Experience with U-shaped gluteal thigh flap for reconstruction of radionecrosis in the sacral region

The gluteal thigh flap first reported by Hurwitz in 1980 can provide a large reliable flap for coverage of the sacrogluteal and perineal regions. This flap can be extended quite some way along its axial inferior gluteal vessels, but its width is limited to approximately 10 cm if direct approximation of the donor site defect is required. In this article, we report a U-shaped modification of the gluteal thigh flap for efficient use of the flap in covering a large defect in the sacrogluteal region.

[Long-term follow-up study after permanent pacemaker implantation in patients aged 60 years or over with sick sinus syndrome]

Ninety-five patients aged 60 years or over with a permanent pacemaker implanted for sick sinus syndrome were divided into two groups: 32 patients with physiological pacing (group P) and 63 patients with ventricular pacing (group V). The mean follow-up period was 45.0 +/- 36.6 months in group P and 50.3 +/- 37.8 months in group V. Paroxysmal atrial fibrillation (Af) occurred in 28% of group P and 71% of group V (p < 0.05). The incidence of stable Af was also lower in group P than in group V (9% vs. 30%, p < 0.05). None of group P with only bradyarrhythmia had stable Af. However, 6 of 21 patients (29%) in group V with bradyarrhythmia showed stable Af. There was no significant difference in stable Af between group P with bradycardia-tachycardia syndrome (BTS) and group V with BTS (19% vs. 31%). A lower incidence of embolic events was also observed in group P (3% vs. 25%, p < 0.05). Nine of 16 patients with embolic events in group V died of complications following embolism (8 patients; cerebral embolism, one patients: renal and superior mesenteric arterial embolism). The survival rates at 5 and 10 years were 80% and 69%, respectively, for group P and 56% and 33% for group V (p < 0.01). Thus, with regard to permanent pacing for patients with sick sinus syndrome, physiological pacing should be selected for control of morbidity and total mortality.

Omentum as gliding material after extensive forearm tenolysis

Tendon adhesion occurring after major replantation can be severe and extensive due to the nature of the trauma, ischaemia, prolonged oedema and/or infection. Therefore there is a high possibility of re-adhesion after tenolysis. In two cases of tenolysis after forearm replantation omentum was used as gliding material and good results were obtained.

Lectin immunohistochemical evaluation of human bladder carcinomas. A comparison of Carnoy's and formalin fixation

A lectin immunohistochemical analysis of 51 human bladder carcinomas, including 44 cases of transitional cell carcinoma (TCC) (G1, 15 cases; G2, 17 cases; G3, 12 cases) and 7 cases of squamous cell carcinoma (SCC), was performed. Tissues were obtained by cold punch biopsies, fixed in Carnoy's or 10% formalin solution, stained for binding of 10 different lectins, and evaluated under the light microscope. The lectins used were concanavalin agglutinin (Con A), soybean agglutinin (SBA), Lotus tetragonolobus agglutinin (LTA), Dolichos biflorusa agglutinin (DBA), peanut agglutinin (PNA), Ricinus communis agglutinin I (RCA1), Ulex europaeus agglutinin I, II (UEA-I, II), wheat germ agglutinin (WGA), and Pisum sativum agglutinin (PEA). TCC prepared with Carnoy's fixation tended to show moderately positive Con A, UEA-I, and WGA reactions for G1, and strongly positive reactions for G2 and G3 lesions. UEA-II was mainly negative in G1, but tended to increase to become moderate in G3. DBA tended to show a moderately positive reaction in G1 and G2, but was mainly negative in G3. With formalin fixation, only RCA1 demonstrated grade specific variation, tendency to react moderately in the G1 and G2 cases, and strongly in G3. There were no further differences among the histopathological grades of TCC for other lectins. Thus, Carnoy's fixation appears superior for distinguishing between grades of lesions. SCC tended to react more strongly than TCC with all the various lectins except PEA, independent of fixation.

Functional expression of human P-glycoprotein in Schizosaccharomyces pombe

Human MDR1 cDNA was introduced into the human cultured cells KB-3-1 and Schizosaccharomyces pombe pmd1 null mutant KN3. The drug sensitivity of KB-G2 and KN3/pgp, expressing human P-glycoprotein, was examined. KB-G2 was resistant to the peptide antibiotics valinomycin and gramicidin D as well as having a typical multidrug resistance (MDR) phenotype. KN3/pgp was resistant to valinomycin and actinomycin D, but not to adriamycin. The ATP-hydrolysis-deficient mutant did not confer KN3 resistance to these antibiotics. Human P-glycoprotein expressed in S. pombe seemed to lack N-glycosylation. The N-glycosylation-deficient mutant, however, conferred a typical MDR phenotype on KB-3-1. These results suggest that human P-glycoprotein functions as an efflux pump of valinomycin and actinomycin D in the membrane of S. pombe.

Digoxin-cyclosporin A interaction: modulation of the multidrug transporter P-glycoprotein in the kidney

The mechanism of a renal tubular digoxin-cyclosporin A interaction was elucidated using a kidney epithelial cell line and the isolated perfused rat kidney. The cells expressed an excess amount of human P-glycoprotein on the apical membranes by transfection with MDR1 cDNA. Cyclosporin A inhibited the transepithelial transport of digoxin mediated by human P-glycoprotein; net basal-to-apical transport across the cell monolayer was 22.8, 21.2, 6.61 and 0.91 pmol/mg of protein/3 hr in the presence of 0, 1, 5 and 10 microM cyclosporin A, respectively. Cyclosporin A also reduced the renal tubular secretion of digoxin by the kidney. The ratio of fractional excretion/filtration fraction for digoxin was 2.88 +/- 0.71 (mean +/- S.D.) in the control, and this was decreased to 1.21 +/- 0.09 and 1.05 +/- 0.13 in the presence of 1 and 5 microM cyclosporin A, respectively. Because no signs of acute nephrotoxicity were observed, a direct effect of cyclosporin A accounted for the reduced secretion. On the other hand, digoxin did not affect cyclosporin A transport by P-glycoprotein. These findings indicate that serum concentrations of digoxin in patients should be carefully monitored when administered concurrently with cyclosporin A. The present transepithelial transport system using the transfectant cells is a simple and useful screening system for predicting drug interactions that can occur in a clinical situation.

Classification of senile plaques by three-dimensional analysis

We evaluated the number of each senile plaque subtype in Alzheimer's brain by the usual two-dimensional analysis using a single, methenamine silver stained section and three-dimensional analysis using serial section reconstruction. The number of classic plaques was underestimated due to a lack of precision in the usual evaluating procedures (two-dimensional analysis), while that of stellate deposits was overestimated. From these results, it was suggested that the three-dimensional analysis by gapless serial sections was indispensable to examine and subclassify senile plaques.

An autopsy case of intracranial hemorrhage during tissue plasminogen activator infusion

We describe an autopsy case of severe intracranial hemorrhage which occurred during the infusion of tissue plasminogen activator (t-PA) for acute myocardial infarction. A 75-year-old man was admitted with substernal chest pain of 3-h duration and electrocardiographic changes consistent with an acute inferior myocardial infarction. Physical examination was unremarkable, except for an initial blood pressure reading of 160/96 mmHg. The patient received 3,000 IU intravenous heparin followed by a 2.4 x 10(6) IU bolus dose of tissue plasminogen activator (t-PA) (Alteplase). This was followed by a drip infusion of 21.6 x 10(6) IU of t-PA over 1 h (total dose 41 mg). Thirty minutes after the infusion of t-PA was initiated, the patient suddenly lost consciousness and began to have violent convulsions, followed by cardiac arrest. Autopsy revealed massive hemorrhage in the bilateral cerebrum and brain stem. To our knowledge, this is the first case of sudden death during t-PA infusion therapy.

Histopathological and morphometric analysis of atypical adenomatous hyperplasia of human cirrhotic livers

Atypical adenomatous hyperplasia (AAH) is a hyperplastic parenchymal nodular change in the cirrhotic liver, in which overt hepatocellular carcinoma (HCC) occasionally arises. AAH is defined as a sizable hepatocellular nodule with a variable degree of hepatocellular atypia not regarded as HCC, and is different from ordinary adenomatous hyperplasia in which hepatocellular atypia is absent. In the present study, we attempted to evaluate carcinogenetic processes and to find histological variables which indicate malignant transformation in AAH, using 49 surgically resected or autopsied nodules. AAH frequently showed morphological heterogeneity. Atypical lesions within AAHs were divisible into the following three categories from overall histopathological appearances: malignant (A), equivocal (B), or non-malignant (C) lesions. Analysis of combination of these three lesions, which were frequently intermixed in a given AAH, suggested that B lesions appear subsequent to C lesions, and A lesions finally appear in AAH nodules. Among the 14 histological variables, enlargement, hyperchromasia and irregular contour of nuclei were found to correlate well with A lesions. Increased nuclear density, iron resistance, reduction of reticulin fibres, clear cell change, sinusoidal dilatation and presence of abnormal arteries were suggestive of A or B lesions. Nuclear deviation toward the sinusoids, acinar and compact arrangements, fatty change and Mallory's hyaline alone were not useful indicators of A or B lesions. These results indicate that AAH is a preneoplastic or borderline lesion in which overt HCC is likely to evolve through several steps. Although a needle liver biopsy is a useful tool for diagnosis of benign, equivocal and malignant hepatocellular nodular lesions, the needle biopsy specimen should be carefully evaluated by considering the morphological heterogeneity of the AAH and a variable combination of 14 histological variables.

Frequent isolation of human herpesvirus 7 from saliva samples

Human herpesvirus 7 (HHV-7) was isolated frequently from saliva specimens. The isolation rates were 81% (13/16) in adults, 70% (7/10) in children over 1 year old, and none (0/7) in children less than 1 year old, respectively, indicating that infection of HHV-7 occurs during early infancy and the virus shedding rate after infection is very high. Human herpesvirus 6 (HHV-6) was not isolated from saliva specimens although some studies on isolation of HHV-6 from saliva was reported previously.

Inflammatory cytokines in virus-associated hemophagocytic syndrome. Interferon-gamma as a sensitive indicator of disease activity

PURPOSE

We assayed serum interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha) and interferon gamma (IFN-gamma) levels in children with virus-associated hemophagocytic syndrome (VAHS) to evaluate the relationship of these cytokines to other laboratory parameters. We also studied the role of IFN-gamma as a macrophage activator in hemophagocytic syndrome (HPS).

PATIENTS AND METHODS

Interleukin-1 beta, TNF-alpha, and IFN-gamma were measured in 42 serial sera from six children with VAHS using a sensitive radioimmunoassay.

RESULTS

The cytokine IFN-gamma or TNF was detected in 19/19 (100%) or 11/19 (69%) samples, respectively, during the active febrile phase, at much higher levels than during the remission phase of the disease (IFN: p < 0.00001; TNF: p < 0.01). In contrast, IL-1 could be detected in only two sera obtained from a patient during severe relapse. Serial cytokine examination revealed that the elevated TNF and IFN-gamma levels decreased rapidly to an undetectable level in concert with clinical improvement after an effective treatment, and that IFN-gamma, but not TNF, was detected just before a relapse marked by spiking fever. In the active phase, the CD4/8 ratio was depressed, and the total number of CD3+ HLA-DR+ cells was increased. Of the activated T cells, CD8+ cells outnumbered CD4+ T cells. By the Spearman's rank sum test, the IFN-gamma level correlated positively with the peripheral leukocyte count [Correlation coefficient (CC): 0.585, p < 0.05] and serum lactate dehydrogenase level (CC: 0.538, p < 0.05) and negatively with the CD4/8 ratio (CC: -0.618, p < 0.05), but not with any other parameter including ferritin and C-reactive protein. Although TNF and IL-1 were not statistically linked to these parameters, TNF levels were related to IFN-gamma levels (product moment CC: 0.546, p < 0.05).

CONCLUSIONS

These results suggest that circulating IFN-gamma is one of the most sensitive indicators of disease activity; it may act as a potent macrophage activator during the hypercytokinemic state of childhood VAHS.

[Arteriosclerosis obliterans]

Arteriosclerosis obliterans (ASO) has become one of major health problems in the elderly people in Japan. This paper reviews the recent progress in the diagnosis and treatment of ASO. Both medical and surgical treatments, such as atherectomy catheters, endovascular metallic stenting, laser angioplasty and LDL-apheresis have recently been greatly developed. As atherosclerosis is a generalised disease, patients with ASO tend to have other atherosclerotic diseases, i.e., cerebrovascular disease, coronary heart disease and renal vascular disease. For the selection of treatments, we have to consider the whole background of the patients, including a quality of life.

Detection of DNA in the nucleoids of chloroplasts and mitochondria in Euglena gracilis by immunoelectron microscopy

DNA in the nucleoids of chloroplasts and of mitochondria in Euglena gracilis was detected with anti-DNA antibodies by immunoelectron microscopy. After treatment with the antibodies, DNA in these organelles combined with gold particles that had been coated with anti-IgM antibodies such that it was possible to trace the outlines of the nucleoids. Nucleoids in chloroplasts appeared to be composed of twisted threads 50–70 nm in diameter. The twisted threads were entangled to form thicker nodes of 100–200 nm diameter. Most nucleoids in mitochondria were spherical or ovoid, 70–130 nm in diameter. Nucleoids both in chloroplasts and in mitochondria contained cores with which DNA threads were in tight contact. The structure of the nucleoids was very different from those previously observed by conventional electron microscopy.

Erythrocyte galactokinase assay with high performance liquid chromatography

An assay for erythtocyte galactokinase based on high performance liquid chromatographic determination of galactose 1-phosphate (Gal-1-P) is described. The determination of Gal-1-P was applied to a post-column fluorometric detection of reducing sugars using arginine. This method is as sensitive and accurate as conventional radioisotopic methods, but needs no radioisotopic facilities. It requires only a small blood sample and is suitable as a follow-up test in neonatal screening.

Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap

In reconstruction of large scalp and skull defects, the usefulness of microvascular free tissue transfer is manifest. We have performed 4 scalp and skull reconstructions by free serratus anterior osteomuscle flap transfer. The usefulness of serratus anterior osteomuscle flap for reconstruction of combined, extensive scalp and skull defects is emphasized.

Trivalent cold recombinant influenza live vaccine in institutionalized children with bronchial asthma and patients with psychomotor retardation

Twenty asthmatic children and 48 patients with severe psychomotor retardation were inoculated intranasally with trivalent cold-adapted recombinant (CR) influenza vaccine containing CR-125 (H1N1), CR-159 (H3N2) and CRB-117 (B). The vaccinees were mostly seropositive. Severe adverse reactions or asthmatic attacks were not observed, but 7 (15%) of 48 vaccinees with severe psychomotor retardation developed mild to moderate fever. Significant antibody responses in hemagglutination-inhibition tests were demonstrated in 33 (49%) vaccinees to CR-125, 20 (29%) to CR-159 and 8 (12%) to CRB-117. Two nosocomial outbreaks of influenza were observed in the subsequent winter. During an outbreak with H3N2 in one ward of severe psychomotor retardation patients, 2 (11%) of 18 vaccinees became infected compared with 10 (48%) of 21 placebo controls in the same ward (P < 0.05). In the other outbreak, with influenza B virus, 2 (14%) of 14 vaccinees and 13 (52%) of 25 controls in the ward for asthmatic children were infected (P < 0.05). The results indicate that trivalent CR vaccine is safe and effective against nosocomial outbreaks of influenza.

[Hyperinsulinemia and hypertension in an elderly Japanese population--the Hisayama Study]

Hyperinsulinemia has been closely associated with hypertension in several epidemiological studies, but little is known about this condition in the elderly. The authors studied the relationship between serum insulin and blood pressure levels, and the prevalence of hypertension according to insulin levels in the elderly in a Japanese rural community, Hisayama. In 1988, 75 g oral glucose tolerance test was performed on 426 male and 567 female Hisayama residents aged 60 to 79 years. Fasting and 2 hr serum insulin values were measured by radioimmunoassay. In the subjects, excluding those receiving antihypertensive drugs, the sum of fasting and 2 hr postload insulin (sigma IRI) significantly correlated with systolic (r = 0.15 and 0.25 for males and females, respectively) and diastolic blood pressure (r = 0.20, 0.16). In multiple regression analyses, the correlation with systolic blood pressure remained significant in females after controlling for age, body mass index, alcohol intake, smoking habits, serum total cholesterol, HDL-cholesterol, triglycerides, and fasting plasma glucose. In contrast, sigma IRI did not remain as an independent variable relevant to blood pressure among males. The age-adjusted prevalence rates of hypertension (> or = 160/95 mmHg or receiving drug treatment) significantly increased with increasing quartiles of sigma IRI in females. The prevalence of hypertension which was not treated with drugs also increased significantly with increasing sigma IRI in females. However, no significant association was observed in males. In conclusion, the present study suggests that hyperinsulinemia can be related to hypertension in the female elderly in the general population of Japan.

[Cerebral protection with selective cold blood cerebral perfusion by gravity during aortic arch reconstruction]

Selective cold blood cerebral perfusion by gravity using specially designed reservoir with a built-in heat exchanger was applied to 30 consecutive patients who required aortic arch reconstruction. Rectal and brain temperature during cerebral perfusion were maintained at 22 degrees C and 16 degrees C respectively. Patients were divided into two groups according to postoperative condition of consciousness. Twenty three patients had uneventful recovery of consciousness (Group-1), and 7 patients showed delayed recovery or disturbance of consciousness (Group-2). Age, sex, causes of aneurysm, rectal temperature and conditions of cerebral perfusate were not statistically significant in both groups. Selective cerebral perfusion time in Group-1 was 68 +/- 36 min and 85 +/- 31 min in Group-2 (statistically not significant). Extracorporeal circulation time in Group-2 (243 +/- 61 min) was significantly longer than in Group-1 (187 +/- 56 min) (p < 0.05). Five of seven patients (71%) in Group-2 were in shock pre- or early post-operative period contrary to 0% in Group-1 (p < 0.001). These results suggest that selective cold blood cerebral perfusion protects effectively the brain during aortic arch reconstruction in the patients without hemodynamic deterioration.

Association of the antibodies against human papillomavirus 16 E4 and E7 proteins with cervical cancer positive for human papillomavirus DNA

Occurrence of the antibodies against human papillomavirus (HPV) 16 proteins E4 and E7 is specifically but independently associated with cervical cancer. To correlate HPV DNA and antibody data, we examined the biopsy specimens and sera, by polymerase chain reaction (PCR) and by ELISA, respectively, from 51 patients with cervical cancer (including 3 recurrent cases) and 22 with cervical intra-epithelial neoplasia. Consensus primers for the L1 region were used for PCR and bacterially expressed, purified fusion protein HPV-16 E4 and non-fusion protein HPV-16 E7 were used for ELISA. HPV-16 DNA and other HPV types were detected in 17 and 25, respectively, out of 51 cases of cervical cancer. Ten out of the 17 HPV-16-DNA-positives were positive either for anti-E4 or for anti-E7: positivities for anti-E4, for anti-E7, and for both were 6/17, 5/17 and 1/17 respectively. Three anti-E7-positives consisted of those for HPV-33, -52 and -58 DNA, suggesting that limited cross-reaction occurred between the HPV types. Among the HPV-16-DNA-positive cases of cancer, lymph-node or distant metastasis was recorded more frequently in the seropositives than in the seronegatives. Our results show that the HPV-16 anti-E4 or anti-E7 occurs in some, but not in all, of the HPV-16-DNA-positive cases, and support the hypothesis that the presence of the HPV-16 antibodies can be used as a marker for possible metastasis.

Enzymatic diagnosis of steroid sulfatase deficiency by high performance liquid chromatography

We established a reversed phase high performance liquid chromatographic (HPLC) method of assaying lymphocyte steroid sulfatase activity using estrone sulfate as the substrate. Application of this method for diagnosis of 8 patients allowed us to clearly distinguish the patients from the normal controls. This method is simpler and less expensive than the method previously reported, since neither radioisotope labeled substrates nor radioisotope facilities are required. We consider it to be easily used and widely available in most clinical laboratories.

P-glycoprotein-mediated transcellular transport of MDR-reversing agents

Understanding of the interactions between P-glycoprotein and multidrug resistance (MDR) reversing agents is important in designing more effective MDR modulators. We examined transcellular transport of several MDR modulators by using a drug-sensitive epithelial cell line, LLC-PK1, and its transformant cell line, LLC-GA5-COL300, which expresses human P-glycoprotein on the apical surface. Basal-to-apical transports of azidopine and diltiazem across the LLC-GA5-COL300 monolayer were increased and apical-to-basal transports were decreased compared to those across the LLC-PK1 monolayer, indicating that P-glycoprotein transports azidopine and diltiazem. Movements of nitrendipine and staurosporine across the epithelial monolayer were not affected by P-glycoprotein. These results suggests that some MDR modulators exert their inhibitory effect not only by blocking the initial binding of anticancer drugs but throughout the course of the transport process.