Clinical significance of extra-pulmonary involvement of invasive aspergillosis: a retrospective autopsy-based study of 107 patients

Disseminated aspergillus infection has a poor prognosis, but few reports have been published on extra-pulmonary involvement in aspergillosis. We reviewed 107 autopsy records of patients with invasive aspergillosis. Fifty-five patients had extra-pulmonary aspergillosis. Organs involved included heart, kidney, central nervous system, gastrointestinal tract, spleen, liver, thyroid gland and pancreas. Extra-pulmonary aspergillosis produces different manifestations according to involved organs. Risk factors associated with dissemination included cytotoxic chemotherapy within a month of death (P=0.0087). Lack of response to empiric or preemptive treatment of amphotericin B predicted IA dissemination (P=0.0328). To improve prognosis of IA, it is important to recognize clinical features of extra-pulmonary aspergillosis and to institute the aggressive anti-fungal treatment.

Ibudilast: a non-selective PDE inhibitor with multiple actions on blood cells and the vascular wall

Ibudilast (3-isobutyryl-2-isopropylpyrazolo[1,5-a]pyridine) is a nonselective inhibitor of cyclic nucleotide phosphodiesterase (PDE). It is widely used in Japan for improving prognosis and relieving symptoms in patients suffering from ischemic stroke or bronchial asthma. These clinical applications are based on the properties of ibudilast that inhibit platelet aggregation, improve cerebral blood flow and attenuate allergic reactions. The inhibition of platelet aggregation and vasodilatation by ibudilast may be due to synergistic elevation of intracellular cyclic nucleotides and release of nitric oxide (NO) or prostacyclin from endothelium, rather than direct inhibition of PDE5 or PDE3. Another important property of ibudilast is its antiinflammatory activity possibly associated with potent inhibition of PDE4. Combined with its relaxing effects on bronchial smooth muscle, antiinflammatory activity of ibudilast could favorably influence pathophysiology of asthma by antagonizing chemical mediators triggering asthmatic attacks. Ibudilast was also reported to significantly attenuate inflammatory cell infiltration in the lumbar spinal cord in an animal model of encephalomyelitis. Future investigations should include effects of ibudilast on inflammatory reactions between endothelium and blood cells, which may initiate the development of atherosclerosis.

Electron microscopy of actin rods and bundles in Dictyostelium discoideum by high-pressure freezing

A new type of actin rods comprising actin tubules appears in dormant spores of Dictyostelium discoideum. Occasionally, the rods in the nucleus were observed in an amorphous state using a combination of high-pressure freezing and freeze-substitutions. Also in the case of actin bundles formed in the nudeus of vegetative cells exposed to dimethyl sulphoxide, actin filaments seemed to be embedded in matrices. The karyoplasm of spores fixed by the above method appeared to be denser than that obtained by other methods. As soluble materials may be efficiently retained in the nucleus, actin tubules or actin filaments embedded in those materials may result in hazy images of actin rods and bundles.

[Perioperative management for radical esophagectomy in a patient with polycythemia vera]

We experienced perioperative management of a 75 year-old patient with polycythemia vera (PV) who underwent transthoracic esophagectomy. After treatment for 14 days of ranimustine and hydroxycarbamid, the preoperative hemoglobin, hematocrit values and platelet count were 17.9 g.dl-1, 58% and 54 x 10(4).mm-3 respectively. During the perioperative period, phlebotomy, elastic stockings, intermittent pneumatic compression, infusion of nafamostat, and early extubation (the day of operation) were performed to prevent deep venous thrombosis. The postoperative course was uneventful and the patient was discharged 34 days after the operation.

S-Adenosyl-L-homocysteine hydrolase is sequestered into actin rods in Dictyostelium discoideum spores

Here we show evidence that S-adenosyl-L-homocysteine hydrolase (SAHH) is linked to the actin cytoskeleton. Actin rods formed in Dictyostelium discoideum spores during the final stage of development are structurally composed of novel bundles of actin filaments. SAHH only accumulates with actin at this stage of development in the life cycle of D. discoideum. Recently SAHH is believed to be a target for antiviral chemotherapy and the suppression of T cells. Our finding may contribute to designing novel antiviral and immunosuppressive drugs.

Diabetes attenuates the minimum anaesthetic concentration (MAC) and MAC-blocking adrenergic response reducing actions of clonidine in rats

BACKGROUND

It is well known that clonidine, an alpha2 agonist, reduces anaesthetic requirement and attenuates haemodynamic responses against noxious stimuli. However, the diabetic state is known to affect several functions of alpha2 adrenoceptors. We investigated the effects of streptozotocin (STZ)-induced diabetes mellitus (DM) on these beneficial actions of clonidine in halothane-anaesthetized rats.

METHODS

The rats were randomly assigned to one of three groups: diabetes (n=24, induced by 50 mg x kg(-1) IV STZ), diabetes treated with insulin (n=24), or control (n=24). We evaluated the effects of clonidine on minimum anaesthetic concentration (MAC) and minimum concentration of halothane needed to suppress cardiovascular responses evoked by a noxious stimulus (MAC-blocking adrenergic responses: MAC-BAR) in each group. MAC and MAC-BAR of halothane were determined by the tail clamp method. MAC-BAR was defined as the MAC which attenuated haemodynamic responses within 10% following the tail clamp.

RESULTS

The diabetic state decreased MAC of halothane by approximately 10%, while MAC-BAR of halothane had been little affected. In the diabetes group, MAC reducing action of clonidine (30 and 100 microg x kg(-1), IV) was completely abolished and MAC-BAR reducing action of clonidine was partially reduced (30 but not 100 microg x kg(-1), IV). Insulin treatment preserved these actions of clonidine.

CONCLUSION

It is suggested that the diabetic state attenuates the beneficial actions of clonidine and that insulin treatment of diabetes preserves these actions of clonidine.

Enhanced platelet sensitivity to prostacyclin in patients in an active stage of Takayasu arteritis

Patients in an active stage of Takayasu arteritis are often complicated with thrombosis in the affected vessels. We investigated whether alteration of platelet sensitivity to prostacyclin is involved in platelet function in these patients. Twelve female patients in an active stage (48.3+/-11.8 years, mean+/-S.D.), diagnosed clinically by a persistently elevated erythrocyte sedimentation rate (>40 mm/h) with typical symptoms, along with 10 gender- and age-matched patients in an inactive stage and 12 control subjects were enrolled. Half-maximal concentration (EC(50)) for platelet aggregation to collagen was determined in the presence and absence of 1 nM iloprost, a stable prostacyclin analog. Sensitivity of platelets to prostacyclin was quantified by the ratio of EC(50) (R) in the presence of iloprost to that in its absence. Patients in an active stage exhibited enhanced platelet aggregation, as demonstrated by significantly lower EC(50) to collagen and increased plasma thromboxane B(2) concentration. However, R values in these patients were significantly higher (4.00+/-1.05; P<.001) than those in the inactive patients or controls (2.58+/-0.62 and 2.43+/-0.68, respectively), suggesting enhanced sensitivity to prostacyclin in patients with active disease. Plasma 6-keto-PGF1 alpha levels were lower in the active patients than those in other groups of subjects. We conclude that platelets in an active stage of TA may be sensitive not only to collagen but also to prostacyclin. The increase in sensitivity of the platelets to prostacyclin could be a compensatory mechanism against a decrease in the prostanoid production, presumably associated with endothelial dysfunction.

Postural tachycardia syndrome in a 28-year-old Japanese woman

Postural tachycardia syndrome is defined as the development of orthostatic symptoms without orthostatic hypotension. We report a 28-year-old female patient with postural tachycardia syndrome who exhibited palpitation, low-grade fever and weight loss. Evaluation of autonomic nervous system functions showed that cardiovagal function was normal. Sweat response to acetylcholine was decreased. Excessive blood pressure elevation was seen in phase IV of the Valsalva maneuver. Pathophysiologic factors in this case were considered to be alpha adrenergic denervation and beta adrenergic hyperresponsiveness. It is important that this syndrome be widely recognized and properly diagnosed.

Cofilin-2, a novel type of cofilin, is expressed specifically at aggregation stage of Dictyostelium discoideum development

BACKGROUND

A conventional cofilin, cofilin-1 in Dictyostelium discoideum plays significant roles in cell proliferation, phagocytosis, chemotactic movement and macropinocytosis.

RESULTS

We identified a new member of the cofilin family, named cofilin-2 in D. discoideum. Cofilin-2 shows significant homology to a conventional Dictyostelium cofilin, cofilin-1, through its entire sequence, and contains residues conserved among the cofilin family that are responsible for actin-binding. On the other hand, several residues that are conserved among the cofilin family are missing from cofilin-2. Purified cofilin-2 depolymerized actin filaments in a dose- and pH-dependent manner and reduced the apparent viscosity of an actin solution, although they did not co-sediment with actin filaments at all. Cofilin-2 was not expressed in vegetative cells, but was transiently induced during the aggregation stage of development, whereas cofilin-1 was predominantly expressed in vegetative cells. Immunocytochemistry revealed that cofilin-2 localizes at substrate adhesion sites, where cofilin-1 is almost completely excluded. Disruption of the cofilin-2 gene caused an increase in actin accumulation at the substrate adhesion sites. We also found that cofilin-2 did not rescue Deltacof1 yeast cells, whereas cofilin-1 did.

CONCLUSIONS

Cofilin-2 may play a distinct role from that of cofilin-1 in destabilization of the actin cytoskeleton during Dictyostelium development.

The formation of actin rods composed of actin tubules in Dictyostelium discoideum spores

A new type of actin rod formed in both the nucleus and the cytoplasm, as well as tyrosine phosphorylation of actin, is implicated in the maintenance of dormancy and viability of Dictyostelium discoideum spores. Here the ultrastructure of the rods and their relationship to the phosphorylation of actin were examined. The rods first appeared in premature spores at the midculmination stage as bundles composed of actin tubules hexagonally cross-linked. The 13-nm-diameter bundles were composed of three actin filaments. Formation of the actin rods begins during the late culmination stage and proceeds until 2 days after completion of fruiting bodies. The physical events occur in the following order; association of several modules of bundles, close packing and decrease in diameter of actin tubules, elongation of rods across the nucleus or the cytoplasm. Actin phosphorylation levels increased at the late culmination stage and reached a maximum level 12 h later. Immediately following activation of spore germination, actin was rapidly dephosphorylated, followed shortly thereafter by the disappearance of rods. Shortened actin tubules once again became arranged in a hexagonal pattern. This hexagonal arrangement of actin tubules is possibly involved in rod formation and disappearance and does not depend upon actin phosphorylation. In contrast, rod-maturation processes may correlate with actin phosphorylation.

A suspected case of proximal diabetic neuropathy predominantly presenting with scapulohumeral muscle weakness and deep aching pain

A 48-year-old man with a 14-year history of type 2 diabetes with proliferative diabetic retinopathy and distal symmetrical diabetic polyneuropathy visited our hospital. Eight months later, he subacutely developed difficulty in both shoulder movement and trouble standing up from a squatting position. This was accompanied by severe bilateral shoulder and thigh pain. Magnetic resonance imaging of the brain, cervical and lumbar spine, computed tomography of the shoulder and X-ray films of the cervical spine and shoulder revealed no abnormality. Cerebrospinal fluid showed a mild elevation of protein (0.93 g/l) without cell infiltration. Antiganglioside antibodies and point mutation of mitochondrial DNA at position 3243 were not found. Neuropathology of the sural nerve showed a moderate myelinated fiber loss, active axonal degeneration, but onion-bulb formation, endoneurial or epineurial vasculitis were not observed. Electromyography revealed neurogenic changes in the proximal upper limb muscles. Nerve conduction studies revealed mild bilateral slowing in nerve conduction velocity in both of the upper and lower limbs. The diagnosis of this patients was suspected to be a proximal diabetic neuropathy (diabetic amyotrophy). The pain and muscle weakness had persisted more severely in the shoulder than in the thigh throughout the clinical course. His unbearable symptoms could be partially alleviated by an administration of a selective serotonin reuptake inhibitor, fluvoxamine maleate. Proximal diabetic neuropathy is a rare disabling type of neuropathy, which is characterized with subacute bilateral muscle weakness and wasting in the proximal part of the lower limbs. The involvement of the scapulohumeral region observed in this case is very unusual in proximal diabetic neuropathy.

Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery

STUDY OBJECTIVE

To examine the relationship between the duration of the preoperative smoke-free period and the development of postoperative pulmonary complications (PPCs) in patients who underwent pulmonary surgery, and the optimal timing of quitting smoking.

DESIGN

Retrospective cohort study.

SETTING

Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

PATIENTS

Two hundred eighty-eight consecutive patients who underwent pulmonary surgery between January 1997 and December 1998.

MEASUREMENTS AND RESULTS

We collected information on the preoperative characteristics, intraoperative conditions, and occurrence of PPCs by reviewing the medical records. Study subjects were classified into four groups based on their smoking status. A current smoker was defined as one who smoked within 2 weeks prior to the operation. Recent smokers and ex-smokers were defined as those whose duration of abstinence from smoking was 2 to 4 weeks and > 4 weeks prior to the operation, respectively. A never-smoker was defined as one who had never smoked. The incidence of PPCs among the current smokers and recent smokers was 43.6% and 53.8%, respectively, and each was higher than that in the never-smokers (23.9%; p < 0.05). The moving average of the incidence of PPCs gradually decreased in patients whose smoke-free period was 5 to 8 weeks or longer. After controlling for sex, age, results of pulmonary function tests, and duration of surgery, the odds ratios for PPCs developing in current smokers, recent smokers, and ex-smokers in comparison with never-smokers were 2.09 (95% confidence interval [CI], 0.83 to 5.25), 2.44 (95% CI, 0.67 to 8.89), and 1.03 (95% CI, 0.47 to 2.26), respectively.

CONCLUSIONS

These findings indicate that preoperative smoking abstinence of at least 4 weeks is necessary for patients who undergo pulmonary surgery, to reduce the incidence of PPCs.

Suicidal ideation among patients with acute life-threatening physical illness: patients with stroke, traumatic brain injury, myocardial infarction, and spinal cord injury

Suicide is one of the leading causes of death in the community. The risk of suicide is greater among patients with physical illnesses than among the general population. This study was undertaken to evaluate the clinical characteristics and correlates of suicidal ideation in patients with acute life-threatening physical illnesses and to assess the duration of suicidal ideation. The study included a consecutive series of patients admitted with stroke, traumatic brain injury, myocardial infarction, or spinal cord injury (n=496). Study participants were administered a semistructured psychiatric interview as well as a series of standardized quantitative scales of mood, cognitive function, physical impairment, social ties, and social functioning. Follow-up evaluations of up to 24 months were also carried out. This study found that 36 (7.3%) patients with acute medical illness had clinically significant suicidal ideation. The suicidal ideation occurred mostly among patients with major depression and sometimes in those with minor depression. About 25% of patients with major depression and acute physical illnesses developed suicidal ideation. After the improvement of depressive disorders, suicidal ideations were ameliorated. These findings suggest that the detection and treatment of depressive disorders is the most important factor in preventing suicide among this patient population.

Suicidal ideation among patients during the rehabilitation period after life-threatening physical illness

A total of 496 patients were examined for suicidal ideation during the acute hospital period and at 3, 6, 12, and 24 months' follow-up after suffering either stroke, traumatic brain injury, myocardial infarction, or spinal cord injury. A total of 7.3% of patients had suicidal ideation during the in-hospital evaluation (acute-onset suicidal ideation), and 11.3% developed it during the chronic 3 to 24 month rehabilitation period (delayed-onset suicidal ideation). Compared with delayed-onset suicidal patients, acute-onset suicidal patients had more predisposing risk factors (i.e., personal psychiatric history and alcohol abuse/dependence) and less social support (i.e., lower frequency of being married). Both acute and delayed-onset suicidal ideation, however, were strongly associated with the existence of major depression and impaired social functioning. These findings suggest that the detection and appropriate treatment of depressive disorders and social isolation may be the most important factor in preventing suicide both during the acute and chronic period following life-threatening physical illnesses.

The morbidity, time course and predictive factors for persistent post-thoracotomy pain

After thoracotomy, patients often suffer from a persistent pain syndrome called post-thoracotomy pain. To elucidate morbidity, time course, and predictive factors for this syndrome, we analyzed follow-up data for 85 post-thoracotomy patients. We used a four-point scale to assess pain: none, slight, moderate and severe. Of 85 patients, 50 reported pain (39 slight, 11 moderate) one day after surgery. A year after surgery, the patients were polled using a simple questionnaire received by the mail. Sixty patients reported persistent pain (34 slight, 14 moderate, 12 severe) a month after surgery, and 35 patients reported persistent pain (33 slight, two moderate) around the time of the poll (1 year after surgery). Although pain deterioration was observed in 40% (34/85) of patients during month 1 after surgery, pain alleviation was seen in 48% (41/85) of patients during months 2-12. Stepwise regression analysis revealed that female gender and pain at postoperative day 1 were predictive for persistent pain both 1 month and 1 year after thoracotomy. Among 35 patients with persistent pain 1 year after surgery, 24 cases reported paresthesia-dysesthesia, and 14 cases reported hypoesthesia. The present data thus suggests that persistent pain is common and often severe 1 month after surgery but is alleviated after 1 year. Clinical time course and symptoms indicate that nerve impairment rather than simple nociceptive impact may be involved in this syndrome.

An obstructed venous aneurysm presenting as an abdominal mass: report of a case

We report herein the case of a 32-year-old woman found to have a venous aneurysm originating from the ovarian vein. The patient presented with a 9-cm abdominal tumor, and surgery was performed under the preoperative diagnosis of a mesenteric cyst. The tumor was easily ablated from the mesentery and resected with the right ovarian artery and vein. Histologically, the wall of the cyst showed the structure of a vein, and the diagnosis of a venous aneurysm was made. This disease is difficult to diagnose preoperatively when a patient presents with no symptoms other than a palpable mass, or when the lumen is obstructed by thrombus. This report serves to demonstrate that a venous aneurysm should be considered in the differential diagnosis of an asymptomatic abdominal mass.

[Monitoring of cerebral oxygenation status with near-infrared spectroscopy during inferior vena caval reconstruction under extracorporeal circulation]

We report two cases of anesthetic management with monitoring by near-infrared spectroscopy in patients with renal cell carcinoma and with adrenal cortical carcinoma, who had tumor thrombus invading into the inferior vena cava. In inferior vena caval reconstruction, extracorporeal circulation such as veno-veno bypass or cardiopulmonary bypass is frequently required. The hemodynamic unstability under extracorporeal circulation may lead to severe cerebral damage, especially in elderly patients. We monitored cerebral oxygenation state during reconstruction of the vena cava by near-infrared spectroscopy. One patient underwent surgery with veno-veno bypass and another patient with partial cardiopulmonary bypass. Oxygenated hemoglobin decreased during extracorporeal circulation, especially during the use of partial cardiopulmonary bypass compared with veno-veno bypass. However, these decreased oxygenated hemoglobin was restored rapidly at the end of extracorporeal circulation. Both patients showed no post-operative neurological complication. We concluded that near-infrared spectroscopy, which is continuous and non-invasive monitoring of cerebral oxygenation status, is one of the useful monitors during extracorporeal circulation.

Successful bone marrow transplantation for adult T-cell leukemia from a donor with oligoclonal proliferation of T-cells infected with human T-cell lymphotropic virus

We describe a patient who underwent successful BMT from her sibling for the treatment of adult T-cell leukemia/lymphoma. Pre-transplant examination of the donor revealed oligoclonal integration of HTLV-I proviruses within the germ line, and our concern was that clinical sequelae of HLTV-I infection might become evident in the setting of post-transplant immunosuppression. However, the patient has been in complete remission for 14 months after transplantation, and no clonality of HTLV-I provirus was detected in the peripheral blood cells using southern blotting analysis. Our experience supports the possibility of transplantation from HTLV-I positive donors.

[Transthoracic radical esophagectomy after extensive myocardial infarction]

We experienced the perioperative management of a 47 year-old patient for transthoracic esophagectomy after myocardial infarction. He was admitted to our hospital and diagnosed as having advanced esophageal cancer and he developed extensive myocardial infarction on the day of admission. Revascularization with PTCA was not successful, and circulatory support (IABP) was required for 7 days. Complete occlusion of the right coronary artery and extensive akynesis of the right ventricle occurred. Two months later, transthoracic esophagectomy was scheduled. The patient was monitored with pulmonary artery catheter during perioperative period. The postoperative course was uneventful and the patient was discharged 64 th day after the operation.

A study of 13 patients with gastric tube in place after esophageal resection: use of omeprazole to decrease gastric acidity and volume

STUDY OBJECTIVE

To investigate whether oral omeprazole 20 mg decreases the risk of aspiration pneumonia in patients with gastric tube reconstruction.

DESIGN

Consecutive study.

SETTING

Operation room of cancer center.

PATIENTS

Thirteen patients with gastric tube reconstruction for esophageal cancer.

INTERVENTIONS

Oral omeprazole 20 mg was given the night before surgery. A rapid-sequence induction with cricoid pressure was employed for induction of anesthesia. After tracheal intubation, a nasogastric catheter was inserted into the gastric tube and the contents were aspirated.

MEASUREMENTS AND MAIN RESULTS

The pH and volume of the gastric contents were measured. The pH and volume of the gastric tube contents were 4.5 +/- 1.6 (range from 2.5 to 7.0) and 9.5 +/- 10.2 mL (range from 0 to 30 mL), respectively. Food residue was recognized in nine patients. There was no patient with a pH below 2.5 and a volume of 25 mL or greater.

CONCLUSIONS

Omeprazole 20 mg decreased the acidity and volume of the gastric tube contents and reduced the risk of aspiration pneumonia in patients with a gastric tube in place.

Toward the creation of NMR databases in chiral solvents for assignments of relative and absolute stereochemistry: proof of concept

[structure: see text] An NMR database approach in a chiral solvent allows us to predict both relative and absolute stereochemistry of an unknown compound without degradation and/or derivatization. N,alpha-Dimethylbenzylamine (DMBA) is a suitable solvent for this purpose. Using the C.5-C.10 portion of oasomycin A, the feasibility and reliability of this approach is demonstrated.

Toward the creation of NMR databases in chiral solvents for assignments of relative and absolute stereochemistry: NMR desymmetrization of meso compounds

[structure: see text] Examples of (13)C NMR desymmetrization of meso compounds are presented. On analysis of the NMR profiles of 1,3-diols, the additivity is recognized to predict the NMR profiles of 1,3,5-tirols.

Toward the creation of NMR databases in chiral solvents for assignments of relative and absolute stereochemistry: scope and limitation

[structure: see text] Three additional NMR databases, 1-3, in a chiral solvent are presented. The C.21-C.38 portion of oasomycin A is used to demonstrate the scope and limitation of the universal NMR database approach in a chiral solvent for assignment of relative and absolute stereochemistry without degradation and/or derivatization.