous expression. While all were expressed during embryogenesis, only four of them (CpTbx2, CpTbx3, CpUbiqT and brachyury) were detected in developing limbs and/or tails. Except for brachyury, they were continuously expressed in normal adult appendages and showed elevated expression levels in regenerating limbs, whereas only CpTbx2 showed significant up-regulation in regenerating tails. Compared with orthologous genes in other species, CpTbx2, CpTbx3 and CpEomesodermin showed several notable differences such as an abundance of maternal transcripts of CpEomesodermin, a unique insertion sequence within the T-box domain of CpTbx2, and a lack of visible expression of CpTbx2and CpTbx3 in the apical ectodermal region of developing limbs. In view of the uniqueness of the newt, these results are discussed with respect to the possibility of their involvement in regeneration.

Expression of polymorphonuclear leukocyte adhesion molecules and its clinical significance in patients treated with percutaneous transluminal coronary angioplasty

OBJECTIVES

This study evaluated the role of neutrophil adhesion molecules LFA-1 (CD11a/CD18), Mac-1 (CD11b/CD18) and p150,95 (CD11c/CD18) in patients undergoing percutaneous transluminal coronary angioplasty (PTCA).

BACKGROUND

Several recent studies have suggested that cell adhesion molecules on both neutrophils and vascular endothelial cells play an important role in the process of tissue inflammation.

METHODS

Thirty-eight patients (30 men, 8 women; mean [+/-SE] age 56 +/- 5 years, range 38 to 76) with single-vessel coronary artery disease of the left anterior descending artery underwent coronary angioplasty. Peripheral blood was sampled at baseline before, immediately after and 12, 24, 48 and 144 h after PTCA. The expression of CD18, CD11a, CD11b and CD11c on the surface of polymorphonuclear leukocytes was examined by flow cytometry with monoclonal antibodies.

RESULTS

In patients without subsequent restenosis, there was no change in mean channel fluorescence intensity (MFI) of CD18 at each sampling time. However, in the patients with restenosis, the MFI of CD18 significantly increased at 48 h after PTCA (from 57 +/- 6 to 73 +/- 8, p = 0.0008). The MFI of CD11b increased slightly at 48 h after PTCA in patients without restenosis (from 584 +/- 121 to 735 +/- 114, p = 0.037). In patients with restenosis, the MFI of CD11b was slightly increased at 24 h after PTCA (from 586 +/- 122 to 768 +/- 214, p = 0.018) and significantly increased at 48 h after PTCA (to 1,534 +/- 268, p = 0.0006). The expression of CD11a and CD11c did not change at any sampling points after PTCA in either of the two patient groups. Percent change in the expression of CD18 at 48 h after PTCA (from baseline) and that of CD11b were correlated (r = 0.73, p = 0.0008) in patients with restenosis.

CONCLUSIONS

Inflammatory stimuli within the coronary vessels associated with coronary angioplasty may upregulate Mac-1 expression on the surface of polymorphonuclear leukocytes. This process may be more marked in patients who experience later restenosis. Thus, activation of neutrophil adhesion molecule Mac-1 at 48 h after PTCA may have value as a predictor of subsequent restenosis.

[Synthesis and antibacterial properties of quinoxaline 1,4-dioxide derivatives]

Novel quinoxaline 1,4-dioxide derivatives were synthesized from benzofuroxans and the enolic form of 1,3-diketones or 3-oxoalkanoic esters or 3-oxoalkanamides or butanedioic esters catalyzed by silica gel or molecular sieves and their antibacterial activities were evaluated. As the results of antibacterial screening tests in vitro, quinoxaline 1,4-dioxides revealed strong activities against Bacteroides fragilis.

A mechanism of ischemic preconditioning during percutaneous transluminal coronary angioplasty

Manifestation of ischemic preconditioning and its mechanisms during percutaneous transluminal coronary angioplasty (PTCA) was evaluated. Twenty-two patients with angina pectoris, who had one-vessel coronary artery disease of the proximal left anterior descending artery but without visual collateral circulation, underwent elective PTCA performed by balloon inflations of 90 s, repeated three times or more. Changes in standard 12-lead electrocardiogram, hemodynamics and oxygen saturation of the great cardiac vein by a fiber-optic catheter were analyzed. Anginal chest pain occurred in 21 patients (95%) during the first balloon inflation, and in only 9 patients (41%) during the third inflation. In comparison with the first inflation, the third produced less shifts in ST junction (p < 0.01) and peak T (p < 0.01), which were measured and averaged by 4 chest leads from V2 to V5. The heart rate-blood pressure product during the third inflation was equivalent to that during the first. The great cardiac vein oxygen saturation decreased equally during the first and third inflations. However, the ratio of the saturation at reactive hyperemia after balloon deflation to baseline was higher (p < 0.01) in the third than in the first inflation. The adenosine content of the great cardiac vein measured in 11 patients just prior to balloon deflation was also higher (p < 0.05) in the third inflation than the value in the first. Repeated coronary artery occlusion during PTCA could cause ischemic preconditioning, which may be derived from mechanisms common to accelerated reactive hyperemia, for example an increase in intrinsic adenosine levels.

Relationship between regional abnormality of left ventricular rapid filling and coronary microcirculation disturbance in hypertrophic cardiomyopathy

BACKGROUND AND HYPOTHESIS

To investigate the mechanism of regional left ventricular diastolic filling disturbance in hypertrophic cardiomyopathy (HCM), we assessed the relationship between abnormalities of regional ventricular rapid filling and regional coronary microcirculation using radionuclide ventriculography and exercise 201thallium (201TI) myocardial scintigraphy with sector analysis.

METHODS

Thirty patients with HCM and 14 patients with atypical chest pain syndrome (controls) were studied. Left ventricular images (left anterior oblique view) were obtained by electrocardiogram-gated 99mtechnetium radionuclide angiography and were divided into three sectors radiating from the geometric center. The time-activity curves and their first derivative curves were analyzed, and the peak filling rate (PFR), the ratio of the time-to-peak filling rate per diastolic interval (TPFR/T) were calculated for the global left ventricle and for the lateral and septal sectors. Exercise stress 201TI myocardial scintigraphy was also performed, and early and delayed images were obtained. The regional washout rate (WR) was then evaluated for the lateral and septal sectors.

RESULTS

In HCM patients, the regional PFR in the septal sector (corresponding to the region of hypertrophic myocardium) was 285 +/- 76%/s, and was significantly lower than that in the controls (398 +/- 90%/s, p < 0.01). The regional TPFR/T in the septal sector (32 +/- 10%) was prolonged compared with the value of 21 +/- 5% in the controls (p < 0.05). The regional WR in the septal sector was 21 +/- 9%, and was significantly lower than that in the controls (43 +/- 5%, p < 0.01). Moreover, regional WR correlated positively with regional PFR (r = 0.5, p < 0.05) and showed a weak negative relationship with regional TPFR/T (r = -0.4, p < 0.07) in the septal sector.

CONCLUSIONS

These results suggest that regional impairment of rapid filling might be related to a disturbance of the coronary microcirculation in HCM.

Systemic amyloidosis following ankylosing spondylitis associated with congestive heart failure. A case report

We report the case of a 38-year-old man who developed fatal, systemic amyloidosis following ankylosing spondylitis. He was admitted for symptoms of congestive heart failure. Based on parotid gland biopsy and echocardiography, he was diagnosed as having systemic amyloidosis following active ankylosing spondylitis. However, the clinical course was rapidly progressive and eventually the patient died of acute necrotizing pancreatitis. The association has been reported thus far in a limited number of cases worldwide. The literature has featured localized lesions and a benign clinical course of the amyloidosis. This case, the first report from Japan, indicates that the amyloidosis associated with ankylosing spondylitis might exhibit a rapidly progressive clinical course, thereby suggesting that in such a case, meticulous treatment is required.

Plasma thrombomodulin levels in coronary sinus blood in patients with coronary artery disease

Plasma thrombomodulin (TM) levels in coronary sinus blood were measured in 15 patients with coronary artery disease who underwent elective PTCA (group A). TM was also measured in eight patients with coronary artery disease (group B) and six patients without coronary artery disease (group C), who only underwent diagnostic coronary angiography. The baseline level was 21.6 +/- 3.4 U/ml in group A, and 21.0 +/- 4.9 in group B, and both levels were slightly higher (P < 0.05) than those in group C (15.1 +/- 3.3). In group A, the level increased to 27.5 +/- 8.3 (P < 0.01) immediately after PTCA and then returned to 22.2 +/- 5.1 by 24 h. In groups B and C, levels showed no change immediately after angiography. In group A, the percentage increase in the TM level immediately after PTCA from that before the procedure correlated with the number of balloon inflations (r = 0.76, P < 0.01). In conclusion, the plasma TM level in coronary sinus blood might indicate endothelial damage due to atherosclerotic coronary artery disease and an increase in the level after PTCA might directly indicate vascular injury by balloon inflation.

Heart failure progression due to secondary organ dysfunction in acute heart failure

Although the pathophysiology of heart failure progression is important to survival it is not fully understood. In 92 patients with acute heart failure due to myocardial infarction or dilated cardiomyopathy, secondary organ dysfunction was evaluated to determine whether this factor contributed to heart failure progression and death. Forty-one patients had renal dysfunction, hepatic disease or loss of consciousness after the onset of the acute heart failure, and 26 of them (63%) died of progressive heart failure during the follow-up period of 20 months on average. The one-year survival rate was 22%. Although 51 other patients showed the same initial clinical features and cardiac function, they did not develop concurrent organ dysfunction during the course and only 11 (22%, p < 0.001) died of progressive heart failure. The one-year survival rate was 67%. The survival rate decreased in the order of renal dysfunction, hepatic disease and loss of consciousness. Transient low cardiac output of less than 2.2 l/min/m2 was more frequent in patients with organ dysfunction. It is suggested that heart failure progresses, in part, due to organ dysfunction secondary to heart failure and careful treatment to prevent organ dysfunction is important to long term survival.

Torsades de pointes in paced patients with sick sinus syndrome after disopyramide administration

Three ventricular inhibited mode (VVI) pacemaker implanted patients, all above 65 years, female and having sick sinus syndrome suffered from torsades de pointes; one patient after 2.5 years and the other two patients within a day of disopyramide therapy. All had hypopotassemia and plasma disopyramide was below the therapeutic range in two patients. Torsades de pointes was induced following ventricular paced beats and suppressed by cessation of disopyramide in all or by setting a higher pacing rate in one. In our department, permanent VVI pacemakers were implanted in 43 patients with sick sinus syndrome including 26 with bradycardia-tachycardia syndrome, nine of whom were treated by disopyramide. Torsades de pointes was observed only in those disopyramide treated bradycardia-tachycardia patients. Our report stresses the proarrhythmic nature of combined VVI pacing and antiarrhythmic agents in the presence of hypopotassemia.

Days required for 75% suppression of ventricular premature contractions by antiarrhythmic agents obtained from continuous in-hospital ECG monitoring

To determine the number of days required to obtain 75% suppression of ventricular premature contractions (VPCs) by antiarrhythmic agents, which was expressed as t1/4, we performed 32 in-hospital continuous all day ECG monitoring trials in four groups of 28 symptomatic patients (ages; 54 +/- 20 years-old) with frequent VPCs. Nine patients had no organic heart disease (group 1, 11 trials), nine had valvular heart disease (group 2, 10 trials), three had dilated cardiomyopathy (group 3, 3 trials) and seven had myocardial infarction within two to four weeks onset (group 4, 8 trials). All patients were monitored by ECG telemetry with an arrhythmia analyzer, which could count hourly and daily VPCs. Class I antiarrhythmic agents were given in 18 trials, class II in two trials and class I+ class II in 12 trials. Plasma concentrations of the antiarrhythmic agents were monitored in 11 trials. In 21 trials, t1/4 could be obtained; ten (91%), six (60%), three (100%) and two trials (25%) in the four groups, respectively (p < 0.05). The value of t1/4 in the four groups was 6 +/- 6, 7 +/- 6, 14 +/- 11 and 13 +/- 2 days, respectively (mean 8 +/- 7 days; N.S.). Immediate response to the initial antiarrhythmic agent administration, expressed as percent VPC count after three hours, correlated significantly with t1/4 (r = 0.696, p = 0.0006), but ejection fraction, patient's age, control VPC counts or plasma antiarrhythmic agent level did not correlate with t1/4. In conclusion, t1/4 is a useful index for the evaluation of VPC suppression, revealing wide inter-individual variations and can be roughly estimated from the immediate response to the initial antiarrhythmic agent administration.

Vasodilatory capacity of coronary resistance vessels in dilated cardiomyopathy

Both the endothelium-dependent and endothelium-independent vasodilatory responses of coronary resistance vessels were studied in patients with dilated cardiomyopathy (DCM). A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery in 14 patients with DCM and in 10 patients with chest pain syndrome and a normal heart (control subjects). The ratio of maximum mean coronary blood flow velocity after intracoronary administration of the endothelium-independent vasodilator papaverine (10 mg) to resting mean coronary blood flow velocity (Vp/Vo) in patients with DCM was diminished compared with that in control subjects (2.2 +/- 0.6 vs 4.1 +/- 0.9, p < 0.001). The ratio after administration of the endothelium-dependent vasodilator acetylcholine (40 micrograms) (Va/Vo) in 10 DCM patients was also diminished compared with that in seven control subjects (1.3 +/- 0.5 vs 2.4 +/- 0.8, p < 0.01). In DCM patients, Vp/Vo was correlated with left ventricular end-diastolic pressure (r = -0.48, p < 0.05), left ventricular end-diastolic volume index (r = -0.68, p < 0.01), ejection fraction (r = 0.75, p < 0.01), and left ventricular end-diastolic wall stress (r = -0.73, p < 0.01). However, Va/Vo was not correlated with any of these parameters. These results indicate that impairment of the vasodilatory capacity of coronary resistance vessels in DCM may be related to endothelial dysfunction and to an extravascular factor resulting from left ventricular dysfunction.

Immunohistochemical expression of human chorionic gonadotropin and P-glycoprotein in human pituitary glands and craniopharyngiomas

In order to clarify the cellular origin of craniopharyngiomas, the authors examined the distribution of P-glycoprotein (PGP) and human chorionic gonadotropin (HCG) in five normal adenohypophyses and in 23 craniopharyngiomas using peroxidase immunohistochemistry. The correlation between the expression of PGP in craniopharyngiomas and the recurrence of these tumors was also investigated. A number of pars intermedia cyst-lining cells immunostained positively for anti-PGP antibodies. A small number of adenohypophysial cells were also positive for PGP, but squamous epithelial nests were negative in all samples. However, HCG-beta was consistently demonstrated in adenohypophysial cells, pars intermedia cyst-lining cells, and squamous epithelial nests. In 11 craniopharyngiomas, the apical portion of cuboidal cells and some polygonal cells immunostained positively with anti-PGP antibodies. In four HCG-producing craniopharyngiomas, a large number of tumor cells were immunostained with anti-PGP antibodies, three of which showed a recurrence of cystic tumors. By double labeling, the coexpression of HCG-beta and PGP was demonstrated in these recurrent tumors. Accordingly, it is suggested that craniopharyngiomas produce HCG-like peptides and that craniopharyngiomas are unique squamous neoplasms arising in the sellar region from progenitor cells of a neuroendocrine lineage.

QT prolongation and possibility of ventricular arrhythmias after intracoronary papaverine

The incidence of ventricular arrhythmias following the intracoronary injection of papaverine was assessed. A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery and 6-12 mg of papaverine was injected into the left coronary artery in 42 patients. After intracoronary papaverine, the corrected QT interval on the electrocardiogram was prolonged from 0.43 +/- 0.03 to 0.49 +/- 0.07 s (p < 0.001). Occasional premature beats were observed in 2 patients (4.5%) with dilated cardiomyopathy. In 1 patient (2.3%) with 99% stenosis of the left anterior descending artery, polymorphous ventricular tachycardia with marked QT prolongation occurred. This patient also had hypokalemia (2.5 mEq/l) due to primary aldosteronism. In conclusion, careful use of intracoronary papaverine is necessary because of the risk of occasional serious ventricular arrhythmias.

Features of coronary artery lesions related to left ventricular aneurysm formation in anterior myocardial infarction

To determine the factors of left ventricular aneurysm formation in acute myocardial infarction, the authors studied the distribution of coronary artery lesions and the left ventricular wall motion of 43 patients with anterior myocardial infarction. Of 15 patients with aneurysm, 9 (60%) showed a single-vessel disease with severe stenosis of the proximal left anterior descending artery. Of 9 patients with triple-vessel disease, 8 (89%) had no aneurysm. In patients with the aneurysm, the Gensini score of the culprit lesion was significantly higher (p < 0.05) and the score except for the culprit lesion was less (chi 2 = 5.7, p < 0.05). In 23 patients with single-vessel disease, the collateral score was significantly less (p < 0.05) in patients with the aneurysm. The systolic wall motion on the ventriculogram appeared more impaired in the anterior infarct area but well maintained in the posterior noninfarct area in patients with the aneurysm. In conclusion, the important factors of left ventricular aneurysm formation were as follows: (1) A culprit lesion of the myocardial infarction was severe, but other coronary artery lesions were mild. (2) Collateral vessels were poor. (3) The left ventricular wall motion of the infarct area was impaired, but that of the noninfarct area was relatively good.

Pronounced ST-segment depression during paroxysmal supraventricular tachycardia

To determine the clinical significance of ST-segment depression observed in paroxysmal supraventricular tachycardia (PSVT), we evaluated the 12-lead electrocardiogram (ECG) during spontaneous PSVT in 54 patients (27 men and 27 women: mean age +/- SD; 47 +/- 18 years), who came to our clinic for the treatment of PSVT. Coronary angiography was performed in 16 patients (16 to 74 years; mean = 50 +/- 18) and treadmill exercise testing was performed in 21 patients. A cardiac electrophysiological study was carried out in 24 patients. During PSVT, ST-segment score was calculated as the sum of the ST-segment depression in 12 leads. The correlations between the ST-segment score, PSVT rate and age of the patient were analyzed as follows: The most significant positive correlation was observed between the ST-segment score and the PSVT rate (r = 0.615, p < 0.000001). The next most significant correlation was found between the PSVT rate and the age of the patient (r = -0.500, p = 0.00011). A negative correlation was also observed between the ST-segment score and the age of the patient (r = -0.429, p = 0.0012). In 13 of 16 patients, coronary angiography did not reveal any significant (> or = 75% in area) stenosis. Exercise testing induced significant ST-segment depression in 3 patients, of whom two had significant coronary artery lesions. PSVT was due to atrioventricular reentry via an overt (n = 3) or concealed accessory pathway (n = 15), atrioventricular nodal reentry (n = 5) and sinus node reentry (n = 1). In conclusion, patients with a faster PSVT rate revealed more pronounced ST-segment depression than did those with a slower PSVT rate, possibly reflecting the modified repolarization process instead of coronary artery involvement.

Venoarterial carbon dioxide tension gradient in acute heart failure

The venoarterial carbon dioxide tension gradient (P[v-a]CO2) was studied in patients with acute myocardial infarction. Seven patients with congestive heart failure (CHF group) and 10 patients without heart failure (control) were enrolled in this study. In all patients, hemodynamics were continuously monitored. Simultaneously, arterial and mixed venous blood were sampled, and blood gases and lactate concentration were analyzed. At the initial measurement before therapy, arterial and mixed venous pH and bicarbonate values were within the normal range, and there was no significant difference between the CHF group and controls. There was also no difference in arterial oxygen tension under the differential conditions of oxygen inhalation. However, cardiac index and mixed venous oxygen saturation (SvO2) were significantly lower, while the oxygen extraction ratio (OER) and arterial lactate were significantly higher in the CHF group than in the controls. On the other hand, P[v-a]CO2 was significantly higher in the CHF group (7.8 +/- 2.6 vs. 3.5 +/- 2.2 mm Hg, p < 0.01). This finding was due to the elevated mixed venous carbon dioxide tension in the CHF group, since arterial carbon dioxide tension was the same in both groups. Analysis of a total of 42 measurements obtained during the therapeutic course in the CHF group revealed a correlation of P[v-a]CO2 with cardiac index (r = -0.3, p < 0.05), OER (r = 0.57, p < 0.001), SvO2 (r = -0.56, p < 0.001) and lactate (r = 0.62, p < 0.001). The increase in P[v-a]CO2 observed in acute heart failure suggests the evidence of intracellular acidosis despite the absence of acidemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary flow reserve in patients with dilated cardiomyopathy

Coronary flow reserve was studied in patients with dilated cardiomyopathy. A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery in each of 10 patients with dilated cardiomyopathy (CDM group), seven patients with coronary artery disease that involved only the left anterior descending artery (CAD group), and seven patients with chest pain syndrome and normal hearts (control group). Coronary flow reserve was calculated as the ratio of the maximum mean coronary blood flow velocity after intracoronary administration of papaverine (10 mg) to resting flow velocity (M/R). The time until maximum flow velocity was reached after papaverine administration (Tmax) was also measured. M/R was lower in the DCM (p < 0.001) and CAD (p < 0.001) groups when compared with the control group. Tmax was not abnormal in the DCM group but was prolonged in the CAD group (p < 0.05). In the DCM group, the M/R ratio correlated with the left ventricular end-diastolic pressure (r = -0.69; p < 0.05), the left ventricular end-diastolic volume index (r = -0.7; p < 0.05), the ejection fraction (r = 0.82; p < 0.01), the left ventricular mass (r = -0.7; p < 0.05), and the left ventricular end-diastolic wall stress (r = -0.84; p < 0.001). These results indicate that coronary flow reserve was decreased in patients with dilated cardiomyopathy and that the mechanism of its reduction may differ from that in patients with coronary artery disease.

[A case of coronary artery embolism associated with combined valvular heart disease]

A 53-year-old-man afflicted with combined valvular heart disease and atrial fibrillation was admitted to our department complaining of chest pain. ST elevation on ECG (II, III, aVF) and elevated CPK value were recognized. He was diagnosed as having acute myocardial infarction, and percutaneous transluminal coronary recanalization was performed immediately. The coronary angiogram showed occlusions at the proximal left branch (#12). But these lesions could not be recanalized by 960000 IU urokinase administration. The cineangiogram after one month revealed perfect recanalization of these occlusions. Mitral stenosis with neovascularity to the left atrium and aortic regurgitation were recognized. We supposed this infarction caused by coronary embolism originated from left atrial thrombi. Acute myocardial infarction associated with mitral stenosis has been reported in fifteen cases previously in Japan, but only three cases revealed coronary occlusion in the acute phase with normal coronary artery in the chronic stage. However, there has been no report, except for this case, demonstrating occlusion in two coronary arteries at the same time. So, our case is the first report of the involvement of two coronary artery occlusions.

Oxygen demand-supply relationship in peripheral tissues as a therapeutic indicator in acute myocardial infarction with advanced heart failure

Oxygen demand-supply relationships in peripheral tissues were studied in 14 patients who had acute myocardial infarction with advanced pump failure. Seven patients with acute myocardial infarction but without pump failure were studied as a control. In all patients, a Swan-Ganz catheter and a radial arterial cannula were inserted for the purpose of hemodynamic monitoring, and arterial and mixed venous blood were sampled. Initially, oxygen delivery (DO2) (p < 0.01) was lower, and oxygen extraction ratio (OER) (p < 0.001) and oxygen tension at 50% saturation (P50) (p < 0.01) were higher in patients with pump failure than in the controls. During the therapeutic course, with an increase in the cardiac index and DO2, oxygen uptake (VO2) did not change but OER (p < 0.001) and P50 (p < 0.01) significantly decreased in 6 survivors with pump failure. In contrast, an increased VO2 (p < 0.01) and no change of OER and P50 were observed in 8 nonsurvivors with pump failure. These results suggest that reversibility of oxygenokinetics might be an important factor for recovery from critical heart failure.

OPC-13340, a new dihydropyridine calcium channel blocker attenuates rapid vascular smooth muscle cell growth in spontaneously hypertensive rats

We investigated the mechanism of the antimitotic effects of calcium channel blockers in vascular smooth muscle cells (VSMC) from spontaneously hypertensive rats (SHR). VSMC from SHR exhibited rapid proliferation through a quick transition from the G0/G1 to the DNA synthetic (S) phase and from the S to the G2/mitotic (M) phase, whereas the DNA synthetic rate itself was equal to that of Wistar-Kyoto rats (WKY). OPC-13340, a new dihydropyridine calcium channel blocker, dose-dependently decreased incorporation of [3H]thymidine into the DNA fragments in randomly cycling VSMC in SHR. Cell cycle analysis showed that the rapid transition from the S to the G2/M period was restored by OPC-13340 to the control level in WKY, whereas the quick transition from G0/G1 to S was unaffected. This antimitotic effect of OPC-13340 was reflected by attenuation of enhanced cellular protein synthesis during the G2/M period. Protein synthesis in the G0/G1 period was not influenced by OPC-13340. Thus, these data indicate that the calcium channel blocker OPC-13340 mitigates the enhanced proliferation observed in randomly cycling VSMC from SHR and that this effect is primarily due to normalization of the premature mitosis during the G2/M period.

Left ventricular diastolic dysfunction in coronary artery disease: effects of coronary revascularization

Left ventricular diastolic dysfunction was studied globally and regionally in patients with coronary artery disease, and the effects of coronary revascularization were evaluated. A total of 25 patients with angina pectoris who had a stenotic lesion (greater than or equal to 90%) in only left anterior descending branch underwent coronary revascularization [percutaneous transluminal coronary angioplasty (PTCA) in 13 patients and coronary artery bypass graft (CABG) in 12]. Nine patients with normal coronary artery were studied as controls. Left ventricular volume and radial axes were measured on serial frames of one cardiac cycle by cine left ventriculography. The radial axes were drawn from the left ventricular gravity to left ventricular wall at every 20 degrees. Left ventricular filling fraction and distension rate of radial axes were calculated at the times of 25%, 50%, 75%, and 100% of diastolic period, 100% being end-diastole. Although there were no significant changes of the systolic function by revascularization, the filling fraction increased from 11.2 +/- 2.6 to 14.5 +/- 3.5% (p less than 0.001) at 25% time of diastole, from 29.9 +/- 4.9 to 32.5 +/- 5.0% (p less than 0.05) at 50% time in the PTCA group, and from 11.8 +/- 3.7 to 13.4 +/- 3.8% (p less than 0.01) at 25% time in the CABG group. The distension rate of radial axis to the anterior wall also increased significantly at 25% and 50% time of diastole after revascularization, and the change was marked in the PTCA group. However, these increases did not apply to the control patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemofiltration as treatment for patients with refractory heart failure

Hemofiltration was performed in 15 patients with refractory congestive heart failure. All of these patients had oliguria, although intensive treatment with diuretics, digitalis, vasodilators, and catecholamines was prescribed. Hemofiltration was performed under hemodynamic monitoring in 14 patients. The water removal by hemofiltration decreased pulmonary arterial pressure, pulmonary capillary wedge pressure and right atrial pressure. Despite these hemodynamic improvements, nine patients (60%) died within one month after the start of hemofiltration; the causes were fatal arrhythmia in three, renal failure in two, sepsis in one and irreversible cardiogenic shock in three. Oliguria for over 15 h or a serum creatinine concentration of more than 4.0 mg/dl at the start of hemofiltration related to poor prognosis. In view of these results, hemofiltration for refractory heart failure should be started earlier and performed carefully in order to avoid arrhythmia, cardiogenic shock, and other complications.

Effects of secondary organ failure on compensation of acute heart failure in patients with myocardial infarct and dilated cardiomyopathy

Compensation for heart failure can be influenced by cardiac loads due to organ failure. This investigation studied the effect of secondary organ failure on the hemodynamics of acute heart failure. Of 106 patients with acute heart failure due to myocardial infarction or dilated cardiomyopathy, 49 (46%) patients had secondary organ failure, either kidney, liver, brain or blood. Their acute heart failure was sustained for significantly longer than that of 57 patients without organ failure. A transient but severe decompensation induced secondary organ failure, although the left ventricular ejection fraction was not different from that of the control without heart failure. Hypervolemia in cases of renal failure, bradycardia in loss of consciousness, hyperdynamic state in anemia and low blood pressure in liver dysfunction caused the sustained acute heart failure. These results suggested that secondary organ failure might occur in 46% of patients with acute heart failure, and might disrupt compensation by different kinds of hemodynamic loads in low cardiac function.

Cerebral vasospasm with elevated creatine phosphokinase following surgery of unruptured arteriovenous malformation

Delayed cerebral vasospasm associated with marked elevation of serum creatine phosphokinase (CPK) is reported. A 21-year-old man with unruptured arteriovenous malformation (AVM) in the left temporal lobe developed postoperative symptomatic vasospasm lasting for 2 weeks. A postoperative computerized tomography scan showed intraventricular hematoma without subarachnoid hemorrhage in the basal cistern. On day 5 after surgery, the patient developed motor aphasia due to marked vasospasm around the bifurcation of internal carotid artery. On day 7 and 8, serum CPK was elevated as high as 1175 and 1376 IU/l, respectively. On day 35 when he had completely recovered from cerebral vasospasm both clinically and angiographically, the level of CPK was normalized. The causative factors of symptomatic cerebral vasospasm following surgery of unruptured AVM associated with CPK elevation are discussed.

Higher Gensini score of coronary arteries in acute inferior myocardial infarction with precordial ST-segment depression

To investigate the significance of precordial ST-segment depression in acute inferior myocardial infarction, we compared the Gensini score of coronary artery stenosis between 2 groups of patients with and without precordial ST-segment depression. Group I consisted of 28 patients who showed ST-segment depression on admission (greater than or equal to 1 mm in V2-V6) and Group II (n = 16) those without ST-segment depression (less than 1 mm). The Gensini score of the coronary arteries (56 +/- 29 vs. 28 +/- 18; p less than 0.001), the partial score of the infarction-related artery (29 +/- 16 vs. 17 +/- 11; p less than 0.01) and of the infarction-nonrelated artery (27 +/- 24 vs. 11 +/- 12; p less than 0.02) were significantly higher in Group I than in Group II. The Killip score (greater than or equal to II) (34% vs. 6%; p less than 0.05), frequency of arrhythmias (75% vs. 38%; p less than 0.02) and peak CK value (3,676 +/- 2,290 vs. 1,818 +/- 1,153 IU/L; p less than 0.005) were higher in Group I than in Group II. Four patients in Group I died following admission, while no patient died in Group II (N.S.). Autopsy findings from the 4 Group I patients revealed fresh extensive inferior infarction and healed diffuse subendocardial infarction which could not be predicted from electrocardiograms. All patients who survived the acute stage performed treadmill exercise testing and 22 patients underwent exercise thallium-201 single photon emission computer tomography (SPECT). On treadmill exercise test, there was no significant difference between the 2 groups in the frequency of angina pectoris and ST-segment depression. On SPECT, the perfusion defect area under 55% of maximum uptake at the redistribution phase was 45.8 +/- 19.6 cm2 in Group I (n = 14) and 34.7 +/- 21.3 cm2 in Group II (n = 8; N.S.). In conclusion, precordial ST-segment depression in acute inferior myocardial infarction suggested advanced atherosclerosis in both the infarction-related and nonrelated coronary arteries, indicating a larger infarct size.

P-glycoprotein as the drug efflux pump in primary cultured bovine brain capillary endothelial cells

The expression of a functional P-glycoprotein (P-gp) which pumps drugs out of brain capillary endothelial cells (BCEC) into blood was studied by evaluating the steady-state uptake and efflux of vincristine (VCR) by primary cultured bovine BCEC. The steady-state uptake of VCR was increased in the presence of metabolic inhibitors, and an anti-P-gp monoclonal antibody, MRK16, as well as verapamil and steroid hormones which are known to reverse multidrug resistance in tumor cells. Furthermore, efflux of VCR from BCEC was inhibited by verapamil. By immunohistochemistry, P-gp was localized at the luminal side of the capillary endothelial cells in both gray matter of bovine brain and primary cultured BCEC. These data suggest that P-gp functions as a drug efflux pump at the luminal side of BCEC and regulates the transfer of certain lipophilic drugs from the blood into the brain.

Survival from acute occlusion of the left main coronary artery with preexisting collateral vessels--a case report

A thirty-two-year-old man suffered from evolving acute myocardial infarction caused by total occlusion of the left main coronary artery, which was 95% stenosed before the onset. Nevertheless, he had a good clinical course. The myocardium may have been protected by well-developed preexisting collateral vessels as evidenced by serial coronary angiograms.

Aortic dissection associated with aortitis syndrome

A 50-year-old woman with aortitis syndrome complicated by aortic dissection, is reported. The dissection was observed at the level of the descending thoracic aorta by aortography and at the intimal side of the dilated aorta on CT. An aneurysm of the right subclavian artery and a diffusely thick wall of the abdominal aorta were also observed. This case suggests that the uneven wall of the aorta in aortitis syndrome might be dissected at the intimal side by dilatation.

Lower pacemaker in high degree atrioventricular block is modulated electrotonically by atrial excitations

To see if the lower pacemaker in patients with atrioventricular (AV) block was modulated electrotonically by atrial excitation, we studied R-R intervals in two groups of AV block patients using a phase response curve (PRC). Group I consisted of 20 patients with high degree AV block, including seven patients in whom complete AV block was transiently observed in the course of acute inferior myocardial infarction. Group II consisted of 19 patients with complete AV block. In every patient, PRC was obtained from the continuous electrocardiogram by plotting each R1-R2 interval (response) on the ordinate as a function of the R1-Px interval (phase, x = 1, 2 ...) on the abscissa. In Group I, the R-R interval was prolonged when the P wave fell in the initial half of the R-R interval, and was abbreviated when the P wave fell in the later half of the cycle. In Group II, the fluctuation of the R-R interval was minimum. In ten group I patients, with the improvement of the AV block, PRC became sharper and transition from prolongation to shortening occurred at shorter R-P intervals. We conclude that, in Group I, lower pacemaker was modulated electrotonically by atrial excitations through decreased electrical coupling along the AV node.

Antihypertensive effects of cicletanine and renal protection in Dahl salt-sensitive rats

We designed experiments to reveal the antihypertensive properties of cicletanine, a novel antihypertensive drug, in Dahl salt-sensitive (Dahl-S) rats. Cicletanine (39 mg/kg body weight per day for 6 weeks) ameliorated the development of hypertension in Dahl-S rats fed a high-salt (4% NaCl) diet. This blood pressure reduction was associated with a decrease in heart weight and vascular wall thickness. Moreover, urinary prostacyclin (PGl2) excretion was increased with cicletanine treatment, being inversely related to systolic blood pressure. Proteinuria and urinary excretion of n-acetyl-beta-D-glucosaminidase were decreased and glomerular filtration rate was increased with this treatment. Morphological investigation revealed an improvement in glomerulosclerosis, renal tubular damage and intrarenal arterial injury in the salt-induced hypertensive rats. In contrast, trichloromethiazide, which decreased blood pressure to the same extent as cicletanine, lowered urinary PGl2 excretion and generally did not ameliorate the deteriorated renal functions and morphological abnormalities. Thus, these data indicate that cicletanine ameliorates the development of hypertension in Dahl-S rats and protects the cardiovascular and renal systems against the injuries seen in the hypertension. The enhanced vasodepressor PGl2 synthesis probably participates, to some extent, in these beneficial properties of long-term cicletanine treatment.

Left ventricular diastolic filling in patients with coronary artery disease without myocardial infarction

Left ventricular diastolic dysfunction at rest was studied in 24 patients with coronary artery disease but no evidence of previous myocardial infarction. Seven patients with normal coronary arteries were studied as control. Diastolic filling was analyzed by the serial left ventricular volume and 14 radial axes from the gravity point of the left ventricle with cine left ventriculography. There were no differences in the systolic function between coronary artery disease and the normal control. Peak filling rate was decreased significantly in the groups with left anterior descending artery disease (LAD, p less than 0.05) and multivessel disease (MVD, p less than 0.05), but not in the group with right coronary artery disease (RCA). Time to peak filling rate was prolonged in each group of LAD (p less than 0.05), RCA (p less than 0.05), and MVD (p less than 0.001), compared with controls. The time-volume curve showed disturbed rapid filling in the LAD and RCA groups, and also both depressed rapid and slow filling in the MVD group. In the LAD group, the filling fraction was decreased significantly at the time of 25% of the diastolic period (p less than 0.001) and radial distension to the anterior wall was decreased at the time of 25%, 50%, and 75% of the diastolic period, compared with controls. In the RCA group, the filling fraction (p less than 0.001) and radial distension to the posterior wall were decreased only at the time of 25% of the diastolic period. In the MVD group, filling fraction and radial distension to the most wall were decreased at 25%, 50%, and 75% of the diastolic period.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for medial-mass regression in the vascular wall of Dahl hypertensive rats by cicletanine treatment

We designed experiments to investigate the effects of cicletanine, a novel antihypertensive drug, on medial hypertrophy in Dahl rats susceptible to salt-induced hypertension (Dahl S rats). Cicletanine treatment (500 mg of cicletanine/kg of chow) for 6 weeks lowered blood pressure by 19% in Dahl S rats challenged with a high-salt (4%) diet. The blood pressure reduction was associated with a significant decrease in weight of the aortic vessels. Morphological examination revealed that this treatment decreased medial hypertrophy and expansion of intimal tissue, in concert with resolution of the periarteritis in the intrarenal arteries. In fact, the content of actin in the aortic wall, analyzed by SDS-PAGE, was decreased significantly with this treatment and myosin content was reduced to the same extent as well. Moreover, cicletanine per se lowered protein synthesis in randomly cycling cultured vascular smooth muscle cells (VSMCs) from Sprague-Dawley rats. Actin formation by VSMCs was decreased with cicletanine. Thus, these data indicate that chronic cicletanine treatment produces regression of the medial hypertrophy in Dahl S rats. Direct inhibitory effects on cytoskeleton protein synthesis, as well as its antihypertensive action, are partly responsible for this regression in vivo.