Molecular cloning, sequencing and characterization of the genes for adenosylcobalamin-dependent diol dehydratase of Klebsiella pneumoniae

Klebsiella pneumoniae and some of the other Enterobacteriaceae form both diol dehydratase and glycerol dehydratase in response to growth substrates. To compare these enzymes produced by the same bacterium, the pdd genes of K. pneumoniae encoding adenosylcobalamin-dependent diol dehydratase were cloned and sequenced. The sequential three open reading frames (pddA, pddB, and pddC genes) encoded polypeptides of 554, 228, and 174 amino acid residues with predicted molecular weights of 60,379(alpha), 24,401(beta), and 19,489(gamma), respectively. The deduced amino acid sequences of the subunits were 84-100% and 54-71% identical with those reported for diol dehydratases and glycerol dehydratases, respectively.

Comparison of electrophysiologic and autonomic tests in sensory diabetic neuropathy

We examined autonomic function in 46 patients with symmetric sensory non-insulin dependent diabetic neuropathy without autonomic symptoms and 31 age-matched control patients using the composite autonomic scoring scale (CASS) and electrophysiologic examination. The patients were divided into three groups by subjective severity of pain or numbness; 17 had slight pain or numbness, 15 had mild pain or numbness, and 14 had moderate pain or numbness. The patients in the moderate group had the following: a mild reduction in systolic and mean blood pressure (BP) within 1 minute of head-up tilt and a partial recovery after 5 minutes; an excessive fall in early phase II (IIe), an absence of late phase II (IIl) and reduced phase IV beat-to-beat BP responses to Valsalva maneuver (VM); a poor heart rate response to deep breathing; a reduced quantitative sudomotor axon reflex test (QSART) response in distal leg and foot; the highest CASS among the 3 groups; and reduced conduction velocity and amplitude in post-tibial nerve and sural nerve. The mild group had a mild reduction in BP during phase IIe and an absent phase IIl but normal phase IV overshoot during VM; a reduced QSART in the foot; a CASS between the moderate and slight groups; and reduced conduction velocity and amplitude in post-tibial nerve and reduced amplitude in sural nerve. The slight pain group had no abnormalities except for mild cardiovagal dysfunction. CASS gathered from all cases had a significant correlation with amplitude of sural nerve. These results suggest that the patients with symmetric sensory diabetic neuropathy may also have autonomic dysfunction, although they did not have any obvious autonomic symptoms, and that abnormalities in autonomic function parallel changes in somatic function in peripheral nerve. The CASS may be a sensitive tool, similar to the neurophysiologic test, for assessing diabetic neuropathy.

Aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization

We report a case of aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization. A 61-year-old man with a history of hypertension underwent surgery at our hospital in November 1995 for local peritonitis caused by perforation of the sigmoid colon secondary to cancer. On the 9th postoperative day, he developed shock, with complaints of epigastric and back pain. Abdominal computed tomography showed an enhanced mass, thought to be a peripancreatic aneurysm. Emergency angiography demonstrated an aneurysm arising from the arcade of the anterior pancreaticoduodenal artery. After diagnostic angiography, transcatheter arterial embolization was performed. With steel coils, the anterior superior pancreaticoduodenal artery and anterior inferior pancreaticoduodenal artery were embolized near the origin of the aneurysm. Angiography 7 weeks later revealed no recanalization of the aneurysm and the absence of anomalous collateral vessels. The patient has been well for 19 months without re-bleeding or recurrence of sigmoid colon cancer. Transcatheter arterial embolization is an effective therapeutic approach for aneurysm of the pancreaticoduodenal artery and is the preferred initial treatment.

Transcatheter occlusion of patent ductus arteriosus with a new detachable coil system (DuctOcclud): a multicenter clinical trial

A multicenter clinical trial of DuctOcclud, a new detachable coil for transcatheter occlusion of patent ductus arteriosus (PDA), was conducted. DuctOcclud was used in 35 patients (12 male and 23 female) for transcatheter occlusion of PDA between January, 1996, and April, 1997. The age of the patients ranged from 0.5 to 27.2 years (median 7.6 years) and weight from 6.3 to 70.0 kg (median 23.0 kg). The smallest diameter of PDA was 2.0+/-0.7 mm (range 1.0-3.3 mm). Pulmonary-systemic flow ratio (Qp/Qs) was 1.3+/-0.3 (range 1.0-2.2). The coils were successfully implanted in 32 (91%) patients. Of 31 patients who were followed 6 months after the procedure, 26 (84%) had no residual shunt and 5 (16%) had trivial residual shunt. One patient had infective endocarditis 1 month after the procedure but recovered completely. There were no incidences of coil embolization, hemolysis, late coil migration, or pulmonary artery stenosis. We conclude that DuctOcclud is a safe and effective device of transcatheter occlusion of PDA.

Differential production of monoclonal antibodies to carbohydrate moiety or peptides moiety of glycoproteins by different routes of immunization

The administration of ABO blood group active glycoproteins via the rear footpads of BALB/c mice with subsequent fusion of popliteal lymph node lymphocytes produced hybridomas differentially secreting antibodies to the peptide moiety of antigens. On the other hand, conventional intraperitoneal immunization of the same antigens and intraperitoneal boost followed by splenic lymphocyte fusion produced hybridomas differentially secreting antibodies to the carbohydrate moiety of antigens. Similar results were obtained in the production of monoclonal antibodies to erythrocyte membranes. Almost all hybridomas obtained by rear foodpad immunization secreted antibodies to the peptide moiety of erythrocyte membrane proteins, and those obtained by intraperitoneal immunization secreted antibodies to both peptide and carbohydrate moieties of erythrocyte membrane components. These results suggest the possibility of differential production of monoclonal antibodies to the carbohydrate moiety and the peptide moiety of some glycoproteins by different immunization routes.

[A case of endometrioid carcinoma of the prostate]

A case of endometrioid carcinoma of the prostate is reported. A 64-year-old man was admitted to our department with initial macrohematuria and dysuria. The transrectal ultrasonogram showed remarkable prostatic hypertrophy and the serum level of both prostatic specific antigen (PSA) and prostatic acid phosphatase (PAP) ranged within normal limits. Urethrocystographical and cystoscopical findings indicated prostatic hypertrophy with elongation of prostatic urethra and mild trabeculation of bladder wall. During transurethral resection of the prostate, papillary tumor was accidentally found in the left lobe near the vermontanum. Histopathological examination revealed adenocarcinoma of the prostatic urethra and the tumor displayed no immunoreactivity for PSA or PAP. Under diagnosis of prostatic urethral cancer total cystoprostatectomy and urethrectomy were performed and ileal conduit was constructed for urinary diversion. As intraductal papillae and complex ramifying glands were histopathologically confirmed in the specimen and the immunohistochemical staining showed positivity of PSA and PAP, the tumor was diagnosed as endometrioid carcinoma of the prostate.

[Topical treatment of onychomycosis by occlusive dressing using bifonazole cream containing 40% urea]

Topical treatment with an antifungal agent was performed in 70 cases of onychomycosis (69 cases of tinea unguium and 1 case of Candida onychomycosis). The patients were treated every night by occlusive dressing using bifonazole cream containing 40% urea, and then by simple application of 1% bifonazole solution in the morning. During the treatment period, the softened affected nails were removed as completely as possible with nail clippers and files. The nails were observed every two weeks, and the efficacy was evaluated after 12 weeks. Two cases were excluded and 28 cases dropped out leaving 40 cases for efficacy evaluation. Among the 40 patients, 20 appeared to be mycologically negative (mycological cure rate: 50.0%). Clinical response was judged by the changes in opacity and thickness of the nails. Nine patients were evaluated as showing "marked improvement" and 16 as showing "improvement" (improvement rate: 62.5%). Erosion was noted as an adverse reaction in 2 patients. In one patient, treatment was stopped and the lesion was improved by antibiotic ointment, and in another, treatment was resumed when erosion was cured by discontinuation of the treatment. These results suggest that the topical treatment of onychomycosis by occlusive dressing is a useful method for those patients who have difficulties in or do not wish to be treated with oral antifungal agents.

Dilatation mechanism of balloon angioplasty in children: assessment by angiography and intravascular ultrasound

PURPOSE

Little information is available about the dilatation mechanism in children. This prospective study aimed to (1) evaluate the dilatation mechanism of balloon angioplasty in children with arterial stenosis, and (2) compare the morphological changes seen by intravascular ultrasound (IVUS) and angiography.

METHODS

Twenty consecutive patients, who had undergone a total of 23 procedures, were examined before and immediately after balloon angioplasty with a 4.3 Fr, 30 MHz rotational tip IVUS system. The lesions for IVUS study had resulted from coarctation of the aorta in six patients, pulmonary arterial stenosis in five, Blalock-Taussig shunt stenosis in three, subclavian artery stenosis in two, renal artery stenosis in two, coronary artery stenosis in one and ductus arteriosus in one.

RESULTS

Four distinctive morphological types were identified: type I with arterial stretching, type IIa with superficial tearing, type IIb with deep intimal-medial tearing, type III with flap formation, and type IV with dissection. The diameter of the narrowest site before and after balloon angioplasty increased significantly from 2. 1 +/- 1.4 mm to 4.6 +/- 3.4 mm (p < 0.001). Eighteen of the 23 angioplasty procedures (78%) were considered to be successful, with a dilatation ratio of more than 50%. In most patients with successful dilatation, non-stretch mechanisms such as tearing, flap formation, or dissection were found. The positive percent (70%) of non-stretch mechanisms seen by IVUS was significantly higher than the positive findings (39%) by angiography (Chi2 = 6.47, p < 0.02).

CONCLUSIONS

Non-stretch morphology of the arterial wall may be a common mechanism of dilatation after balloon angioplasty in children with arterial stenosis. IVUS is a useful modality for evaluating the effectiveness of balloon angioplasty and the mechanism of dilatation in individual cases.

[Retrospective analysis of the relationship between HUS incidence and antibiotics among patients with Escherichia coli O157 enterocolitis in the Sakai outbreak]

An outbreak of Escherichia coli O157:H7 infection occurred in July 1996 in Sakai City. About 5000 children were infected, 122 of whom developed hemolytic uremic syndrome (HUS). In this outbreak, almost all patients were administrated some type of antibiotics. The effects of antibiotics on E. coli O157 associated hemorrhagic colitis (HC) have been controversial. In this study, we focused on the effects of antibiotics on development of HUS in the HUS in the Sakai outbreak. We retrospectively determined the antibiotics administrated within three days after the onset of HC, clinical courses, and laboratory data of 301 patients who were hospitalized and identified as Escherichia coli O157 infection by stool culture, from results of questionnaires sent by the Osaka Prefecture Medical Association to hospitals in Osaka Prefecture. The antibiotics used could be identified for 216 patients. The incidence of HUS among these patients was 11.6%. They were divided into 19 groups based on the type of antibiotics administrated. The incidence of HUS in the new quinolone (3.7%) group was low, but was high in the intravenous cephalosporin (18.2%) group. The differences in the incidence of HUS among the 19 antibiotic groups was significant (p < 0.05) on analysis of covariance which eliminated the contributions of variables including age, sex and laboratory data. These findings indicate that the suitable antibiotics can prevent the development of E. coli O157-associated HUS.

Recanalisation after coil embolisation of persistent ductus arteriosus

A 5 year old girl underwent recanalisation after coil embolisation of a persistent ductus arteriosus. Recanalisation is uncommon after coil embolisation and may be related to shrinkage of the coil, a change in its position, and ductal shape.

[A case of retroperitoneal fibrosarcoma: usefulness of magnetic resonance imaging]

A 62-year-old man with dyspnea was admitted to our hospital. Computed tomography showed a large right renal mass. Results of T1- and T2- weighted magnetic resonance imaging showed a very low-intensity region suggestive of retroperitoneal fibrosarcoma. On March 13, 1996, complete tumor resection and lymphadenectomy were done. The histopathological diagnosis was of fibrosarcoma. After the operation, the patient was treated twice with a combination chemotherapy regimen consisting of cyclophosphamide, vincristine, adriamycin and dacarbazine. At the most recent follow-up, 1-year postoperatively, the patient was well with no local recurrence or distant metastases.

Reversible glomerular hypertrophy in adult patients with primary focal segmental glomerulosclerosis

The present study was performed to assess the pathogenetic role of glomerular hypertrophy in patients with primary focal segmental glomerulosclerosis (FSGS). We studied 14 patients with FSGS by morphometry. In seven patients, minimal change nephrotic syndrome (MCNS) was diagnosed on the first renal biopsy, but FSGS was diagnosed on the second biopsy (MCNS-FSGS group). Seven other patients with FSGS on the first biopsy underwent second biopsies while in remission (FSGS-R group). Biopsy results were compared with biopsies from 10 patients with MCNS and seven control subjects. Nonsclerotic glomeruli were examined. The mean glomerular tuft area, whole glomerular area, and number of mesangial cells were significantly increased in both biopsies from the MCNS-FSGS group and in the first biopsies obtained during the nephrotic stage of the FSGS-R group, compared with control subjects and patients with MCNS. Biopsies from FSGS patients in remission showed that the mean glomerular tuft area and number of mesangial cells were significantly decreased. The fractional extracellular matrix area (extracellular matrix area/glomerular tuft area) and mesangial cell density (mesangial cell number/glomerular tuft area) in FSGS during both nephrotic and remission stages were the same as those in control subjects and patients with MCNS. The present study suggests that glomerular hypertrophy precedes the development of glomerulosclerosis in FSGS and is reversible when patients are in remission. These features support the pathogenetic importance of glomerular hypertrophy in patients with primary FSGS.

[Mid-term follow-up results of coil embolization for patent ductus arteriosus]

Mid-term follow-up results of coil embolization for patent ductus arteriosus (PDA) were evaluated in 19 patients aged from 2 years 9 months to 13 years (median: 5 years and 10 months) who underwent coil embolization for PDA. The minimum diameter of PDA ranged from 1.0 to 3.5 mm (mean 2.3 +/- 0.8 mm). Coil embolization was performed by the retrograde approach in 16 patients and the anterograde approach in 3, using a Gianturco coil in 11 and a Jackson detachable coil system in 8. Sixteen patients underwent single coil embolization and three patients received two coils simultaneously with detachable coil systems. Follow-up evaluation was performed with color flow mapping and pulsed Doppler echo to identify residual shunt or acquired left pulmonary artery stenosis after embolization at 1 day, 1 week, 1, 3, 6 and 12 months, and every 6 months thereafter. In two patients, a coil had migrated into the distal left pulmonary artery immediately after implantation, and could be safely retrieved. Minimum residual shunt was found in six patients (32%) on the day after the procedure. Spontaneous closure was noted in all patients within 6 months. Recanalization of completely occluded PDA was observed in one patient at 1 month after embolization. However, spontaneous closure of the residual shunt was found at 1 year and 6 months of follow-up. There was no evidence of acquired left pulmonary artery stenosis during the follow-up period (14.5 +/- 5.8 months). Coil embolization is an effective and safe therapy for PDA. Small residual shunt may be observed immediately after the coil embolization, but will close spontaneously during the follow-up. Recanalization occurred after complete coil occlusion, so careful follow-up with color flow mapping is mandatory.

Late persistent expressions of ICAM-1 and VCAM-1 on myocardial tissue in children with lymphocytic myocarditis

BACKGROUND

Both intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) have been implicated in cardiac allograft rejection. However, there is little information about the relationship between the expression of these adhesion molecules and myocarditis in children.

METHODS AND RESULTS

Immunoreactivities of ICAM-1 and VCAM-1 were examined by enzyme immunoassay in 31 biopsy specimens obtained from 11 pediatric patients with biopsy-proven myocarditis or cardiomyopathy. Five of the 11 patients had clear evidence of acute myocarditis. The other 6 had ECG abnormalities identified by mass screening for heart disease, and subsequently had been histologically diagnosed as having non-specific cardiomyopathy. The period between onset of myocarditis or identification of ECG abnormality and immunohistochemical studies was 23 to 60 days and 8 months to 3 years, respectively. Expression of ICAM-1 and VCAM-1 was assessed by counting ICAM-1 and VCAM-1 positive vessels and dividing by the total number of vessels. ICAM-1 was significantly present on 81% (P < 0.01) of myocardial tissue samples in the 5 patients with healing-stage acute myocarditis, and on 45% (P < 0.05) in the remaining 6 patients with non-specific cardiomyopathy, compared with 24% in control specimens obtained from right ventricular muscle resected at surgery for tetralogy of Fallot. VCAM-1 was also present on 50% (P < 0.05) of the samples from the 5 patients with acute myocarditis, but was not present in those with non-specific cardiomyopathy.

CONCLUSION

This persistent expression of ICAM-1 suggests that myocardial cell damage may persist immunologically for a long period in myocarditis. In addition, immunostaining for these adhesion molecules may be diagnostic value in clinically silent lymphocytic myocarditis and chronic cardiomyopathy.

Balloon angioplasty for aortic coarctation--report of a questionnaire survey by the Japanese Pediatric Interventional Cardiology Committee

The aim of this study was to analyze the results of a questionnaire survey regarding acute and late effects of balloon angioplasty for aortic coarctation in Japan. Considerable controversy still exists regarding the effectiveness and safety of balloon angioplasty in native coarctation. Moreover, little information about this mode of treatment is available from Japan. A questionnaire was sent to 55 Japanese institutions with pediatric cardiology units. A total of 208 patients from 35 institutions were reported and analyzed for indications for balloon angioplasty, acute and late results, and complications. Balloon angioplasty was performed in 56 patients with native coarctation (group I) and in 152 patients with postoperative recoarctation (group II). In group I, the pressure gradient across the coarcted site decreased significantly from 34 +/- 19 to 16 +/- 21 mmHg (p < 0.001), and the diameter of the coarcted site increased significantly from 3.7 +/- 1.7 to 6.0 +/- 2.5 mm (p < 0.001). In group II the pressure gradient significantly decreased from 41 +/- 20 to 15 +/- 15 mmHg (p < 0.001) and the diameter of the coarcted site significantly increased from 4.2 +/- 2.2 to 6.8 +/- 3.1 mm (p < 0.001). The restenosis rate was significantly higher in group I (19/41, 46%) than in group II (25/139, 18%) (p = 0.0006). Redilation was successfully performed in 27 of 29 of the patients with restenosis. Major complications included femoral pulse loss, transient bradycardia, and arrhythmia. No patient died of a cardiac event related to the procedure. The significant risk factors for late restenosis included type of coarctation, age under 4 months, balloon size used, pressure gradient and coarctation diameter before the procedure. Balloon angioplasty is a suitable treatment for aortic coarctation in both native coarctation and postoperative recoarctation. Restenosis was significant after initial balloon angioplasty in native coarctation but redilation was effective in most cases. The most significant risk group for restenosis is young children with native coarctation.

Apoptosis as a possible cause of wall thinning in end-stage hypertrophic cardiomyopathy

A 15-year-old boy with hypertrophic cardiomyopathy died of congestive heart failure with progressive left ventricular wall thinning with poor systolic function. Microscopic examination revealed patchy fibrosis in the ventricular myocardium with wall thinning, and immunohistochemical evaluation of apoptosis showed apoptotic cells and bodies in the destroyed myocytes along the border between the fibrotic area and myofibril.

[Reconstructive surgery for head and neck cancers under multiple facility cooperation system]

The problems with the system for reconstructive surgery for head and neck cancers in our department where plastic surgeons are regularly invited from distant facilities were discussed. Especially, the importance of preoperative discussion between the plastic surgeons and ENT doctors was stressed. The computer system with Internet will play an important role in exchanging information such as CT scans and MRI scans between the plastic surgeons and ENT doctors. Moreover, the establishment of a system to prevent postoperative troubles such as closure of anastomosed vessels was stressed. Twenty-seven re-vascularized free flaps had been transferred with a 96.3% success rate (26 of 27 cases). We concluded that the system for reconstructive surgery under the multiple facility cooperation system worked well.

Thymidine phosphorylase activity required for tumor angiogenesis and growth

Thymidine phosphorylase (TP) is identical to platelet-derived endothelial cell growth factor (PD-ECGF), and has angiogenic activity. We examined the involvement of TP activity in tumor growth and angiogenesis. KB cells were transfected with wild-type or mutant (L148R) PD-ECGF cDNA, and two sublines with high TP activity, KB/wt4 and KB/wt6, and one subline with no TP activity, KB/L148R, were cloned, respectively. The doubling times of these subclones in vitro were similar to that of KB cells. However, the growth of KB/wt4 and KB/wt6 cells was significantly faster when xenografted into nude mice than that of control cells with no TP activity. The tumors with high TP activity (KB/wt4 and KB/wt6) had significantly more microvessels than those with no TP activity (KB/-, KB/CV and KB/L148R) (P<0.01). These results, taken together with previous reports, suggest that the TP enzyme activity itself is involved in angiogenesis and growth of the KB tumors.

Clinical and morphological predictors of renal outcome in adult patients with focal and segmental glomerulosclerosis (FSGS)

In this retrospective study, we examined 35 adult patients with biopsy-proven, primary focal and segmental glomerulosclerosis (FSGS) and nephrotic syndrome to determine whether any of the clinical and morphological features of FSGS were associated with a higher risk of a poor renal outcome. Clinical factors assessed were the age, sex, amount of urinary protein, and presence of microscopic hematuria, hypertension and renal dysfunction at onset in each patient. Morphological parameters included the number of segmental sclerosis and global sclerosis, sclerosis score, location of segmental sclerosis, mean glomerular diameter, grade of tubulo-interstitial changes, and presence of vascular lesions. Twenty-three patients (66%) were in complete or incomplete (partial) remission, and 12 (34%) were non-responders at the end of follow-up. On univariate analysis, the age at onset, sclerosis score, mean glomerular diameter, and grade of tubulo-interstitial changes in no response were significantly greater than those parameters in remission. Multivariate logistic regression analysis revealed that the degree of tubulo-interstitial changes and mean glomerular diameter were independent risk factors for a poor renal outcome. These findings suggest that the estimation of these latter two parameters allows the nephrologist to predict the probable course and prognosis of an adult with FSGS. Intensive and prolonged therapy is recommended for patients without these two morphological features.

Cloning, sequencing, and high level expression of the genes encoding adenosylcobalamin-dependent glycerol dehydrase of Klebsiella pneumoniae

The gld genes encoding adenosylcobalamin-dependent glycerol dehydrase of Klebsiella pneumoniae were cloned by cross-hybridization with a DNA fragment of Klebsiella oxytoca diol dehydrase genes. Since the Escherichia coli clones isolated did not show appreciable enzyme activity, plasmids for high level expression of cloned genes were constructed. The enzyme expressed in E. coli was indistinguishable from the wild-type glycerol dehydrase of K. pneumoniae by the criteria of polyacrylamide gel electrophoretic, immunochemical, and catalytic properties. It was also shown that the recombinant functional enzyme consists of Mr 61,000, 22,000, and 16, 000 subunits. Sequence analysis of the genes revealed four open reading frames separated by 2-12 bases. The sequential three open reading frames from the first to the third (gldA, gldB, and gldC genes) encoded polypeptides of 555, 194, and 141 amino acid residues with predicted molecular weights of 60,659(alpha), 21,355(beta), and 16,104(gamma), respectively. High level expression of these three genes in E. coli produced more than 14-fold higher level of fully active apoenzyme than that in K. pneumoniae. It was thus concluded that these are the genes encoding the subunits of glycerol dehydrase. The deduced amino acid sequences of the three subunits were 71, 58, and 54% identical with those of the alpha, beta, and gamma subunits of diol dehydrase, respectively, but failed to show any apparent homology with other proteins.

Clinical evaluation of taste dysfunction using a salt-impregnated taste strip

We have used special tests to investigate taste function in detail. To evaluate acuity for a salty taste, we used a paper with salt crystals, Salsave. The procedure is simple and takes only a few minutes. We analyzed the relationships between the magnitude of the threshold of response to this test and the results of other taste function tests in 126 patients who visited our clinic. The mean magnitude of the response to Salsave significantly correlated with the results of other taste tests. Thus, this is a useful method for screening the detection and recognition threshold of a salty taste.

Clinicopathologic characteristics of hypertrophic cardiomyopathy detected during mass screening for heart disease

Between 1981 and 1992 a total of 10 patients with hypertrophic cardiomyopathy (HCM) were detected by mass screening for heart disease in Tokyo's Adachi Ward. Four were first grade elementary school children and six were first grade junior high school adolescents. Two-dimensional echocardiography at the initial evaluation revealed asymmetric septal hypertrophy in four patients, diffuse hypertrophy of the left ventricle in five, and poor left ventricular contractility with wall thinning in one (dilated phase). Three of the five patients with diffuse hypertrophy progressed to asymmetric septal hypertrophy during the average 4-year follow-up period. The degree of septal thickness and the left ventricular wall thickness index were significantly less than in those of young adult controls (12 +/- 3 versus 21 +/- 9 mm, p < 0.05; and 22 +/- 4 versus 28 +/- 16 mm, p < 0.05, respectively). Right ventricular endomyocardial biopsy specimens obtained from 9 of the 10 patients showed features typical of HCM (e.g., myocyte hypertrophy with myofibril disarray) in five patients and atypical features (mainly interstitial fibrosis with perivascular cell infiltration) in another four. One patient with dilated phase disease died of congestive heart failure 6 months after the initial evaluation. These results indicate that HCM detected during mass screening is a mild form of the disease and may have atypical pathologic features, such as interstitial fibrosis and perivascular cell infiltration, mimicking the sequela of chronic myocarditis.

Idebenone improves cerebral mitochondrial oxidative metabolism in a patient with MELAS

We report a 36-year-old man with MELAS in whom a 5-month course of high-dose oral idebenone, a derivative of coenzyme Q10, increased markedly cerebral metabolic ratio of oxygen and oxygen extraction fraction without increased cerebral blood flow with PET. The results indicate that idebenone improves mitochondrial oxidative metabolism in the brain and suggest a therapeutic potential of idebenone for MELAS.

Application of percutaneous transluminal coronary angioplasty to coronary arterial stenosis in Kawasaki disease

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) has rarely been performed on patients with coronary lesions that result from Kawasaki disease. In this study, we retrospectively evaluated the effectiveness of PTCA in five patients with coronary arterial stenosis that resulted from Kawasaki disease and reviewed previous reports for possible indicators of PTCA effectiveness.

METHODS AND RESULTS

Five patients, ranging in age from 2 to 16 years (median 8 years) underwent conventional PTCA for localized stenosis. The lesion targeted for PTCA was located in the middle right coronary artery of three patients and in the left anterior descending artery in two patients. In four of the five patients, PTCA was angiographically effective, with stenosis rates improving from 84 +/- 10% to 33 +/- 11% (P<.05). When the previously reported cases of six similar patients were taken into consideration, the only predictor of successful PTCA seemed to be the time elapsed between the onset of Kawasaki disease and performance of this procedure.

CONCLUSIONS

In cases in which patients show significant localized stenosis as a result of Kawasaki disease, PTCA should be attempted within 6 to 8 years of the onset of the disease. Additionally, intravascular ultrasound imaging was found to be a useful tool for evaluating internal morphology before and after PTCA. In older patients with coronary calcification, other alternatives to PTCA, such as the use of a rotablator or an atherectomy catheter, should be considered.

Alterations in extracellular matrix components and integrins in patients with preeclamptic nephropathy

The glomerular features of patients with preeclampsia consist of swelling of endothelial cells, subendothelial deposits of incompletely defined material, and thickening of the capillary walls. These abnormalities are thought to resolve in the postpartum period. The distribution of extracellular matrix (ECM) components and integrins was investigated in 10 such patients. Frozen sections and paraffin-embedded sections were stained with antibodies to type IV collagen, laminin (LN), fibronectin (FN), vitronectin (VN), tenascin (TN), fibronectin receptor (FNR), and vitronectin receptor (VNR). In preeclamptic nephropathy, the accumulation of type IV collagen, LN, FN, TN, and FNR was observed in the thickened capillary walls, particularly in the subendothelial layer and, to some extent, in the mesangium. However, deposits of VN were sparse and the distribution of VNR was similar to that in normal kidney. In segmental sclerotic lesions, the amounts of type IV collagen, LN, FN, VN, and TN were increased, whereas those of FNR and VNR were markedly decreased. These results suggest that the materials deposited in the subendothelial space consist of ECM components as well as of plasma-derived proteins, and that the deposition of ECM components and of FNR may be involved in the development and the reparative process of the characteristic glomerular lesions. The formation of sclerotic lesions was linked to the accumulation of ECM components, but not to an interaction with integrins.

Angiographic assessment of the stretch-recoil-gain relation after balloon coarctation angioplasty and its relation to late restenosis

The effects of stretch and immediate recoil after balloon angioplasty were evaluated in 21 patients with coarctation of the aorta who underwent balloon coarctation angioplasty. A total of 28 procedures were performed in these patients, who ranged in age from 1 month to 17 years with a mean of 4.3 years. The systolic pressure gradient and coarcted diameter changed significantly from 42 +/- 22 to 14 +/- 9 mmHg (P < 0.0001) and from 4.0 +/- 1.7 to 6.1 +/- 2.0 mm (P < 0.001), respectively. Immediate recoil was responsible for the loss of 33% of the potentially achievable coarcted dimension. Recoil was determined mainly by the degree of arterial stretch. Gain increased exponentially with an increase in stretch. There was a narrow range of % stretch (60-80%) within which an effective diameter gain could be obtained. Both gain and stretch were the best predictors for late restenosis: patients with a larger immediate gain and stretch developed more restenosis. These results suggest that the stretch-recoil-gain relationship may be clinically important for evaluating the best predictor of late restenosis after balloon coarctation angioplasty.

Relationship between abnormal sensation in the throat and menopause

Abnormal sensations in the throat (AST) are commonly encountered in general and otolaryngological practice, especially among middle aged women. These sensation may occur alone, or more often, in combination with the systemic symptoms, including those of menopause. We analyzed 26 Japanese women with a complaint of an abnormal sensation in the throat who were taking a synthetic sex hormone (Methermon-F). Multianalysis of variance (MANOVA) was used to evaluate the efficacy of the treatment using the quantitative scores of Kupperman's climacteric symptoms. The presence of the excessive perspiration and vertigo, insomnia, and the absence of fatigue were associated with clinical efficacy of the hormone, while the presence of hyposthenia and tingling sensation were associated with a poor response. Results suggested that the clinical efficacy of this hormone in treating middle-aged menopausal women with AST was related to the menopausal symptoms.

Corticosteroid therapy for ventricular tachycardia in children with silent lymphocytic myocarditis

OBJECTIVE

The objective of our study was to describe the efficacy of corticosteroids for ventricular tachycardia in four children with structurally normal hearts in whom endomyocardial biopsy revealed histologic changes of lymphocytic myocarditis.

PATIENTS

The four patients had unexplained ventricular tachycardia. Three dysrhythmias were sustained, and one was inducible by exercise. Patient ages ranged from 4 months to 12 years. Three of the four patients had no symptoms. In two of them, ventricular tachycardia was identified by mass screening for heart disease. Two patients received oral steroids and two received pulse steroid therapy.

RESULTS

In all four patients, significant underlying diseases were not found by noninvasive evaluation. Right ventricular endomyocardial biopsy revealed abnormal histologic findings of chronic lymphocytic myocarditis in all patients. Steroid therapy was effective in all four patients, two of whom received methylprednisolone pulse therapy.

CONCLUSIONS

We conclude that unexplained ventricular tachycardia may be the only manifestation of clinically silent myocarditis. Steroid therapy should therefore be considered if conventional antiarrhythmic medication is not effective and histologic findings confirm the presence of lymphocytic myocarditis.

In vivo light scattering intensity in the lens versus in vitro spectral transmission in the nuclear region

In order to understand the correlation between nuclear opacity and spectral light transmission factor, the in vivo light scattering intensity of Scheimpflug lens images and the light transmission through slices of surgically removed nucleus were examined densitometrically as well as spectrophotometrically respectively, using both human and Brown Norway rat lenses. The experiments using rat lenses showed that the increase of the light scattering intensity in the nuclear regions is correlated with a decrease of the spectral transmission factor. The transparent anterior cortical region did not influence the light transmission (T%) through the nucleus. No significant influence was seen from the application of freezing and thawing procedures to measure light transmission. The examinations of the human subjects which were based on the rat study showed that the light transmission of nuclear cataracts objectively evaluated as grade I was almost the same as that observed in noncataractous nuclei. The light transmission of nuclear cataracts graded II or above, however, showed around 50% of the spectral light transmission of noncataractous nuclei.

[Approximation of uroflowmetrograms using micturition model]

One hundred and two uroflowmetric curves obtained from adult men were approximated to investigate the individual micturition quantitatively. We obtained a differential equation under the hypothesis that the factors concerned with micturition are the vesical pressure as the driving force and inertia of urine, friction resistance and elasticity of urethra as resistance. Using one of the solutions of this differential equation, we could approximate the uroflowmetric curves for normal and abnormal micturition. Furthermore, we could describe the calculated vesical pressure curve from the differential equation. There was a lag in the phase of the calculated vesical pressure curve against the uroflowmetric curve, which was considered to appear according to the resistance due to both inertia of urine and elasticity of urethra. The mean value of the difference of the calculated vesical pressure during micturition in normal cases was larger than that in abnormal cases. This suggests that it is necessary to maintain a high vesical pressure during micturition in abnormal cases, to maintain a small difference of the vesical pressure. In conclusion, we approximated the uroflowmetric curves, described the calculated vesical pressure curves and estimated them quantitatively.

Mechanism of balloon angioplasty in children with arterial stenosis assessed by intravascular ultrasound and angiography

Fifteen patients were examined before and immediately after balloon angioplasty with a 4.3F, 30 MHz rotational tip intravascular ultrasound system. In 12 (80%) patients, 13 procedures could be analyzed because of sufficient image quality. The lesions for intravascular ultrasound (IVUS) study consisted of pulmonary arterial stenosis in 4 patients, Blalock-Taussig shunt stenosis in 3, coarctation of the aorta in 2, subclavian artery stenosis in 1, renal artery stenosis in 1, and ductus arteriosus in 1. Three distinctive morphologic types were identified: Group I had arterial stretching (3 patients); group IIa had superficial tearing (3); group IIb had deep intimal-medial tearing (5); group III had dissection (2). In the narrowest site, minimal and maximal luminal diameters, luminal area before and after balloon angioplasty were 3.5 +/- 1.8 mm vs 4.5 +/- 2.5 mm, 4.1 +/- 2.1 mm vs 5.4 +/- 3.5 mm, and 49.8 +/- 30.2 mm vs 88.3 +/- 45.2 mm2, respectively. The recoil value of group IIb with appropriate balloon angioplasty was approximately 0.3. IVUS may be an useful modality for evaluating the morphologic mechanism of dilatation after balloon angioplasty.

[The activity of superoxide dismutase in patients with taste and smell dysfunction]

It was revealed that Zinc deficiency might cause taste and smell dysfunction. Superoxide dismutase (SOD), which scavenges superoxide, is a type of zinc enzyme. It was also demonstrated that the overproduction of superoxide damages normal tissue. We therefore measured the activity of SOD in serum and saliva of patients with taste or smell dysfunction by the cytochrome C reduction method using a xanthine-xanthine oxidase system. As a result, in the patients with taste dysfunction, the activities of SOD in both serum and saliva were normal, but mean level of serum Zinc was near to the lower normal limit. On the other hand, in the patients with smell dysfunction caused by chronic sinusitis or common cold, the activity of SOD in serum was significantly lower than that of healthy volunteers, and that in saliva was normal. These results suggest that Zinc enzymes, except serum and salivary SOD, are involved in the sense of taste, and that further investigation is necessary to clarify the relation between serum SOD deficiency and olfactory dysfunction.

Magnetic resonance imaging and brain-stem auditory evoked potentials in neuro-Behçet's disease

We studied central nervous system lesions in patients with neuro-Behcet's disease using magnetic resonance imaging (MRI) of the brain and recording of brain-stem auditory evoked potentials (BAEPs). MRI revealed abnormal findings in seven of eight patients. MRI studies demonstrated extensive regions with high intensity signal in the brain stem and/or basal ganglia on T2-weighted images obtained during the acute stage of the disease in three patients. One of these patients had a strongly gadolinum-enhanced round lesion in the lower pons. In four of the other five patients with chronic disease, brain-stem atrophy was observed on T1-weighted images. Atrophic changes were more severe in the brain stem than in the cerebellum. Abnormal BAEPs were observed in three patients and consisted of prolongation of interpeak latency of waves III-V and defects of wave III or V. Abnormal BAEPs were recorded in patients with severe inflammatory changes or progression of atrophic changes in the brain stem. Our findings show that MRI and BAEPs are useful in detecting the presence and assessing the degree of neurological involvement in patients with neuro-Behçet's disease.

Criteria for differentiation of normal and abnormal uroflowmetrograms in adult men

OBJECTIVE

To study parameters which serve as criteria for differentiation of normal and abnormal uroflowmetrograms.

SUBJECTS AND METHODS

A total of 105 subjects were investigated, 43 of whom had no symptoms of dysuria, 57 of whom had dysuria demonstrated as an abnormal uroflowmetrogram, subjective symptoms and a small residual urine volume, and five patients who were about to undergo transurethral resection of the prostate. The three parameters used to specify the shapes of the uroflowmetrogram curves were: (i) the ratio of the maximum flow rate (Qmax) and the voiding time (T100), Qmax/T100; (ii) the ratio of the time to peak flow (TQmax) and the voiding time, TQmax/T100; and (iii) the newly introduced voiding efficiency (epsilon), measured by the ratio of the voided volume (VV) and T100 x Qmax, epsilon = VV/(T100 x Qmax), were taken for each patient.

RESULTS

The criteria for normal uroflowmetrograms were: Qmax/T100 > or = 0.78, 0.32 < or = TQmax/T100 < or = 0.54, 0.63 < or = epsilon < 1, respectively. In the patients who underwent transurethral resection of the prostate the values of all three parameters improved and returned almost to normal after operation.

CONCLUSION

Using these three parameters the micturition pattern can be expressed quantitatively.

[A case report of ureteral stump metastasis from renal-cell carcinoma]

This is a case report of the 21st documented case of ureteral metastasis from renal cell carcinoma. A 75-year-old woman was admitted because of asymptomatic gross hematuria. Right radical nephrectomy for renal cell carcinoma had been performed 2 years and 9 months prior to admission. Cystoscopy revealed efflux of blood from right ureteral orifice. Right retrograde ureterogram revealed a filling defect at the upper end of the stump, where a soft tissue mass was observed by computerized tomographic scan. She underwent right ureteral stump excision with a bladder-cuff. Pathological study was consistent with metastatic renal cell carcinoma. The literature on ureteral metastasis from renal cell carcinoma is briefly reviewed and a mechanism for the metastasis is proposed.

Dilation of intra-atrial baffle fenestrations: results in vivo and in vitro

Spontaneous closure of intra-atrial baffle fenestrations occurred early postoperatively following a Fontan procedure in three patients (ages 0.8-2 yr) and were reopened using transvenous balloon dilation. Following this clinical experience with this complication we studied the effects of high pressure balloons of different sizes on fenestrations created in polytetrafluoroethylene (PTFE) patches. The intra-atrial baffle fenestration was found closed within hours after surgery in two patients and 32 days postoperatively in the other. Increasing edema, chest tube drainage, and renal dysfunction ensued rapidly. At catheterization the balloon dilation in two patients reduced the elevated right atrial pressure, edema, and pleural effusion and allowed an acceptable arterial saturation. In the other patient, with acidosis and a low cardiac output, transient cardiac arrest occurred following passage of the catheter through the fenestration and during later unsuccessful operation the fenestration, although open, was traversed by strands of clot. In the experimental study, a total of 45 fenestrations 4 mm in diameter were dilated with 5, 6, 7, 8, and 9 mm balloons. The fenestration areas remained increased significantly during the 14 days of observation in room air, with the larger balloons producing larger holes. Balloon dilation may be effective for spontaneous fenestration closure occurring in the early postoperative period after a fenestrated Fontan procedure. Our experimental data may be useful in selecting the balloon size in this setting.

Inguinal lymph node metastasis from contralateral testicular origin

A twenty-eight-year-old man had a testis tumor eighteen years after orchiopexy and inguinal lymph node metastasis in the contralateral side. It is suggested that scrotal surgery may lead to the formation of new lymph channels and alter the pattern of nodal metastases.

Two cases of urothelial tumor with high serum level of carcinoembryonic antigen and TA-4

Two rare cases of urothelial tumor with high serum carcinoembryonic antigen (CEA) and TA-4 levels are presented. One is a case of lymph node metastasis due to bladder tumor: pathological diagnosis revealed mucoepidermoid carcinoma. The other is a case of left renal pelvic tumor: pathological diagnosis revealed transitional cell carcinoma with glandular and squamous differentiation. The serum CEA and TA-4 levels, high before surgery, decreased after surgery.

[Clinical evaluation of intra-arterial methotrexate, vinblastine, doxorubicin and cis-platinum for bladder cancer]

Chemotherapy regimens including Methotrexate, Vinblastine. Doxorubicin and Cis-platinum (M-VAC) have shown objective responses in more than 50% of uroepithelial tumors. And intra-arterial chemotherapy can theoretically increase the drug concentration delivered to the tumor with maximum efficacy and less toxicity. In this report we review our experience at Matsuyama Red Cross Hospital between September 1987 and February 1991 using intra-arterial M-VAC in 21 evaluable patients with bladder cancer. Response was observed in 62% of the treated patients, two with complete remission and eleven with partial remission. WBC nadir and platelet nadir were mild to moderate. Other adverse effects such as mucositis, hair loss and creatinine elevation were seen in a small number of patients. Intra-arterial M-VAC can be one of the most useful forms of chemotherapy for patients with bladder cancer.

[Evaluation of physical fitness and exercise performance in patients with chronic pulmonary emphysema]

Physical fitness was studied in patients with chronic pulmonary emphysema using Kraus-Weber methods in addition to pulmonary function and exercise tolerance. In Kraus-Weber tests, explosive strength of abdominal muscles in these patients were within the normal range, but both abdominal and back muscle endurance were significantly diminished compared to age-matched controls. On the other hand, flexibility was not different between the patients and the controls, although large variation was present. Exercise performance as assessed by 6 minutes' walk distance in patients was significantly correlated with FEV1.0, DLco and maximal inspiratory mouth pressure, as well as explosive strength of abdominal muscles and abdominal and back muscle endurance capacity. Treadmill walking training for 20 minutes with a load greater than 80% VO2max, twice a week for 2 months was performed in 11 patients with mild to moderate pulmonary emphysema. Six minutes' walk distance (6MD) was significantly prolonged with improvement of back muscle endurance and flexibility. Another walking training consisting of five repetitions of two minutes' near maximal walking and a two minute interval of rest was performed in 6 patients with severe pulmonary emphysema. 6MD tended to increase with improvement of both back and abdominal muscle endurance. However, pulmonary function tests and VO2max showed no significant changes after both types of training. Improved walked distance after the training was significantly correlated with improved VO2 at AT. Furthermore VO2, VE, HR and lactate production during exercise at the same load were significantly decreased compared to pre-training. Dyspnea sensation measured by modified Borg scale during exercise was improved after the training. It is concluded that a physical training program adapted to the condition of the individual patients could improve exercise performance, and should be prescribed in addition to medication.

Intermediate-term results of balloon valvuloplasty for isolated and complicated pulmonary valve stenosis

The purpose of this study is to report our experience regarding the acute and intermediate-term results of balloon pulmonary valvuloplasty (BPV) in various types of congenital pulmonary valve stenosis.

METHODS AND RESULTS

Twenty-four consecutive patients with a median age of 6.6 years (ranging from 1 month to 24 years old) underwent BPV between January 1988 and September 1991. These patients were divided into 2 groups; Group 1 consisting of 13 patients with isolated pulmonary valve stenosis, and Group 2 consisting of 11 patients with complicated pulmonary valve stenosis (supravalvular, subvalvular, valved conduit and post-right ventricular outflow reconstruction). Mean peak systolic pressure gradients from the right ventricle to the pulmonary artery were as follows: In group 1, 48 +/- 21 (mean +/- SD) mmHg before BPV, 18 +/- 8 mmHg immediately after BPV and 13 +/- 5 mmHg at the longest follow-up based on catheterization or Doppler echocardiographic studies. The gradients in group 2 were 65 +/- 28 mmHg before BPV, 46 +/- 25 mmHg immediately after BPV and 47 +/- 21 mmHg at the longest follow-up.

CONCLUSIONS

BPV provides both acute and intermediate-term gradient relief in patients with isolated pulmonary valve stenosis. In complicated pulmonary valve stenosis, on the other hand, the effect of BPV was unsatisfactory and appears to depend on the mechanism of associated obstruction. Therefore accurate evaluation of the anatomy of associated obstruction in the pulmonary valve region is needed to determine that BPV is indicated.

Plasma endothelin concentration: relation with vascular resistance and comparison before and after balloon dilatation procedures

Endothelin (ET) is a potent vasoconstrictor peptide with an as yet uncertain physiological role in cardiovascular disease. We measured blood plasma ET concentrations using a recently developed radioimmunoassay and analysed the relations between ET concentration, systemic arterial pressure and systemic vascular resistance. In addition, ET levels before and after percutaneous balloon valvuloplasty and angioplasty were measured. Fifty-one patients were studied: (1) 13 patients with small left-to-right shunting or Kawasaki heart disease (age ranged from 4 to 144 months); (2) 10 patients who had undergone balloon valvuloplasty or angioplasty (age ranged from 1 to 233 months) and (3) 28 healthy infants and children (age ranged from 3 to 152 months). Systemic vascular resistance was calculated by the formula (mean aortic pressure--mean right atrial pressure) X 80/cardiac output (dyne.sec.cm-5). Plasma ET concentrations in healthy children less than 2 years were significantly higher than those over 2 years (2.48 +/- 0.62 vs 1.31 +/- 0.53 pg/ml). In eight patients in groups 1 and 2, plasma ET concentration in the pulmonary artery (2.00 +/- 0.43 pg/ml) was significantly lower than that in the femoral vein (2.39 +/- 0.69 pg/ml) and aorta (2.23 +/- 0.59 pg/ml), suggesting ET secretion derived from endothelial cells in peripheral pulmonary vessels. There was a significant positive correlation between ET concentrations in the femoral vein and systemic vascular resistance (r = 0.55, p less than 0.05). After balloon dilatation ET concentration rose from 2.15 +/- 0.82 pg/ml to 2.61 +/- 1.38 pg/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

[Combined effect of TNF and anticancer chemotherapeutic agents on murine bladder tumor (MBT-2)]

The antitumor activity of combination therapy of recombinant human tumor necrosis factor alpha (rHu-TNF alpha) and chemotherapeutic agents against murine bladder tumor (MBT-2) was studied. Tumors were intradermally transplanted into the hind leg of C3H-HeN mice and allowed to grow until they reached a diameter of 8 to 10 mm 10 days after transplantation. TNF (3,000 units) was given intraperitoneally from day 10 to day 19, and the chemotherapeutic agents, 5-FU (60 mg/kg), CPM (100 mg/kg), CDDP (10 mg/kg) and ADM (5 mg/kg), were applied once intraperitoneally on day 10. The antitumor effects were evaluated based on tumor volume on day 20. 5-FU, CPM and ADM enhanced the antitumor effect when combined with TNF, but CDDP did not. These findings suggest that combination therapy of TNF and certain antitumor chemotherapeutic agents is effective cancer treatment.