[Myelofibrosis complicated by T-cell lymphoma followed by leukemic transformation]

A 37-year-old man was admitted because of pancytopenia with leukoerythroblastosis and anisocytosis in January 1986. Bone marrow aspiration resulted in a dry tap and biopsy showed marked myelofibrosis. Three months after admission, generalized lymph node swelling and multiple skin tumors were recognized. A biopsied lymph node revealed lymphoblastic lymphoma. The surface markers of lymphoma cells showed an immature T-cell phenotype, whereas T-cell receptor beta and gamma chain genes showed germ line configuration. The patient was treated with combination chemotherapy in June 1986. A month later, he developed leukemic transformation with features of acute myelocytic leukemia and he died of pneumonia. Autopsy disclosed extramedullary hematopoiesis in the liver and spleen. Primary myelofibrosis complicated by T-cell lymphoma is extremely rare.

Spontaneous resolution of an acute spontaneous spinal epidural hematoma without neurological deficits

A 46-year-old woman presented with sudden severe pain in the interscapular region. Physical examination, including detailed neurological evaluation, did not disclose any abnormalities. However, magnetic resonance imaging revealed an epidural hematoma anterior to the thoracic spinal cord and its spontaneous resolution thirty days after onset. Her hospital course was uneventful. To our knowledge, this report documents the first case of a spontaneous spinal spidural hematoma without neurological deficits. Spinal epidural hematoma may be more common than previously thought because some cases have probably been misdiagnosed as transient back pain of unknown etiology.

Long-term prognosis after thrombolytic therapy for acute myocardial infarction

In order to clarify the relationship between the patency of the infarcted arteries and subsequent long-term prognosis after thrombolytic therapy, we evaluated 116 patients with acute myocardial infarction treated with intracoronary (112 patients) or intravenous (four patients) urokinase. Patients treated with angioplasty after thrombolysis were excluded. The infarcted vessel was recanalized in 52 patients (patent group) and was not in the remaining 64 patients (occluded group). Five-year and 8-year follow up was conducted in 91% and 81% of the patients, respectively. The 1-, 5- and 8-year survival rate for the patent and occluded group was 91.8 and 80.9%, 80.8 and 79.2%, and 75.9 and 75.6%, respectively. The survival rate in the patent group tended to be higher than that in the occluded group up to 4 years. However, after 5 years, both groups showed similar survival rates. Therefore, reopening of the infarcted arteries with thrombolysis was not an independent predictor for late cardiac death (Cox regression analysis).

Serum hyaluronate predicts response to interferon-alpha therapy in patients with chronic hepatitis C

BACKGROUND/AIMS

The response to interferon therapy for chronic hepatitis is known to decrease with progression of the hepatic fibrosis. On the other hand, serum hyaluronate reflects hepatic sinusoidal capillarization or liver cirrhosis, and also serum type IV collagen, which is one of the main components of the basement membrane, rises with the progression of hepatic fibrosis. In this study, the relationship between the degree of hepatic fibrosis and the response to interferon-alpha was determined retrospectively in patients with chronic hepatitis C. In addition, whether the measurement of serum hyaluronate and type IV collagen before interferon-alpha therapy was useful for predicting the response to interferon-alpha therapy in chronic hepatitis C was determined.

MATERIALS AND METHODS

Thirty-seven patients with elevated serum ALT levels for at least 6 months and histologically determined chronic hepatitis were studied. All patients were positive for anti-HCV and negative for hepatitis B surface antigen. Twenty-eight healthy adults with normal blood biochemical data, who were negative for hepatitis B antigen and HCV antibody tests, had limited alcohol intake were used as controls. The test group was given IFN-alpha by intramuscular injection for 14 days, and then were treated 3 times per week for 24 weeks.

RESULTS

The extent of hepatic fibrosis, particularly, perisinusoidal fibrosis (P < 0.01) was significantly greater in nonresponders than in responders. The mean serum hyaluronate and type IV collagen levels were more elevated in nonresponders than in responders, especially, the serum hyaluronate level showed a significant difference (P < 0.01). Most of the patients having a serum hyaluronate level of more than 100 ng/ml were nonresponders who had chronic active hepatitis with bridging necrosis on liver biopsy. Serum hyaluronate and type IV collagen levels showed significant positive correlation with degree of the portal fibrosis (P < 0.01), perisinusoidal fibrosis (P < 0.001) and focal necrosis (P < 0.01) in histological findings of liver biopsy specimens.

CONCLUSION

These results suggest that serum hyaluronate and type IV collagen levels reflect the extent of the hepatic fibrosis in chronic hepatitis C and also that serum hyaluronate level predicts the response to interferon-alpha therapy in patients with chronic hepatitis C.

Percutaneous transvenous mitral commissurotomy for mitral stenosis patients with markedly severe mitral valve deformity: immediate results and long-term clinical outcome

In conclusion, to evaluate the efficacy and safety of PTMC for mitral stenosis patients with markedly severe valve deformity, we performed PTMC in 17 patients with severe mitral stenosis assessed by echocardiography (echo score > or = 12). This study demonstrates that PTMC can be performed safely and is clinically useful in treating the mitral stenosis patient with a markedly severe valve deformity.

[Acute promyelocytic leukemia following ulcerative colitis]

We report a case of acute promyelocytic leukemia (APL) following ulcerative colitis (UC). A 23-year-old man was diagnosed as UC in January 1991 and had been treated with salazosulfapyridine and prednisolone with good effect. In September 1993, he developed bleeding tendency and a diagnosis of APL with disseminated intravascular coagulation was made based on the results of bone marrow aspiration and coagulation profile. Complete remission was achieved with All-trans retinoic acid together with combined chemotherapy. He died of sepsis during consolidation chemotherapy in December 1993. Autopsy revealed no recurrence of UC.

[Operative procedures for mitral prolapse and its clinical results]

Mitral valve plasty is the very important procedure for treatment of mitral regurgitation from the view point of post operative quality of life because patients may be possible to be free from postoperative drug therapy especially when the normal sinus rhythm is restored even if the concomitant maze procedure is necessary. In this report, 36 patients who underwent mitral valve plasty for mitral regurgitation were evaluated. In 18 patients who had posterior leaflet prolapse, McGoon's procedure was performed. Two of them required secondary mitral valve replacement 4 days after operation. Reoperation disclosed tissue detachment at the mitral annulus sutures which were not reinforced by a ring. It was considered that annular ring plasty is preferable after resection of prolapsed posterior leaflet by McGoon's procedure. Out of 18 patients who had mitral valve prolapse including anterior leaflet, 8 patients underwent such conventional procedures as transfer of chordae tendinae, leaflet resection and shortening of chordae. Four patients resulted in second look mitral valve replacement 11 days to 1 month after mitral valve plasty. On the contrary, the clinical results of repair of chordae tendineae with artificial chordae of extended polytetrafluoroethylene (ePTFE) were good. It is concluded that the resection of prolapsed leaflet and reconstruction of the annulus with reinforcement using a prosthetic ring is preferable for the posterior leaflet prolapse. For the anterior leaflet prolapse, good results can be obtained by replacement of chordae tendineae with ePTFE sutures.

Acute myelomonocytic leukemia in a patient with multiple myeloma: evidence for different clonal origin

A case of 77-year-old female with multiple myeloma (IgG-k) developed acute myelomonocytic leukemia (AMMoL) following a myelodysplastic stage after chemotherapy with melphalancyclophosphamide combinations for 6 years. The leukemic blast cells expressed both myeloid antigens (CD11b, CD13, CD14, CD15, CD33 and CD34) and T/B lymphoid antigens (CD2, CD4, CD22 and PCA1). Cytogenetic analysis revealed a chromosome deletion -7. Analysis of immunoglobulin genes showed the heavy chain genes in germ line configuration. These findings indicate that the AMMoL was a therapy-related stem cell leukemia and was a clonal origin genetically different from multiple myeloma irrespective of plasma cell phenotype.

Decreased protein C inhibitor after percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction

Plasma thrombin-antithrombin III complex (TAT), FDP-D-dimer, activated protein C (APC)-protein C inhibitor (PCI) complex, and tissue type plasminogen activator (t-PA), PA inhibitor-1 (PAI-I) were significantly increased in patients with acute myocardial infarction (AMI) at onset. These patients exhibited a hypercoagulable state and protein C activation at onset. The plasma PCI level at onset of AMI was within the normal range, but was significantly decreased after percutaneous transluminal coronary angioplasty (PTCA). After PTCA, plasma t-PA, FDP-D-dimer, and plasmin-alpha 2-plasmin inhibitor were increased but APC-PCI complex and TAT were not. The decrease in PCI after PTCA may have been caused by the activation of fibrinolysis. PCI may play an important role in the inhibition of fibrinolysis in stimulated or damaged endothelial cells. These findings suggest that the protein C pathway plays an important role in the onset of AMI and after PTCA.

Modification of the circadian variation of symptom onset of acute myocardial infarction in diabetes mellitus

BACKGROUND

The effects of diabetes mellitus and its treatment on the circadian variation of symptom onset in acute myocardial infarction were examined.

METHODS

We obtained the time of symptom onset in 336 patients who had suffered acute myocardial infarction.

RESULTS

As in earlier studies, the peak of symptom onset occurred in the late morning, between 6:01 a.m. and 12:00 noon. Although a similar circadian variation was observed in non-diabetic patients, the late-morning peak was less prominent in diabetic patients. In diabetic patients receiving treatment, however, the circadian pattern was well preserved, whereas in untreated diabetic patients there were no peaks in the distribution of symptom onset of acute myocardial infarction.

CONCLUSION

These findings suggest that autonomic disturbances in diabetes mellitus may blunt the late-morning peak in the frequency of onset of acute myocardial infarction.

Effect of lipoproteins on tissue factor activity and PAI-II antigen in human monocytes and macrophages

Expression of the tissue factor (TF) and the plasminogen activator inhibitor-II were induced in cultured human monocytes-macrophages by incubation with lipoproteins. Very low-density lipoprotein (VLDL) augmented the TF and PAI-II expression the most, followed by low-density lipoprotein (LDL) and a very weak effect by high-density lipoprotein (HDL). In macrophages pre-cultured for 3 days, oxidized LDL augmented the expression of TF activity in the macrophages to a greater extent than native LDL. These findings indicate that lipoproteins affect both monocytes and macrophages, and that they induce a hypercoagulable-hypofibrinolytic state. Thus hyperlipidemia may be a direct risk factor for thrombotic disease.

Characteristics of human hepatocellular carcinoma cell lines (Hep-KANO) derived from a non-hepatitic, non-cirrhotic hepatitis B virus carrier

We have established two cell lines of hepatocellular carcinoma [Hep-KANO, clone 1 (CL-1) and clone 2 (CL-2)] from tissue obtained at autopsy of a hepatitis B virus (HBV) carrier without histological signs of hepatitis or liver cirrhosis. These cell lines differed considerably from each other in morphology, proliferation pattern, alpha-fetoprotein secretion, albumin synthesis, cytokine secretion, modal chromosome number and transplantability to nude mice. Histologic examinations also revealed differences between them. Amplification of N-myc, L-myc, H-ras, K-ras, N-ras, c-erb-B and c-erb-B-2 and rearrangement of p53 were not found in either of the cell lines. However, CL-1 and CL-2 showed an identical HBV-DNA integration pattern. A 4-fold amplification of c-myc was observed in CL-1, but not in CL-2. Hep-KANO cell lines, CL-1 and CL-2 may be useful in clarifying the question of whether hepatocarcinogenesis is directly caused by HBV infection.

The effects of using a leukocyte removal filter during cold blood cardioplegia

During myocardial ischemia, neutrophils and platelets exert negative effects on the myocardium. In this study, we used a leukocyte removal filter during cardioplegia, and investigated its effect on myocardial damage during reperfusion by measuring the plasma levels of granulocyte components, platelet components, and cardiac enzymes [creatinine phosphokinase (CK) and creatinine phosphokinase myocardial band (CK-MB)] in 24 patients who underwent cardiopulmonary bypass. The patients were divided into two groups of 12 according to whether or not a filter was placed in the cardioplegic route. Blood samples were drawn directly from the coronary sinus before aortic cross clamping, and at 1, 5, and 15 min after declamping. Group F, which had the filter, showed better cardiac enzyme and lipid peroxidation results than group N, which did not. The results of this study suggest that the application of a filter during cold blood cardioplegia may reduce myocardial damage.

Clinical and angiographic determinants of ventricular remodeling after acute myocardial infarction

BACKGROUND

Ventricular remodeling after acute myocardial infarction is a precursor of the development of overt heart failure and is an important indicator of mortality. However, clinical and angiographic determinants of ventricular remodeling have not been fully elucidated. The purpose of the present study was to evaluate the effects of long-standing preinfarction angina and the late reperfusion of the infarct-related coronary artery on ventricular remodeling and function.

METHODS

Coronary angiography and left ventricular cineangiography were performed 35 +/- 16 days after the onset of acute myocardial infarction in 80 patients with a relatively recent anterior Q-wave myocardial infarction who had received conventional therapy.

RESULTS

In patients with preinfarction angina that occurred more than 1 week before the onset of myocardial infarction, the left ventricular size and ejection fraction were better preserved than in those without preinfarction angina. On the other hand, the late reperfusion of the infarct-related coronary artery did not affect ventricular remodeling.

CONCLUSION

Our results indicate that the presence of residual flow to the infarct area through the collateral circulation, presumably developed by repetitive ischemic stimuli, appears to be a crucial determinant of subsequent left ventricular size and function in patients with acute myocardial infarction who have had conventional therapy.

Increased activated protein C-protein C inhibitor complex level in patients positive for lupus anticoagulant

Activated protein C (APC)-protein C inhibitor (PCI) complex and APC-alpha 1antitrypsin (alpha 1AT) complex levels were measured in 29 patients positive for lupus anticoagulant (LA). LA was considered positive if two of the following three criteria were fulfilled: (1) prolongation of the activated partial thromboplastin time, (2) prolongation of the kaolin clotting time (KCT) and KCT mixing test, and (3) prolongation of the dilute Russell's viper venom time (DRVVT) and DRVVT/DRVVT with high lipid concentration. Plasma thrombin-antithrombin III (AT-III) complex and plasmin-alpha 2-antiplasmin inhibitor complex levels in patients positive for LA were increased slightly, but not significantly, and FDP-D-dimer and t-PA levels were not markedly increased. Plasma PAI-1 level in the LA-positive patients was significantly increased compared with normal volunteers. AT-III activity, protein C antigen, PCI antigen, and protein S antigen levels in the LA-positive patients were virtually normal, while protein C activity was slightly, but not significantly, decreased. APC-PCI complex level was increased in all LA-positive patients, and was not detectable in patients with systemic lupus erythematosus and normal volunteers. APC-alpha 1AT complex was increased slightly, in only two LA-positive patients; it was not detectable in the other patients or in the normal volunteers. These findings suggest that patients positive for LA are in a hypercoagulable state and that protein C activity in such patients is decreased, due to the activation of this protein.

[Plasma level of various markers in patients with thrombotic thrombocytopenic purpura]

We examined various markers in 17 patients with thrombotic thrombocytopenic purpura (TTP), 13 with red cell fragmentation syndrome (RCFS) induced by mitomycin C, and 36 with RCFS caused by disseminated intravascular coagulation (DIC). A platelet activating factor and decrease of von Willebrand factor were frequently observed in patients with TTP, but were not in those with RCFS due to either mitomycin C or DIC. Since increased vascular endothelial cell markers and decreased MTT assay were observed in patients with TTP, it is considered that vascular endothelial cell injury is associated with patients with TTP. The increased plasma cytokines and the hypercoagulable and hypofibrinolytic state indicates that the vascular endothelial cell injury might be caused by microthrombus or activated immune system. Although patients with TTP were treated with plasma exchange, anti-platelet therapy, and high dose steroid therapy, the mortality was still high.

Quadruple cancers in a human T-cell leukemia virus type 1 carrier

Human T-cell leukemia virus type 1 (HTLV-1) infection is considered to contribute to the risk of malignancies other than adult T-cell leukemia. We report a 64-year-old male HTLV-1 carrier who developed quadruple malignancies such as cancer of the urinary bladder, skin, larynx and liver.

[A case underwent separate operation for AAE, AR and TAA using elephant trunk method]

A 20-year-old man with Marfan syndrome was recommended emergency operation for impending rupture of TAA. Because he was in the state of acute heart failure due to coexisting AAE and AR, so the simultaneous operations for AAE, AR and TAA were needed. He underwent Bentall, arch replacement and elephant trunk operation utilizing separate extracorporeal circulation and circulatory arrest. Chest CT, taken after 5 months postoperatively, revealed only a small amount of thrombus in TAA. Anticoagulation therapy stood in the way of aneurysmal thrombo-exclusion. The second operation, grafting of descending thoracic aorta, was performed 6 months later and elephant trunk made the second operation easier. Now 12 months passed after the second operation, he is in good health.

Antisense inhibition of myeloperoxidase increases the sensitivity of the HL-60 cell line to vincristine

Myeloperoxidase (MPO), a heme-peroxidase found in the HL-60 myeloblastic cell line, is involved in vincristine (VCR) metabolism and the inactivation of this drug. We have examined whether decreased MPO activity correlated with increased sensitivity to VCR toxicity in myeloid leukemia cells. We have used MPO antisense RNA to reduce 60% of the MPO activity in the HL-60 cells. The MPO-deficient HL-60 cell line, C15, was significantly more sensitive to VCR than the parental MPO-positive cell line. Both cell lines were negative for P170-glycoprotein expression. Conversely, an MPO-positive C15 subclone was more resistant to VCR than the MPO-deficient C15 cell line. No significant differences in cytotoxic effects were observed between MPO-positive and MPO-deficient cells, following treatment with either daunorubicin or actinomycin D, two multidrug resistance-related drugs. These results strongly support an important role for MPO in VCR resistance in HL-60 cells. Antisense manipulation of the MPO content of myeloid cells could be of potential interest in leukemia treatment.

[Experimental study of per-rectal portal scintigraphy using 99mTc-HM-PAO]

Usefulness of per-rectal portal scintigraphy by 123I-IMP has already been admitted. We assessed whether 99mTc-HM-PAO, another agent used for cerebral blood flow scintigraphy, could be utilized for scintigraphic evaluation of the portal system. Animal experiments were carried out to evaluate the usefulness of the examination. Shunt indices obtained from per-rectal portal scintigraphy by 123I-IMP and 99mTc-HM-PAO in shunt models and shunt rate obtained by direct injection of 99mTc-MAA into the inferior mesenteric vein under laparotomy were compared. Correlation coefficient of each agent with 99mTc-MAA was 0.90 for 99mTc-HM-PAO and 0.80 for 123I-IMP. It was also noted that as larger quantity of the tracer could be administrated in 99mTc-HM-PAO than in 123I-IMP, absorption from rectum was optimum and liver extraction fraction was 94.4%. Therefore, we concluded that 99mTc-HM-PAO was useful for per-rectal portal scintigraphy.

A case of myelodysplastic syndrome progressing to acute myelocytic leukemia in which adult-onset Still's disease had occurred 6 years before

A patient with adult-onset Still's disease who presented with myelodysplastic syndrome (MDS) after a course of 6 years is reported. To our knowledge, this is the first such reported case. The patient died of acute myelocytic leukemia. The possibility that cyclosporine contributed to the onset of MDS is discussed.

Treatment of disseminated intravascular coagulation with gabexate mesilate

Gabexate mesilate (FOY) was used to treat 215 patients with disseminated intravascular coagulation (DIC) and 146 patients with a predisposition to DIC (pre-DIC). Sixty percent of DIC patients and 48% of pre-DIC patients exhibited pretreatment organ failure, which resolved after FOY treatment in 16% of DIC patients and 17% of pre-DIC patients. Seventy percent of DIC patients and 49% of pre-DIC patients had a pretreatment bleeding tendency that was ameliorated by FOY treatment in 32% of DIC patients and 30% of pre-DIC patients. Comparison of pretreatment and posttreatment hemostatic studies of the DIC patients revealed that platelet count and levels of fibrinogen degradation products (FDP), thrombin-antithrombin-III complex, and FDP-D-dimer decreased significantly; fibrinogen level increased markedly; and prothrombin time was prolonged. DIC scores were significantly lowered in both leukemic and nonleukemic patients from the third day of treatment with FOY. Among leukemic DIC patients, 59% showed complete remission (CR), 21% partial remission (PR), and 7% exacerbation of their condition; 46% of the nonleukemic DIC patients demonstrated CR, 17% PR, and 17% exacerbation. Of the leukemic pre-DIC patients, 59% showed improvement and 7% exacerbation, whereas 55% of the nonleukemic pre-DIC patients showed improvement and 27% exacerbation.

Increased vascular endothelial cell markers in patients with disseminated intravascular coagulation

We examined vascular endothelial cell markers, thrombomodulin (TM), plasminogen activator inhibitor-I (PAI-I), tissue plasminogen activator (t-PA), and von Willebrand factor, in 80 patients with disseminated intravascular coagulation (DIC). The levels of thrombin-antithrombin III complex (TAT), plasmin-alpha 2 plasmin inhibitor complex (PIC) and FDP-D-dimer were significantly increased both before and after the onset of DIC, but were not correlated with organ failure or prognosis. However, the PIC/TAT ratio was lower in patients with poor prognosis than in those with good prognosis, and it was also lower in those with organ failure than in those without. Plasma TM, PAI-I, and t-PA levels were increased in DIC patients with organ failure or poor outcome, but were not significantly increased before the onset of DIC. We consider that the prognosis of patients with DIC might be related to organ failure or endothelial cell damage and that plasma levels of TM, PAI-I, and t-PA might be useful in the detection of these disorders and in assessing prognosis. A hypofibrinolytic state might enhance organ failure in patients with DIC.

Elevated plasma levels of vascular endothelial cell markers in patients with hypercholesterolemia

Hypercholesterolemia is associated with an increased incidence of vascular complications. To assess the actual degree of activation of coagulation systems and vascular disorders in hypercholesterolemia, plasma levels of vascular endothelial cell markers, such as thrombomodulin (TM), tissue-type plasminogen activator, plasminogen activator inhibitor-I (PAI-I), and von Willebrand factor, were measured in 51 patients with hypercholesterolemia. We also investigated the effects of Pravastatin, an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A reductase, on plasma lipid, lipoprotein a, and hemostatic markers. The mean plasma levels of thrombin-antithrombin III complex (TAT), fibrinopeptide A (FPA), TM, and PAI-I were significantly elevated in hypercholesterolemia. Of the hemostatic markers, only TM was significantly increased in patients with ischemic heart diseases (IHD). The mean concentration of total cholesterol and levels of TAT, FPA, PAI-I, and TM were significantly reduced after the Pravastatin treatment. The PIC/TAT ratio was significantly increased in non-IHD patients after treatment, this was not the case in IHD patients. These findings suggested the presence of a thrombogenic state and vascular endothelial cell disorders in hypercholesterolemia; such a state might well be related to hypofibrinolysis.

Increased levels of vascular endothelial cell markers in thrombotic thrombocytopenic purpura

We found that patients with thrombotic thrombocytopenic purpura (TTP) have significantly elevated plasma thrombin antithrombin III complex (TAT) and FDP-D-dimer levels, while the plasmin-alpha 2 plasmin inhibitor complex (PIC) level was only slightly increased. The tissue-type plasminogen activator (t-PA) level was increased, but it was well correlated with the plasminogen activator inhibitor-I (PAI-I) level. These findings suggest that hypercoagulable and hypofibrinolytic states coexist in these patients, in contrast to patients with disseminated intravascular coagulation, who exhibit coexisting hypercoagulable and hyperfibrinolytic states. Levels of vascular endothelial cell markers, such as PAI-I, thrombomodulin (TM), and t-PA, were increased at the onset of TTP, but the level of von Willebrand factor (vWF) antigen was not increased. The outcome in TTP patients was correlated with plasma t-PA and TM levels but not with TAT or PIC. These results suggest that vascular endothelial cell markers, such as TM and t-PA, are released from injured or stimulated endothelial cells, reflecting the degree of vascular endothelial damage, and that the main factor in the pathogenesis of TTP is vascular endothelial cell injury.

Serum hyaluronate reflects hepatic sinusoidal capillarization

BACKGROUND

Most of circulating hyaluronate has been commonly degraded by hepatic sinusoidal endothelial cells (SECs). In hepatic sinusoidal capillarization, SECs morphologically change and also seem to decrease hyaluronate degradation. This work expands on the relationship between serum hyaluronate levels and changes in hepatic SECs accompanying hepatic sinusoidal capillarization.

METHODS

Serum hyaluronate levels were determined using an enzyme binding assay system. Liver biopsy specimens were collected to examine basement-membrane formation, the localization of Weibel-Palade bodies, and the localization of factor VIII-related antigen (FVIIIRAg) in SECs.

RESULTS

Serum hyaluronate levels increased with the progression of liver disorder, being high in all patients with liver cirrhosis. Patients showing markedly high serum hyaluronate levels, 200 ng/mL or more, had liver cirrhosis involving the SECs, which showed basement-membrane formation, Weibel-Palade bodies, and FVIIIRAg and closely resembled vascular endothelial cells.

CONCLUSIONS

Measurement of the serum hyaluronate concentration allows the evaluation of morphological and functional changes that occur in SEC accompanying hepatic sinusoidal capillarization in various liver disorders. The findings also suggest that patients with high serum hyaluronate levels, 200 ng/mL or more, have liver cirrhosis with typical hepatic sinusoidal capillarization formed by SECs containing FVIIIRAg.

[A case report of redo Fontan operation]

A 21-year-old man, who had undergone Fontan operation for tricuspid atresia type 1b using 21 mm Hancock valved conduit 15 years ago, had right sided heart failure when his heart rhythm turned to atrial fibrillation. On cardiac catheterization, pressure data revealed that trans valved conduit pressure gradient reached to 5.2 mmHg. Chest CT and right atrial angiography showed right atrial wall thrombus. Right upper lobe perfusion defect was detected by lung perfusion scintigraphy. Then he was recommended redo Fontan operation. He underwent resection of stenosed valved conduit, right atrial thrombectomy and reconstruction of new route between right atrium and pulmonary artery with bovine pericardium. He tolerated well that operation and now 3 months passed, he resumed fairly vigorous physical activity.

Hemostatic study before onset of disseminated intravascular coagulation

Early diagnosis is necessary for the treatment of disseminated intravascular coagulation (DIC), but criteria for the stage preceding the diagnosis of DIC (pre-DIC) have not yet been established. To clarify hemostatic abnormalities that occur before the onset of DIC, we performed hemostatic studies in 117 patients within at least a week before the onset of DIC (pre-DIC), in 237 patients with DIC, and in 50 patients without DIC or pre-DIC (non-DIC). Levels of FDP, PT, and fibrinogen, and platelet counts were significantly abnormal after the onset of DIC, but not before. Thrombin-antithrombin III complex (TAT), plasmin-alpha 2 plasmin inhibitor complex (PIC), and FDP-D-dimer levels were significantly higher before the onset of DIC compared to the non-DIC patients. Hemostatic abnormalities were observed within a week before the onset of DIC. Monitoring the plasma levels of TAT, PIC, and FDP-D-dimer might be useful for the diagnosis of a pre-DIC condition.

[A case report underwent simultaneous CEA and CABG followed by FPB]

A case of 67-year-old man with stenoses of both carotid arteries, double vessel diseases of coronary arteries, and left superficial femoral artery obstruction, for which surgical treatments were performed, is herein reported. He was in HYHA class IV because of unstable angina pectoris and pain in the left leg and in the state of chronic renal and hepatic disorders which made his condition worse. Coronary angiography showed stenoses in the origin of the right coronary artery and in the proximal left anterior descending artery at the degrees of about 95% and 90%, respectively. Carotid arteriography revealed both internalcarotid artery stenoses over 90%. The left carotid endarteractomy was not indicated because of presence of obstructive lesions of intracranial arteries in the left side. He underwent simultaneous surgery for the coronary and carotid occlusive diseases. He gained consciousness at the post operative 1st day and underwent left femoroperoneal saphenous vein bypass at the post operative 2nd day. He is leading a normal life without angina pectoris, left intermittent claudication and neurological deficit and has been followed up for 9 months postoperatively.

Emergency coronary angioplasty for acute myocardial infarction: predictors of early occlusion of the infarct-related artery after balloon inflation

THE FACTORS RESPONSIBLE FOR EARLY OCCLUSION OF THE INFARCT VESSEL AFTER emergency percutaneous transluminal coronary angioplasty (PTCA) were retrospectively examined in 191 patients with acute myocardial infarction. During the 24-hour period after the initial balloon inflation, 47 patients (25%) had occlusion of the vessel (occlusion group), whereas 144 did not (nonocclusion group). The former patients immediately underwent repeat PTCA, which was successful in 37. Univariate correlates of early occlusion were a shorter time interval between the onset of symptoms and PTCA (3.5 +/- 2.2 vs 4.5 +/- 2.9 hours, p = 0.025), right coronary artery involvement (53% vs 30%, p = 0.015), prior thrombolytic therapy (49% vs 32%, p = 0.035), and undersized inflation (43% vs 17%, p < 0.001). With multivariate analysis the three independent predictors were undersized inflation (p < 0.001), right coronary artery involvement (p = 0.004), and a shorter time interval until PTCA (p = 0.011). Thus patients undergoing early PTCA and having right coronary artery involvement appear to be at greater risk of having early occlusion. Thrombolytic agents and undersized inflation may also play an important role in its development.

[Operative management of aortic arch aneurysm using selective cerebral perfusion]

Hypothermic circulatory arrest for aortic arch surgery can be tolerated for a limited period of time. To avoid this disadvantage, we used hypothermic cardiopulmonary bypass (CPB) with selective cerebral perfusion (SCP), in which the femoral artery, right axillary artery (RAA) and left common carotid artery (LCCA) were separately cannulated and perfused by individual pump heads. The pressures of bilateral superficial temporal arteries were monitored to maintain the cerebral perfusion pressure at 50 mmHg. The flow of RAA and LCCA was maintained at 5 ml/min/body weight kg, the pressure of each superficial temporal artery at 50 mmHg and the nasopharyngeal temperature at 20 degrees C. To perform the "open distal repair", the CPB was stopped while cerebral perfusion was maintained. Between 1986 and 1991, 20 patients were operated on with this method. Mean duration of SCP was 169 minutes (73 to 210), and mean duration of CPB was 290 minutes (136 to 472). There was no intraoperative death. Operative mortality rate within 30 days after surgery was 10% (2/20). Neurological sequelae occurred in one patient with emergency operation for acute aortic dissection, into LCC of whom we had trouble in inserting a cannula. It was considered that SCP could be performed for at least 2 hours with the results of good cerebral protection.

Plasminogen activators and their inhibitors in leukemic cell homogenates

Plasminogen activator (PA) and PA inhibitor (PAI) were measured in homogenates of leukemia cells. Both PA and PAI levels were higher in non-lymphoblastic leukemia than in lymphoblastic leukemia. The levels were below the sensitivity of determination in chronic myelocytic leukemia (CML) but showed significant increases in blast crisis (CML,bc). The level of the tissue type PA (t-PA) antigen was highest in acute myeloblastic leukemia (AML) and that of the urokinase type PA (u-PA) was highest in acute promyelocytic leukemia (APL). The PAI-I antigen showed no marked cell specificity, but the PAI-II antigen was markedly increased in myelomonocytic leukemia and acute monocytic leukemia (AMoL). From these findings, various PAs and PAIs are considered to be present in leukemia cells and to be involved in hemostatic disorders, thus they are of diagnostic value in leukemia.

[Cyclosporine therapy of adult onset Still's disease with disseminated intravascular coagulation]

In April, 1991, a 61-year-old man was admitted to our hospital because of pancytopenia and disseminated intravascular coagulation (DIC). Five years prior to admission he had developed high fever, skin eruption and arthralgia which had been improved by antibiotics, but recurred. Steroid therapy was ineffective for pancytopenia and DIC. Laboratory findings were as follows: RBC count, 274 x 10(4)/microliters; WBC count, 470/microliters; Platelets, 6.4 x 10(4)/microliters; fibrinogen, 153mg/dl; FDP, 67.0 micrograms/ml; FDP-D.Dimer, 13040ng/ml; thrombin-antithrombin complex, > 60.0ng/ml; and plasmin alpha 2-plasmin inhibitor complex, 10.3 micrograms/ml. As we suspected adult onset Still's disease on the basis of clinical course, we treated him with methylprednisolone pulse therapy, which was, however, ineffective. leukocytopenia, thrombocytopenia and DIC improved after cyclosporine treatment. Since cyclosporine is known to be very effective to autoimmune diseases, we speculate that in this patient immunological mechanism may be involve in the pathogenesis of DIC.

Coronary risk factors used to predict coronary artery disease by logistic regression analysis

Risk factor analysis in coronary artery disease was conducted in 303 patients who underwent coronary arteriography to identify associations between personal characteristics and the prevalence of coronary heart disease. Age, sex, obesity, smoking, alcohol intake, hypertension, diabetes mellitus, serum uric acid, total cholesterol, LDL- and HDL-cholesterol, triglyceride, and atherogenic indices were statistically analyzed. All 13 variables were first compared between patients with positive and negative ergonovine tests. Only total cholesterol was significantly different, while significant differences in age, sex, history of diabetes, total cholesterol, LDL- and HDL-cholesterol, triglyceride and atherosclerotic indices were observed between patients with and without organic coronary artery stenosis. A multivariate analysis was performed, and the resulting equation was tested using the remaining patients. Logistic analysis of all 13 variables identified 5 (age, sex, diabetes mellitus, LDL- and HDL-cholesterol) which accounted for the differences between patients with and without significant coronary artery disease and that were validated in the test group. The sensitivity for prediction of coronary artery disease was 75.8%, specificity 68.5%, and predictive accuracy 71.5% in the test group. Thus, risk factor analysis appears to be very valuable in screening subjects with high-risk organic coronary stenosis and in optimizing the preventive and therapeutic modalities, but not in predicting vasospastic subjects.

[Application of ultrasonography in chest diseases--usefulness of ultrasonography and physiologic evaluation of low pressure vascular system]

Air and bones, which limit echo penetration to the lesion, are the major components of the thorax. Recently, however, there have been many reports concerning the valid application of ultrasonography for evaluation of chest diseases. In this paper, we report the usefulness of ultrasonography to analyze thoracic lesions based on our experience. Generally, ultrasonography is a method providing high resolution and real-time images. Using these characteristics, we tried to obtain physiological information concerning the hemodynamics of the right heart system. We addressed the results of our studies using ultrasonography as follows; 1) relationship between ventilatory change of IVC and central venous pressure, 2) estimation of pulmonary arterial pressure by measuring the size of the pulmonary artery, 3) dynamic changes of SVC configuration.

Hypercoagulable state in patients with hypercholesterolemia: effects of pravastatin

Molecular markers of the coagulation system and the effects of pravastatin on lipid levels and the coagulation markers were studied in 48 patients (mean age, 55 years) with hypercholesterolemia (plasma total cholesterol levels > 280 mg/dl). Each patient received 10 mg of pravastatin daily for 3 months. Plasma total cholesterol and low-density lipoprotein cholesterol levels decreased significantly during treatment and high-density lipoprotein cholesterol levels increased significantly. Above-normal plasma levels of thrombin-antithrombin III complex, fibrinopeptide A, FDP-D-dimer, plasminogen activator inhibitor-I, and thrombomodulin were found in the patients before treatment; each of these was reduced significantly during treatment. The findings suggest the presence of a hypercoagulable state in hypercholesterolemia and that pravastatin might prevent the hypercoagulable state by reducing hypercholesterolemia.

Amplification of plasmid (L factor) DNA and increased production of a plasmid gene product (gamma-interferon) in mouse L cells

It has previously been reported that composite DNAs derived from L factor, a polyoma-related mammalian plasmid, can be established in several mouse cell lines after transfection. Here, we report that the copy number of a plasmid composite DNA consisting of L factor, pBR DNA, dihydrofolate reductase (dhfr) gene, and gamma-interferon (gamma-IFN) gene was increased more than 10-fold after two successive adaptations of the plasmid-bearing mouse L cells to increasing concentrations of methotrexate (MTX), an inhibitor of dhfr. The structure of the amplified L factor plasmid remained intact during prolonged cell culture, but the copy number remained to be amplified only when the selective pressure (presence of MTX in the medium) has been exerted during the culture. Cells bearing the amplified plasmid produced a higher level of gamma-IFN compared with the original clone, which was likely to be derived from the plasmid gamma-IFN gene amplified along with L factor and the dhfr gene.

[Idiopathic thrombocytopenic purpura associated with pregnancy]

We examined 14 patients (18 cases) with idiopathic thrombocytopenic purpura (ITP) during pregnancy at our department. ITP, which had improved, recurred during pregnancy in 4 cases while it developed for the first time during pregnancy in 10 cases. In the other 4 cases, pregnancy occurred in the course of ITP. Although a normal infant was born in 14 cases, 3 stillbirth and a premature infant was observed in 4 cases. Six deliveries had some toxemia of pregnancy. A transient decrease in neonatal platelets was observed in 4 of 14 cases and mother's platelets count was less than 40 X 10(3)/microliters in the 4 cases. Although antinuclear antibody, Coomb's test and antiphospholipid antibody were positive in some cases, these were not markedly related to clinical course or neonatal platelets count. Eleven cases were treated with glucocorticoids, high dose gamma globulin or platelets transfusion, but 11 cases were not treated. Since ITP is frequently observed during pregnancy and may be some risk factor for pregnancy, treatment of ITP is important during pregnancy.

Importance of hydrolysis of amino acid moiety in water-soluble prodrugs of disodium cromoglycate for increased oral bioavailability

The relationship between physicochemical properties and oral absorption was investigated in prodrugs for the oral delivery of disodium cromoglycate (DSCG). To improve the lipophilicity of DSCG, various lipophilic moieties were introduced into the twin carboxyl groups. However, this did not lead to improved oral absorption in rabbits because of loss of water solubility, in spite of improved lipophilicity. Water-soluble prodrugs, in which an amino acid was introduced into a hydroxy group by ester linkage in addition to ethyl residues at twin carboxyl groups of DSCG, were synthesized and examined for oral absorption in rabbits and rats. The oral absorption of these prodrugs was affected by the species of amino acids introduced as a water-soluble moiety. Therefore, we examined the relation between the oral absorption of water-soluble prodrugs and the hydrolysis rate of the amino acid moiety. A good linear correlation was obtained between the oral absorption and the hydrolysis rate constant catalyzed by digestive enzymes, trypsin or alpha-chymotrypsin. It was thus concluded that the amino acid moiety of water-soluble prodrugs must be rapidly hydrolyzed to a permeable lipophilic prodrug still possessing the ethyl moiety at twin carboxyl groups in the small intestinal tract for good oral absorption.

Plasma cytokine levels in thrombotic thrombocytopenic purpura

Plasma cytokine levels were examined in 13 patients with thrombotic thrombocytopenic purpura (TTP). Auto-antibodies, platelet-associated immunoglobulin G, and platelet aggregating factor were detected in many of these patients and high-molecular-weight bands of von Willebrand factor multimers were reduced in 9 of 10 patients examined. Complete remission (CR) was attained in 7 of the 13 patients, but 6 died. Tumor necrosis factor (TNF), Interleukin (IL)-1 beta, IL-6, and soluble IL-2 receptor showed marked increases at onset and decreased at CR. The prognosis tended to be poor in patients with increased IL-6 and soluble IL-2 receptor levels. These findings suggest that immunological mechanisms, such as the activation of macrophage, are involved in the pathogenesis of TTP and are reflected in the plasma cytokine levels.

[Surgical treatment of aortic root abscesses using a hand-made valved xenopericardial conduit]

A case is described in which a new treatment was taken to eradicate an aortic root abscess in a 56-year-old man with aortic prosthetic valve endocarditis. Debridement of all apparently infected tissue created left ventricular-aortic discontinuity, involving the orifice of the right coronary artery. A conduit of a diameter of 23 mm was made by hand with a glutaraldehyde preserved xenopericardial graft. A 21 mm St. Jude Medical prosthetic valve was sewn in it at 2 cm to its edge. The hand-made valved conduit was used to reconstruct the left ventricular outflow tract and aortic root. A saphenous vein graft was anastomosed end-to-side to the right coronary arterial system and to the conduit distal to the prosthetic valve. The aortography revealed no aortic regurgitation nor abnormalities of the conduit, such as aneurysm formation, and the coronary arteriography showed a functioning graft 5 months after surgery.

Revascularization for coronary ostial stenosis in Takayasu's disease with calcified aorta

A case in which a patient with stenoses of the right and left coronary ostia and heavy calcification of the aorta caused by Takayasu's disease was successfully treated by coronary artery bypass grafting is presented. The aortic ends of the two grafts were attached to a xenopericardial patch, which was sutured into the ascending aorta. This technique can be done without fine sutures, which are required for proximal anastomosis of a vein graft, and may reduce the risk of ostial stenosis.

[Operative management of Stanford type A aortic dissection using selective cerebral perfusion]

Ten patients underwent surgical treatment for type A aortic dissection from October 1986 to April 1989 using hypothermic cardiopulmonary bypass (CPB) with selective cerebral perfusion (SCP). CPB was begun with femoral artery cannulation. The right axillary artery (RAA) and the left common carotid artery (LCCA) were separately cannulated and perfused with CPB blood by individual pump heads. The average flow to the RAA was 5.4 +/- 1.2 ml/min/kg body weight (mean +/- SD) and 5.6 +/- 2.6 ml/min/kg body weight to the LCCA. The average blood pressure of the superficial temporal artery was 53.1 +/- 15.1 mmHg in the right side and 52.5 +/- 24.7 mmHg in the left. The nasopharyngeal temperature during SCP was maintained at 19.3-24.7 degrees C (mean, 21.1 degrees C). The SCP time ranged from 112 to 197 minutes (mean, 168 +/- 20.8 minutes). There was one operative death. She died of myocardial infarction 3 days after operation. There were two late deaths. One patient died of infection 3 months after operation and another died of cholecystitis 4 months after operation. Cerebral infarction developed in the last patient. Among the 10 patients it was only one neurological sequela, which was surmised to be caused by technical problem in carotid artery cannulation. The good cerebral protection was obtained in our experience by SCP as mentioned above.

Vitronectin in liver disorders: biochemical and immunohistochemical studies

The concentration of plasma vitronectin was determined and compared with various parameters of liver function including the blood coagulation system in patients with liver diseases. The severity of cirrhosis was graded according to Child's criteria and compared with the plasma vitronectin level. Furthermore, the distribution of vitronectin in the liver of patients with liver diseases was studied by light and electron microscopy using the indirect immunoperoxidase method. The plasma vitronectin level was low in all liver disease groups as compared with the healthy controls. The difference from the controls was significant in patients with hepatocellular carcinoma and decompensated cirrhosis. Moreover, the plasma vitronectin level was positively correlated with the levels of serum cholinesterase, albumin, plasma alpha 2 plasmin inhibitor-plasmin complex and the prothrombin time and results of the hepatoplastin test. Plasma vitronectin decreased with increasing severity of cirrhosis according to Child's criteria. These results suggest that the plasma vitronectin level is a useful parameter of hepatic synthetic function in patients with liver diseases; it may also reflect the severity of cirrhosis. Light microscopy revealed vitronectin in the area of focal necrosis and the portal tracts in the liver of patients with acute viral hepatitis, in the area of piecemeal necrosis in the liver of patients with chronic hepatitis and along the area of fiber deposition in the liver of patients with cirrhosis. Immunoelectron microscopy showed vitronectin in the rough endoplasmic reticulum of hepatocytes. Moreover, vitronectin was seen around inflammatory cells, endothelial cells, Ito cells and hepatocytes in the perisinusoidal area near focal necrosis and piecemeal necrosis and on collagen fibers.(ABSTRACT TRUNCATED AT 250 WORDS)