Right ventricular infarction complicating coronary artery bypass grafting

Intraoperative right ventricular infarction immediately after coronary artery bypass grafting is a rare and potentially serious complication. We report a case in which an additional coronary artery bypass graft to a right ventricular branch with 99% stenosis brought about recovery from profound acute right ventricular failure. This case shows that complete revascularization to all graftable vessels, including even the right ventricular branch, is mandatory for successful coronary artery bypass grafting.

Angioplasty/bypass combination therapy in an 89-year-old man with left main trunk disease

We report a case of an 89-year-old man presenting with unstable angina and left main trunk disease. Minimally invasive direct coronary artery bypass grafting supplemented by catheter intervention was successfully performed. In view of the increasing elderly population, angioplasty/bypass combination therapy may be an important alternative for elderly coronary artery disease patients.

Minimally invasive port-access coronary artery bypass grafting

The Port-Access endovascular cardiopulmonary bypass system (Heartport, Inc., Redwood City, CA, USA), a recent technological innovation in minimally invasive cardiac surgery, was conducted successfully in coronary artery bypass grafting on a 69-year-old woman. The left internal thoracic artery was harvested through a limited left anterior thoracotomy and anastomosed to the left anterior descending coronary artery on a protected and arrested heart. Intraoperative coronary angiography confirmed good graft patency. The patient was discharged from the hospital in good condition 7 days after the operation. This was the first successful minimally invasive Port-Access coronary artery bypass grafting in Japan.

Effect of storage temperature on cell viability in cryopreserved canine aortic, pulmonic, mitral, and tricuspid valve homografts

We determined how long cryopreserved aortic, pulmonic, mitral, and tricuspid valve homografts could be stored in a deep freezer (-80 degrees C) without compromising fibroblast viability. Valves harvested from 20 anesthetized mongrel dogs were grouped into nonfrozen control, frozen and stored in liquid nitrogen (-196 degrees C), and frozen and stored in a deep freezer (-80 degrees C). Frozen groups were divided into subgroups and stored for 2, 4, 8, or 12 weeks. A leaflet of each valve was divided into three fragments, and fibroblast viability was analyzed by flow cytometry. Cell viability was defined as staining by fluorescent diacetate but not by propidium iodide. The viability of untreated control valves from all four sites was about 70%, decreasing to about 50% when treated with low doses of antibiotics. The viability of frozen valves stored in liquid nitrogen was about 45% without a significant difference among storage periods. The viability of valves frozen and stored in a deep freezer was significantly lower than for the liquid nitrogen group at 2 weeks for the mitral valve and at 4 weeks for other valves. These results suggest that homografts can be stored in a deep freezer for up to 2 weeks without deterioration.

Surgical angioplasty of left main coronary stenosis complicating supravalvular aortic stenosis

We successfully treated obstruction of the main coronary artery, not aortic valve leaflet adhesion to the intimal shelf, complicating supravalvular aortic stenosis by modifying the Brom aortoplasty. An autologous pericardial patch was used to enlarge the left main coronary artery as well as the stenotic aorta. This modification allows simple and effective restoration of coronary blood flow, while maintaining the Brom procedure's merit of achieving anatomic geometry of the aortic root in such patients.

GTPase activity and biochemical characterization of a recombinant cotton fiber annexin

A cDNA encoding annexin was isolated from a cotton (Gossypium hirsutum) fiber cDNA library. The cDNA was expressed in Escherichia coli, and the resultant recombinant protein was purified. We then investigated some biochemical properties of the recombinant annexin based on the current understanding of plant annexins. An "add-back experiment" was performed to study the effect of the recombinant annexin on beta-glucan synthase activity, but no effect was found. However, it was found that the recombinant annexin could display ATPase/GTPase activities. The recombinant annexin showed much higher GTPase than ATPase activity. Mg2+ was essential for these activities, whereas a high concentration of Ca2+ was inhibitory. A photolabeling assay showed that this annexin could bind GTP more specifically than ATP. The GTP-binding site on the annexin was mapped into the carboxyl-terminal fourth repeat of annexin from the photolabeling experiment using domain-deletion mutants of this annexin. Northern-blot analysis showed that the annexin gene was highly expressed in the elongation stages of cotton fiber differentiation, suggesting a role of this annexin in cell elongation.

[A case of Chlamydia pneumonia and systemic lupus erythematosus (SLE) pleurisy]

A 40-year-old female was admitted with right chest pain. SLE was absent from her past history, although she complained of polyarthralgia in winter. Atypical pneumonia/pleuritis was suspected by chest X-ray film, showing a nodular shadow in the right lower field and moderate pleural effusion. Chlamydia pneumonia was diagnosed by elevated anti-C. psittsci antibody, while characteristics of pleural fluid revealed serositis accompanied by SLE because of the high titered anti-DNA antibody and the low titered complement. She was cured by clarithromycin and subsequent administration of prednisolone and cyclophosphamide.

Prognosis of Marfan and non-Marfan patients with cystic medial necrosis of the aorta

The characteristics and prognosis of patients with cystic medial necrosis of the aorta were reviewed. Subjects were 46 patients who underwent aortic and/or aortic valve surgery between August 1965 and October 1994. All had histologically documented cystic medial necrosis including 22 Marfan patients. The patients with Marfan syndrome were substantially younger (median age, 32 vs 50 years; p < 0.05), and experienced annulo-aortic ectasia more frequently {81% (17/22) vs 46% (11/24); p < 0.05} than those without the syndrome. Sixty-eight percent (15/22) of the Marfan patients and 63% (15/24) of the non-Marfan patients experienced complications with aortic dissection, although not to a significant degree. The hospital mortality rate was 14% (3/22) in the Marfan group and 21% (5/24) in the non-Marfan group, which was also not significant. Of the 38 survivors, developments in the health of 37 were completely followed-up until October 1997. The cardiovascular event-free rate for Marfan patients at 10 years (28%) was lower than that for non-Marfan patients (68%, p = 0.057), whereas the actuarial survival rates at 10 years were nearly equal (72% for the Marfan patients and 74% for the non-Marfan patients). Reoperation was the first cardiovascular event in 77% (10/13) of the Marfan patients and in 14% (1/7) of the non-Marfan patients (p < 0.05). Cardiovascular event was the main cause of late death both for Marfan patients (80%; 4/5) and for non-Marfan patients (86%; 6/7). In conclusion, independent of the presence of Marfan syndrome, careful follow-up is necessary for patients with cystic medial necrosis of the aorta to eliminate serious late complications.

Thrombin receptor mediated signals induce expressions of interleukin 6 and granulocyte colony stimulating factor via NF-kappa B activation in synovial fibroblasts

OBJECTIVE

To clarify the mechanism of thrombin receptor mediated signal transduction and the induction of cytokines by thrombin stimulation in rheumatoid synovial fibroblasts.

METHODS

Cytokines were measured by enzyme linked immunosorbent assay (ELISA) in the supernatants of cultured rheumatoid synovial fibroblasts stimulated by thrombin. To assess the mechanism of thrombin receptor mediated signal transduction in the rheumatoid synovial fibroblasts, electrophoretic mobility gel shift assay (EMSA), immunoglobulin kappa-chloramphenicol acetyltransferase (CAT) assay, and immunostaining for NF-kappa B subunit molecule was performed.

RESULTS

Thrombin stimulation activated the inducible transcription factor NF-kappa B, and then induced subsequent expressions of interleukin 6 (IL6) and granulocyte colony stimulating factor (G-CSF) in the cells.

CONCLUSION

Thrombin receptor mediated signal transduction could induce the expressions of IL6 and G-CSF, and increase inflammatory events in the cavum articulare via NF-kappa B activation.

[Basic approaches in minimally invasive cardiac surgery (MICS) and its selection]

Recently, minimally invasive cardiac surgery (MICS) has been developed and popularized as a less stressful and less invasive technique in the field of cardiac surgery. There are eight currently available MICS approaches for open heart surgery. The optimum approach should be selected for each patient based on the results of preoperative examination including chest X-ray, computed tomography, and angiography. Between December 1996, when we first introduced MICS for mitral repair, and the end of November 1998, we performed MICS in 67 patients [excluding cases of MIDCAB]. These included 11 patients who received the Port-Access (Heartport, Inc.) system. Although no patients died in hospital stay, one died of cerebrovascular bleeding eight months later. All patients were evaluated in the outpatient department as being NYHA class I. In view of future technological progress, we expect that MICS will gradually become more widespread in cardiac surgery.

Pro-caspase-3 is a major physiologic target of caspase-8

The apoptotic signal triggered by ligation of members of the death receptor family is promoted by sequential activation of caspase zymogens. We show here that in a purified system, the initiator caspases-8 and -10 directly process the executioner pro-caspase-3 with activation rates (kcat/Km) of 8.7 x 10(5) and 2.8 x 10(5) M-1 s-1, respectively. These rates are of sufficient magnitude to indicate direct processing in vivo. Differentially processed forms of caspase-3 that accumulate during its activation have similar rates of activation, activities, and specificities. The pattern and rate of caspase-8 induced activation of pro-caspase-3 in cytosolic extracts was the same as in a purified system. Moreover, immunodepletion of a putative intermediary in the pathway to activation, pro-caspase-9, was without consequence. Taken together these data demonstrate that the initiator caspase-8 can directly activate pro-caspase-3 without the requirement for an accelerator. The in vitro data thus help to deconvolute previous in vivo transfection studies which have debated the role of a direct versus indirect transmission of the apoptotic signal generated by ligation of death receptors.

Plasma (1-->3)-beta-D-glucan measurement and polymerase chain reaction on sputum as practical parameters in Pneumocystis carinii pneumonia

We report a case of Pneumocystis carinii pneumonia in a patient with acquired immunodeficiency syndrome diagnosed and monitored with polymerase chain reaction (PCR) for Pneumocystis carinii on sputum and measurement of plasma (1-->3)-beta-D-glucan (G-test). Results of both studies paralleled the clinical and radiographic improvement. However, the plasma (1-->3)-beta-D-glucan level remained higher than normal when PCR for Pneumocystis carinii became negative in sputum. Both PCR for Pneumocystis carinii on sputum and measurement of plasma (1-->3)-beta-D-glucan are useful for noninvasive diagnosis and monitoring of Pneumocystis carinii, although further investigation is necessary to quantify their relationship.

Inhibition of immediate type allergic reactions by the aqueous extract of Kum-Hwang-San

We studied the effect of aqueous extract of Kum-Hwang-San (KHS) on mast cell-mediated immediate type allergic reactions. KHS (1-100 microg/site) inhibited concentration-dependently mast cell-dependent ear swelling response induced by compound 48/80 (200 microg/site) in mice by both topical and intradermal application. KHS (0.1-100 microg/site) inhibited concentration-dependently passive cutaneous anaphylaxis induced by anti-dinitrophenyl (DNP) IgE in rats by both topical and intradermal application. KHS also inhibited concentration-dependently the histamine release from the rat peritoneal mast cells (RPMC) by compound 48/80 and anti-DNP IgE. Moreover, KHS had a significant inhibitory effect on anti-DNP IgE-induced tumor necrosis factor-alpha (TNF-alpha) secretion from RPMC. These results indicate that KHS inhibits immediate type allergic reactions by inhibition of histamine release and TNF-alpha secretion from mast cells in vivo and in vitro.

[A case of tuberculous pyothorax after an interval of four years of finishing with the first treatment for pulmonary tuberculosis]

We reported a case of tuberculous pyothorax which developed at four years after finishing with the first treatment for pulmonary tuberculosis. A 50-year-old female was admitted to our hospital with right chest pain. Tuberculous pyothorax was diagnosed by means of polymerase chain reaction (PCR method) of pleural effusion and of histological findings of the pleural section. She was cured by operation, pleural drainage and anti-tuberculous drugs. The bone scincigram of 99mTc revealed accumulation in the right 9th rib, tuberculous empyema might have been a secondary development from osteomyelitis.

[An early recrudescent case of Stanford type A closing aortic dissection]

A 81-year-old female was hospitalized with chest discomfort. Findings of CT scan revealed Stanford type A acute aortic dissection, but the dissecting lumen had already closed with thrombus. Aortogram showed no intimal tear, intimal flap or ulcer like projection. Under the diagnosis of "closing aortic dissection", conservative treatment was selected. The dissecting lumen was disappearing gradually, but she had a sudden chest pain on hospital day 4 and CT scan demonstrated an enlarged and enhanced dissecting lumen. She underwent an emergency operation and a hemiarch replacement was performed successfully. Her postoperative course was uneventful and she was discharged from the hospital in good health.

[Minimally invasive approach for mitral valve, aortic valve, and atrial septal defect surgery]

We successfully introduced minimally invasive cardiac surgery (MICS) to japan by performing thoracoscopic clipping of a patent ductus arteriosus in July 1992. MICS via a small right parasternal incision (Cosgrove procedure) was applied for one patients with severe rheumatic mitral stenosis, one with severe aortic regurgitation, and one with atrial septal defect (ASD). Mitral valve replacement (MVR), aortic valve replacement (AVR), and direct closure of the ASD were performed successfully by MICS for the the first time in Japan. All three patients required no blood transfusion and had no complications postoperatively, being discharged from hospital at 15, 13, and 9 days after their operations. MICS was satisfactory for mitral valve and ASD operations, but AVR by this approach took much longer than by standard midline sternotomy due to the poor surgical field obtained via the small right parasternal incision. A minimally invasive approach for surgery on the aortic valve and ascending aorta may require transection of the sternum or some other method. MICS has several advantages, including less trauma and pain, faster patient recovery, shorter ICU and hospital stays, a lower cost, and a better cosmetic outcome. Therefore, it is better for the patient when it is feasible. MICS should develop and be applied to more patients with cardiovascular disease in the future. Some of the standard cardiovascular operations may soon be replaced by MICS.

Altered monocyte calcium dynamics in sepsis

PURPOSE

This study was designed to evaluate monocyte calcium concentration and mobilization in normal and septic surgical patients.

METHODS

Monocytes were isolated from 15 "septic" surgical patients, washed, and loaded with the fluorescent calcium chelator, FURA-2. Monocytes from 20 normal volunteers served as controls. Intracellular calcium concentration ([Ca2+]i) was measured by means of fluorescent spectrophotometry before, during, and after stimulation with concanavalin A. Differences were evaluated for statistical significance by analysis of variance. The study was repeated using normal monocytes preincubated in "septic" serum and "septic" monocytes preincubated in normal serum. Additional paired whole blood specimens were obtained from the control group and were incubated with Escherichia coli endotoxin. Monocytes were then isolated and evaluated as described.

RESULTS

Sepsis was associated with significantly low resting monocyte calcium concentrations. Although concanavalin A stimulation resulted in marked calcium mobilization in both normal and septic cells, final cellular calcium concentration was significantly lower in the stimulated "septic" monocytes. Similar alterations were seen in normal cells incubated with septic serum, but could not be reproduced by incubation with endotoxin. This deficiency could not be corrected in septic cells incubated in normal serum.

CONCLUSION

Sepsis is associated with a significant alteration of monocyte calcium dynamics in both resting and stimulated cells. These changes appear to be modulated by a serum factor other than endotoxin.

Thrombin activates NF-kappa B through thrombin receptor and results in proliferation of vascular smooth muscle cells: role of thrombin in atherosclerosis and restenosis

We investigated the role of thrombin in the pathogenesis in atherosclerosis and restenosis. First we examined the effect of thrombin on cultured human vascular smooth muscle cells (VSMC). We showed that thrombin acts as a mitogen on VSMC through thrombin receptor. The expression of thrombin receptor was increased in the cell lines of VSMC established from directional coronary atherectomy (DCA). This is more pronounced in the cells from patients with restenosis after PTCA. Next we investigated the signaling pathway from thrombin/thrombin receptor. Thrombin activates thrombin receptor resulting in the exposing of the agonist peptide domain (thrombin receptor agonist peptide, TRAP). The signal from thrombin/thrombin receptor activated protein C kinase, tyrosine kinase, and MAP kinase and resulted in NF-kappa B activation. Furthermore, treatment of the cells with antisense p65 oligodeoxynucleotides of NF-kappa B inhibited the thrombin-stimulated growth of VSMC in vitro. These results suggest that thrombin may have a role in the pathogenesis of atherosclerosis and restenosis after PTCA through the thrombin receptor.

Blunt hepatic injury in adolescents: age makes a difference

This analysis of mortality from blunt hepatic injury was performed to define outcome in the adolescent age group in relation to that recorded for children and adults. Children (age 0-10 years) were selected from a multi-institutional trauma registry, adults (age > or = 21 years) from the registry of a Level I trauma center, and adolescents (age 11-20 years) from both. Groups were compared by injury frequency, proportion of severe hepatic injuries (code 864.03 or 864.04 in the International Classification of Diseases, Adapted for Use in the United States 9-CM), immediate laparotomy, mortality, and cause of death. Children had the lowest proportion of severe injury and overall mortality. Torso trauma was the primary cause of death in only three children. Adolescent injury patterns were similar to those of adults in the proportion of severe visceral disruption and incidence of fatal torso trauma. Immediate laparotomy was employed almost twice as commonly in adults as in adolescents. The 64 per cent of adolescents who did not undergo laparotomy had a lower mortality than those who did. Conversely, the 36 per cent of adults without exploration had a significantly higher mortality, which usually occurred before laparotomy could be initiated. Increasing hepatic injury severity brought increasing mortality; however, the cause of death differed with age. Although the incidence of severe liver injury did not differ between adolescents and adults, management and outcome did. These data indicate that individualized management based on overall patient status remains the best approach to care of these injuries.

Comparison of the kidney dose between supine and prone position for pelvic and periaortic irradiation

We compared the doses received by the kidney in supine and prone positions for pelvic and periaortic irradiation. Kidney locations were verified by CT images taken with patients in the same position as during the treatment. Due to the shift of the kidney anteriorly during prone position, treatment in supine position delivered a much lower dose to most of the kidney than treatment in the prone position. Therefore, for periaortic irradiation treatment, the supine position should be considered to minimize the dose to the kidneys, even though the prone position with a belly board can reduce the dose to the small bowel.

Familial presumed cerebral cavernous angiomas diagnosed by MRI: three generations

Familial cerebral cavernous angiomas are rare, with an autosomal dominant pattern of inheritance. To our knowledge, 25 families with this disorder have been described. We report three family members in a direct line of descent, who all brain had lesions typical of cavernous angiomas on MRI.

p53 expression and tumor proliferative activity in testicular germ-cell tumors

We evaluated p53 expression and tumor proliferative activity (TPA) using monoclonal antibodies to Ki-67 and proliferating cell nuclear antigen (PCNA) in 26 patients with seminomatous and nonseminomatous testicular germ-cell tumors (GCTs). Correlation between p53 expression and TPA, as well as the clinical correlation with the expression of these proteins were also assessed. There were eight cases of pure seminoma and 18 cases of nonseminomatous GCTs, collectively consisting of 45 tumors or tumor components. The nonseminomatous GCTs were mixed or pure and included choriocarcinoma (CC), embryonal carcinoma (EC), immature teratoma (IMT), mature teratoma (MT), seminoma, and yolk sac tumor (YST). The ages of the patients with seminomatous GCTs ranged from 24 to 47 years (mean, 34 years) and those for patients with nonseminomatous GCTs ranged from 17 to 43 years (mean, 29 years). Sixteen (44%) of the 36 nonseminomatous GCTs or tumor components were positive for p53 protein. Ten (91%) of eleven ECs, three (38%) of eight YSTs, two (20%) of ten MTs, and the single case of CC were positive for p53 protein. All nine seminomas and three of six IMTs were only focally positive for p53 protein. The p53 expression in ECs and YSTs was significantly higher than that in IMTs, MTs, and seminomas (P=0.0001). TPA was present in the majority of the seminomatous and nonseminomatous GCTs, and was significantly higher in ECs and YSTs than in seminomas, MTs, and IMTs (Ki-67, P=0.0001; PCNA, P=0.0006). In the majority of the cases PCNA expression was higher than Ki-67 expression (P=0.0001). The mean TPA percentage was significantly higher in the p53-positive tumors or tumor components (EC and YST) when compared with the mean TPA percentage in those neoplasms that were focally positive or negative for p53 protein (Ki-67, P=0.003; PCNA, P=0.046). p53 expression was also associated with histologically aggressive tumors (ECs and YSTs) that also exhibit high TPA. No relationship appears to exist between the three tumor markers and the clinical stage or the patients' follow-up and outcome in this small series. Further studies are necessary to elucidate the roles of p53 and proliferation markers in testicular tumorigenesis and as prognostic markers.

Enhanced E-cadherin expression and increased calcium-dependent cell-cell adhesion in human T-cell leukemia virus type I Tax-expressing PC12 cells

Human T-cell leukemia virus type I (HTLV-I) Tax protein induces the expression of host cellular genes, some of which are crucial in cell proliferation and differentiation. We examined the mechanisms by which HTLV-I Tax protein induces phenotypic changes in PC12 cells. We demonstrated that the HTLV-I Tax gene induces epithelioid changes and increases cell-cell contact in PC12 cells. No change in the expression of the neural cell adhesion molecule was observed between HTLV-I Tax-expressing PC12 cells and PC12 cells transfected with a control plasmid. However, HTLV-I Tax-expressing PC12 cells demonstrated a marked change in the abundance and distribution of E-cadherin, which was concentrated at regions of cellular contact and accompanied by changes in calcium-dependent cell adhesion. Although E-cadherin is expressed at low levels in PC12 and PC12 transfected with a control plasmid cells, the steady state level of E-cadherin in tax-expressing PC12 cells increases significantly, apparently as a result of regulation at the transcriptional level. Diminished expression of Tax protein in Tax-expressing PC12 cells exposed to antisense oligonucleotides for the Tax gene suppresses E-cadherin expression and decreases cell-cell adhesion. These findings imply that HTLV-I Tax protein enhanced E-cadherin expression modulates calcium-dependent cell-cell adhesion mechanisms.

[Superior septal approach for mitral valve surgery]

The superior septal approach (SSA) for mitral valve surgery is a useful approach, but it may bring about demage to sinus node function or an atrial electrical vulnerable condition because the sinus node artery is divided and a large portion of both atria is incised. From April 1992 to December 1994, we used this approach in 17 patients. There was no hospital death and none had perioperative complications associated with the approach. All nine patients in sinus rhythm preoperatively returned to sinus rhythm before discharge from the hospital and remained so at late follow-up. Five of 9 patients with sinus rhythm had electrophysiological examination preoperatively and all 9 patients had the examination postoperatively. Atrial vulnerability was not deteriorated after the operation in all cases. Under pharmacologic autonomic blockade, sinoatrial conduction time (SACT), sinus node recovery time (SNRT) after overdrive atrial pacing, and corrected SNRT were 73 +/- 35 msec, 1142 +/- 168 msec, and 365 +/- 122 msec, respectively. All these values were with in normal range and these were no significant differences between before and after the operation. All patients with sinus rhythm had 3 minutes of Bruce stage 1 exercise 9 months after the operation. The heart rate response to the exercise was as good as in healthy control people. In conclusion, as far as the midterm postoperative period, the effect of SSA on sinus node function and atrial vulnerability was acceptable.

Thrombin receptor-mediated synovial proliferation in patients with rheumatoid arthritis

Synovial cell proliferation is one of the pathological bases of rheumatoid arthritis (RA). Several cytokines including IL-1 and IL-6 and growth factors have been shown to be involved in the synovial cell proliferation in RA. Thrombin is a multifunctional protease and acts as a mitogen for several cell types through its specific receptor. To assess whether thrombin is involved in overproliferation of rheumatoid synovial cells, we measured the concentration of thrombin-anti-thrombin III (ATIII) complex (TAT) in synovial fluid obtained from patients with RA or osteoarthritis (OA). We also examined the effect of thrombin or thrombin receptor agonist peptide (TRAP) on cell growth of synovial cell clones (SCCs) established from an RA patient. The concentrations of TAT in the synovial fluid from patients with RA were significantly higher than in those with OA. Moreover, both thrombin and TRAP enhanced proliferation of synovial cells in vitro. We also characterized the expression of thrombin receptor mRNA by reverse transcription-PCR. The expression of mRNA for thrombin receptor was up-regulated by thrombin or TRAP stimulation. Thrombin receptor antigen was also detected on both SCCs and synovial tissue from RA patients by immunostaining using a monoclonal antibody against thrombin receptor. These findings indicate that thrombin may act as a mitogen for synovial cells through thrombin receptor and may play some role in synovial overproliferation and remodeling in RA.

Histologic characteristics of residual renal-cell carcinoma following interferon-alpha-based therapy - correlation with clinical-parameters

To compare the histologic characteristics of residual renal cell carcinoma (RCC) following an interferon-alpha (IFN-alpha)-based therapy with clinical parameters, we examined 12 metastatic and 6 primary kidney tumors resected from 18 patients with advanced RCC. The histologic parameters including tumor necrosis, nuclear grade, inflammatory response and hemosiderin deposition were assessed. The immunophenotypes of tumorinfiltrating lymphocytes (TILs) were also characterized. The tumors of the 12 patients who had partial clinical response (responders) showed more tumor necrosis than the tumors of the 6 non-responders (patients with minor response or stable disease) (p = 0.0061). A tendency of longer overall survival was observed in the group with tumor necrosis compared to the group without necrosis. Predominance of T-cell TIL was demonstrated in all 9 responders compared to 3 non-responders (p = 0.053). Our findings suggest that tumor necrosis and a high percentage of T-cell TILs in residual RCC may be associated with favorable clinical response following IFN-alpha-based therapy.

Kissing aneurysms of distal anterior cerebral arteries demonstrated by magnetic resonance angiography

BACKGROUND Multiple aneurysms, associated with distal anterior cerebral artery (ACA) aneurysm, are not rare; therefore, it is important to examine multiplicity of the aneurysms preoperatively. CASE REPORT A case of ruptured distal ACA aneurysm, associated with another one in a mirror position, is reported. A 43-year-old woman suffered subarachnoid hemorrhage. Conventional angiography demonstrated a saccular aneurysm on the bifurcation of the right or left distal ACA; however, magnetic resonance angiography (MRA) revealed two mirror-image aneurysms on both bifurcations. CONCLUSION MRA was useful for preoperative diagnosis of kissing aneurysms on distal ACAs.

["Disproportionately large, communicating fourth ventricle" due to membranous obstruction of Magendie's foramen]

A case of disproportionately large, communicating fourth ventricle (DLCFV) with the entire ventricular system dilated symmetrically due to membranous obstruction of Magendie's foramen is reported. A 20-year-old female complained of headache and nausea. Slight papilledema was found in both eyes. CT scan and MRI showed that the entire ventricular system was dilated symmetrically, but we could not locate the cause of this disease, for example, tumor, arachnoid cyst, cerebellar malformation and so on. Although cinemode-MRI showed CSF pulsation as if CSF flowed through Magendie's foramen, we were not convinced that CSF flowed through it. We speculated that something obstructed CSF flow at Magendie's or Luschka's foramen, so surgery was performed by suboccipital craniectomy. As expected, a membranous obstruction was found at Magendie's foramen. After excision of the membrane, all symptoms improved. Postoperative cinemode-MRI clearly demonstrated CSF flow through Magendie's foramen. Ventriculoperitoneal shunting is generally effective for DLCFV, but we do not consider it the optimal treatment. The cause of DLCFV must be confirmed by suboccipital craniectomy if evidence of NPH, mass lesion or cerebellar malformation cannot be found anywhere especially around Magendie's foramen.

Disappearance of arachnoid cysts after head injury

The mechanism of the disappearance of arachnoid cysts is not fully understood. This article discusses the spontaneous disappearance of these cysts after head injury. Five patients underwent computed tomography and were diagnosed as having a subdural hematoma or effusion associated with arachnoid cysts. In four of the five patients, the cyst decreased in size or disappeared. These cases suggest a possible mechanism by which this type of cyst associated with subdural hematoma or effusion might disappear. For the arachnoid cyst to disappear, the rupture of the cyst wall appears to be essential, and after rupture, subdural effusion must develop around the cyst. As this effusion is absorbed, the fluid in the cyst drains away, after which the cyst becomes smaller and gradually disappears. This hypothesis supports the possibility of a "natural cure" for arachnoid cysts without surgical intervention.

[A case of subarachnoid hemorrhage with acute subdural hematoma due to head injury: a case report]

Acute intracranial hemorrhages can be caused by cerebrovascular disease or head injury. Diagnostic imaging is in both cases sometimes similar, so it is difficult to make an exact diagnosis. We report a case of acute subdural hematoma due to head injury after loss of consciousness due to an aneurysmal rupture. A 52-year-old male was found out fallen on the floor in a state of unconsciousness and was brought to the nearest hospital. CT scan showed subarachnoid hemorrhage with left acute subdural hematoma and he was transported to our hospital. Angiography revealed a left MCA aneurysm. The next day, a clipping operation was performed but brain contusion was observed in the left frontal lobe. Postoperative CT scan showed contusional hematoma at the left frontal lobe and plain skull X-ray films demonstrated a diastatic fracture of the right lambdoid suture. Acute subdural hematoma due to the rupture of a cerebral aneurysm is sometimes recognized, but the first CT findings are similar to those observed after head injury. When the clinical course of onset is unclear, we must keep in mind that the cause of acute subdural hematoma may be head injury, even if angiography demonstrates abnormal vessels.

[A case report of surgical repair for distal aortic arch aneurysm with abdominal aortic aneurysm]

A 77-year-old female was referred to our hospital with hoarseness and an abnormal shadow on her chest X ray film. Computed tomography and aortography revealed aneurysms of the distal aortic arch and the infrarenal abdominal aorta. Total aortic arch replacement was performed successfully on the patient, utilizing hypothermic selective cerebral perfusion. The operation employed three technical characteristics for avoidance of cerebral complication. Those were as follows: First, total aortic arch replacement was performed instead of distal aortic arch replacement because of severe sclerosis of the proximal aortic arch. Secondly, to prevent cerebral embolism due to the thrombi on the wall of the abdominal aortic aneurysm, an arterial cannula for cardiopulmonary bypass was inserted in the ascending aorta initially and after completion of the distal anastomosis, it was placed on the graft. Thirdly, the so called "non clamping technique" operation was employed because clamping onto the sclerotic arteries might have caused cerebral embolism. There was no cerebral complication and the postoperative course was satisfactory.

[beta]-Glucan Synthesis in the Cotton Fiber (IV. In Vitro Assembly of the Cellulose I Allomorph)

In vitro assembly of cellulose from plasma membrane extracts of the cotton (Gossypium hirsutum) fiber was enriched by a combination of 3-(N-morpholino)propanesulfonic acid extraction buffer and two independent digitonin solubilization steps consisting of 0.05% digitonin (SE1) followed by 1% digitonin (SE2). Glucan synthase activity assays revealed that, although the SE2 fraction possessed higher activity, only 8.6% of the in vitro product survived acetic/nitric acid treatment. On the other hand, the SE1 fraction was less active, but 32.1% of the total glucan in vitro product was resistant to acetic/nitric acid. In vitro products synthesized from the SE1 fraction contained [beta]-1,3-glucan and fibrillar cellulose I, whereas the SE2 fraction produced [beta]-1,3-glucan and cellulose II. Both celluloses assembled in vitro were labeled with cellobiohydrolase I-gold complex, and the electron diffraction patterns of both products from SE1 and SE2 revealed cellulose I and cellulose II, respectively. Contamination of native cellulose was ruled out by extensive evidence from autoradiography of the ethanol-insoluble and acetic/nitric acid-insoluble materials, including three different controls.

Involvement of NF-kappa B activation in thrombin-induced human vascular smooth muscle cell proliferation

A thrombin receptor has been cloned and is thought to mediate a variety of thrombin-induced responses. However, the transcription factors important for postreceptor signaling have been little clarified. The post-receptor signals are mediated by several protein kinases responsible for NF-kappa B activation, and most thrombin-inducible genes have the kappa B sequence in the regulatory elements. The possibility that NF-kappa B may participate in thrombin signaling was therefore investigated in cultured human vascular smooth muscle cells (VSMCs). Thrombin receptor stimulation resulted in activation of NF-kappa B. Furthermore, treatment of cells with antisense p65 ODNs of NF-kappa B inhibited thrombin-stimulated growth of VSMC in vitro. Results indicate that the activation of NF-kappa B is involved in thrombin signaling and that this pathway causes the proliferation of VSMC induced by thrombin. Therapeutic potential of antisense NF-kappa B ODNs for the treatment with atherosclerosis and restenosis is also indicated.

E5510 antagonizes thrombin receptor signals by inhibiting NF-kappa B activation

We have recently demonstrated that NF-kappa B is involved in a thrombin-signaling and that the antisense oligodeoxynucleotides (ODNs) of NF-kappa B has a marked inhibitory effect on thrombin-induced cellular responses. In this study, we demonstrate that E5510 (4-cyano-5,5-bis(methoxyphenyl)-4-pentenoic acid), a compound with anti-platelet activity preferentially inhibits the thrombin-inducible NF-kappa B activation and then antagonizes the following thrombin-induced cellular responses, proliferation and cytokines production in vascular smooth muscle cell, and the adherency of differentiated HL-60 cells. These data suggest that E5510 is an anti-atherosclerotic or anti-restenotic drug induced by thrombin.

[A case report of the maze procedure with mitral valve replacement]

The maze procedure was performed simultaneously with mitral valve replacement for atrial fibrillation and mitral stenosis in a 66-year-old female. On the first postoperative day, the cardiac status deteriorated suddenly due to a very rapid heartbeat which was later diagnosed as a 1:1 AV conduction of atrial flutter. The atrial flutter responded to an injection of verapamil and changed to a 2:1 conduction. Although atrial flutter had continued until the thirteenth postoperative day, the heart achieved sinus rhythm on that day. Since then it has continued without any antiarrhythmic drugs except digitalis. It was difficult to make a diagnosis of the rapid heartbeat on the 12-lead ECG because P waves could not be seen clearly on the ECG. Recording the electrical cardiac status by using the temporal atrial pacing leads, which were placed during the operation, was helpful in diagnosing the heartbeat as atrial flutter. The electrophysiological examination eight weeks after the operation revealed that the sinus node function was normal and atrial flutter or atrial fibrillation could not be induced. The patient is well and in sinus rhythm 12 months after the operation.

Analysis by somatic-cell fusion of the phenotypic properties of a mutant embryonal carcinoma cell-line

We have previously reported the isolation of an embryonal carcinoma (EC) cell mutant created via retroviral insertion (1). The mutant (NR1-6) is aberrant in respect to morphology, tumorigenicity and response to retinoic acid (RA). In order to determine the dominance/recessive hierarchy and genetic relationships of these phenotypes, we created hybrid lines from mutant and parental cells. Three hybrid clones (Hyb 1, 2a and 2b), which retain both mutant and parental loci, were analyzed. Our results indicate that in all parameters - morphology, adhesion, qualitative and quantitative response to RA and tumorigenicity - the hybrids behave similarly to parental cells. In no case did any of the hybrid lines exhibit a mutant phenotype. The data indicate that the phenotypes we have studied are genetically interrelated and that the parental characteristics are dominant.

[One-staged operation for funnel chest, mitral regurgitation and annulo-aortic ectasia associated of Marfan's syndrome]

One-staged operation was successfully performed in a 23-year-old female with funnel chest, mitral regurgitation and annulo aortic ectasia secondary to Marfan's syndrome. A midline skin incision was made and the sternum and costal cartilages were mobilized for sternal turnover with rectus muscles pedicle. This procedure offered an excellent operative field, even though the heart and aneurysmal ascending aorta were displaced into the left hemithorax. The combined superior-transseptal approach to the left atrium was used to perform mitral valve replacement. This approach also provided an excellent exposure of the mitral valve. Cabrol's operation was done for annulo aortic ectasia. Our concepts for the operation of open heart surgery complicated with severe funnel chest were discussed.

[Purification of pig adrenal 3 beta-hydroxysteroid dehydrogenase/isomerase and influence on microsomal membrane destruction on its enzyme activity]

A 3 beta-hydroxysteroid dehydrogenase/delta 4-delta 5-isomerase (3 beta-HSD/isomerase) has been purified to homogeneity from the pig adrenal microsomes by solubilization with sodium cholate, followed by some conventional column chromatographies. The molecular weight of the enzyme was estimated to be 42000 by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The Km value for pregnenolone as the substrate of the purified enzyme was higher than that of the microsomal enzyme. The purified enzyme was less stable for heat treatment than the microsomal binding enzyme. The microsomal enzyme was treated with various agents or enzymes which destroyed the membrane structure. Lipid peroxidation with Fe2+, digestion with phospholipase A2 or C, and the addition of various free fatty acids, imidazole containing compounds and polymyxin B were utilized for the membrane destruction. Consequently, the 3 beta-HSD/isomerase activity was significantly reduced in all cases, and the Km value of the 3 beta-HSD/isomerase for pregnenolone increased. And the Vmax and Vmax/Km values significantly decreased. Therefore, it is strongly suggested that the normal membrane structure plays an important role in the maintenance of the 3 beta-HSD/isomerase activity.

[Surgical treatment with aortic valve homograft harvested from heart transplant recipients or donors]

From March 1988 to November 1991, 24 patients underwent aortic valve replacement or aortic root replacement with an aortic homograft harvested from a heart transplant recipient or donor that was not suitable for heart transplantation. Those patients were followed from 2 to 34 months (mean 12.6 months). The mean age was 44 years (range 19 to 77 years). The main lesion was aortic stenosis in 8 patients, aortic regurgitation in eight, mixed lesion in eight, annulo-aortic ectasia in two, active prosthetic valve endocarditis in two, and recurrent LVOTO in one. Cardiac status before operation was NYHA class II in one patient, III in nineteen, IV in four. Aortic valve replacement was performed in 17 patients, and aortic root replacement in seven. There was no early or late death. No structural deterioration was found. Surgical technical error resulted in moderate aortic regurgitation in one patient and mild paravalvular leak in another patient immediately after operation. All patients except one were not given anticoagulants postoperatively, but the entire group was free from thromboembolism. All patients returned to NYHA class I. Most homografts in this series were cryopreserved without antibiotic sterilization immediately after harvest, but homograft valve endocarditis did not occur. The results in this series suggested that homografts from heart transplant recipients or donors were encouraging, but more long-term follow-up was required to be determined whether homografts from heart transplant recipients without antibiotic sterilization were superior to homografts prepared in ordinary manner.

[A case of mitral regurgitation treated by combined superior transseptal approach and electrophysiological examination of the sinus node function]

A 67-year-old man with mitral regurgitation underwent mitral valvoplasty and annuloplasty successfully. Combined superior transseptal approach was adopted to expose the mitral valve, because the left atrium was small. The exposure of the mitral valve was excellent. But this approach cannot avoid damaging the sinus node artery, so that why the sinus node function was examined electrophysiologically before and after the operation. Sino-atrial conduction time (SACT) and corrected sinus node recovery time (CSRT) were measured as the indices of the sinus node function. Both SNCT and CSRT after the operation was within normal range. As far as this case, combined superior transseptal approach, which gave good exposure of the mitral valve but needed to cut the sinus node artery, did not deteriorate the sinus node function.

[Three cases of aortic root replacement by cryopreserved homograft with effective usage of its anterior mitral leaflet]

Homograft aortic root replacement was done to three patients and the anterior mitral leaflet of the homograft was used with success in all cases. Case 1. A 37-year-old man had late-onset active prosthetic valve endocarditis with a fistula from the aortic annulus to the left atrium. The fistula was closed by using a homograft anterior mitral leaflet and the aortic root was replaced by a homograft with reimplantation of the coronary arteries. He is very well without evidence of recurrent endocarditis 29 months after the operation. Case 2. A 37-year-old man had early-onset active prosthetic valve endocarditis and developed the same fistula as case 1. He was treated successfully as in case 1. He is very well 4 months after the operation. Case 3. A 50-year-old woman, who had undergone aortic commissurotomy due to aortic valvular stenosis fifteen years before, deteriorated again. She had subvalvular membranous stenosis and a small aortic annulus. Konno-Soma procedure was applied to enlarge the annulus and the aortic root was replaced by a homograft. The interventricular septal incision was closed successfully with use of the anterior mitral leaflet of the homograft. Homograft aortic root replacement was an attractive procedure for prosthetic valve endocarditis or a small aortic annulus, and the homograft anterior mitral leaflet was useful for closing the fistula due to the infection and for closing the interventricular septal incision of Konno-Soma procedure.