Oligo/Amenorrhea Is an Independent Risk Factor Associated With Low Ovarian Response

CAPSULE

Oligo/amenorrhea is an independent risk factor of low ovarian response but not high ovarian response, particularly in women with low AMH levels.

OBJECTIVE

To investigate the association of menstrual cycle length (MCL) with anti-Müllerian hormone (AMH) and ovarian response.

METHODS

This was a retrospective cohort study. A total of 7471 women who underwent ovarian stimulation and oocyte retrieval were enrolled. The main outcome was the number of oocytes retrieved.

MAIN RESULTS

A total of 5734 patients were eligible for analysis. In women without polycystic ovary syndrome (PCOS), serum AMH levels and antral follicle count were significantly lower in women with short cycles and higher in women with oligo/amenorrhea than those with a normal menstrual cycle. In women with PCOS, compared to women with a normal menstrual cycle, women with short cycles and women with oligo/amenorrhea showed higher antral follicle count and higher serum AMH levels. Compared with the 0-25th range group of AMH levels, 75-100th percentile groups showed a significantly increased rate of oligo/amenorrhea in women with and without PCOS [adjusted odds ratio (OR) =1.9 (1.04, 3.46), 2.4 (1.70, 3.35)]. In women without PCOS, the low ovarian response was more common in women with short cycles and less common in women with oligo/amenorrhea compared to women with normal cycles [OR=3.0 (2.38, 3.78), 0.7 (0.55, 0.96), respectively]. When adjusted for AMH levels, both short cycles and oligo/amenorrhea were associated with an increased risk of low response [adjusted OR=1.3 (1.02, 1.75), 1.3 (0.93, 1.86), respectively]. In women without PCOS and with low AMH levels, the low ovarian response was more common in women with short cycles as well as in women with oligo/amenorrhea [OR=1.5 (1.08, 1.98), 1.7 (1.08, 2.69), adjusted OR=1.2 (0.86, 1.74), 2.2 (1.31, 3.82), respectively].

CONCLUSION

AMH levels are significantly associated with increased risk of oligo/amenorrhea in women with and without PCOS. AMH is an indispensable confounder in the association between MCL and ovarian response in women without PCOS. Oligo/amenorrhea is an independent risk factor associated with a low ovarian response in women without PCOS, particularly those with low AMH levels.

Vitamin D supplementation prior to in vitro fertilisation in women with polycystic ovary syndrome: a protocol of a multicentre randomised, double-blind, placebo-controlled clinical trial

INTRODUCTION

Polycystic ovary syndrome (PCOS) is one of the leading causes of female infertility, affecting around 5% of women of childbearing age in China. Vitamin D insufficiency is common in women with PCOS and is associated with lower live birth rates. However, evidence regarding the effectiveness of vitamin D supplementation in women with PCOS is inconclusive. This multicentre randomised, double-blinded, placebo-controlled trial aims to evaluate the effectiveness of vitamin D supplementation prior to in vitro fertilisation (IVF) on the live birth rate in women with PCOS.

METHODS AND ANALYSIS

We plan to enrol women with PCOS scheduled for IVF. After informed consent, eligible participants will be randomised in a 1:1 ratio to receive oral capsules of 4000 IU vitamin D per day or placebo for around 12 weeks until the day of triggering. All IVF procedures will be carried out routinely in each centre. The primary outcome is live birth after the first embryo transfer. The primary analysis will be by intention-to-treat analysis. To demonstrate or refute that treatment with vitamin D results in a 10% higher live birth rate than treatment with placebo, we need to recruit 860 women (48% vs 38% difference, anticipating 10% loss to follow-up and non-compliance, significance level 0.05 and power 80%).

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee in Women's Hospital of Zhejiang University on 2 March 2020 (reference number: IRB-20200035-R). All participants will provide written informed consent before randomisation. The results of the study will be submitted to scientific conferences and a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04082650.

[Antibacterial effectiveness of calcium silicate-based root canal sealer against Enterococcus faecalis biofilms in infected dentinal tubules in vitro]

Objective: To evaluate the antiseptic effect of combined using of 5% sodium hypochlorite and calcium silicate-based root canal sealer against Enterococcus faecalis (Ef) biofilms in infected dentinal tubules in vitro. Methods: Cells of Ef were inoculated into the dentinal tubules of single-rooted teeth (without caries, periapical lesions and malformations extracted due to periodontal disease or orthodontic reasons; collected from Department of Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University) with centrifugation and incubated in brain-heart infusion (BHI) to form 3-week-old biofilms. The infected samples were subjected to sodium hypochlorite or sterile water bathing for 10 minutes followed by calcium silicate-based root canal sealer (iRoot SP) (calcium silicate-based group), Gutta-percha group and sterile water group placed on the root canal wall for 1, 4 and 12 weeks. There were two samples in each treatment at each point. The antiseptic effectiveness of combined use of sodium hypochlorite and calcium silicate-based root canal sealer was analyzed by laser scanning confocal microscope (LSCM), ANOVA and LSD-t test. Results: After treatment with 5% sodium hypochlorite, in calcium silicate-based group for 4 and 12 weeks more Ef biofilm cells [(75.3±3.5)% and (74.8±3.8)%] were killed than in Gutta-percha group [(65.9±4.1)% and (63.0±3.7)%] and sterile water group [(63.9±4.0)% and (64.2±3.5)%] (P<0.05). After being treated with sterile water, the proportion of dead bacterial cells in calcium silicate-based group for 1, 4 and 12 weeks [(27.5±4.6)%, (43.0±4.4)% and (40.3±6.1)%] were more than those in Gutta-percha group and sterile water group (P<0.05). After being treated with 5% sodium hypochlorite or sterile water, more biofilm bacteria were killed in calcium silicate-based group for 4 and 12 weeks than in calcium silicate-based group for 1 week (P<0.05). Conclusions: The combined use of sodium hypochlorite and calcium silicate-based root canal sealer kills more biofilm cells in infected dentinal tubules.

[Killing activity of nonequilibrium plasma against young and old Enterococcus faecalis biofilms with long-term exposure in infected root canals in vitro]

Objective: To evaluate the antimicrobial activity of nonequilibrium plasma against Enterococcus faecalis (Ef) biofilms in vitro and to obtain novel evidence of root canal disinfection with nonequilibrium plasma. Methods: Sterile cover slips and single-rooted canals were filled with Ef and incubated to form 1-week-old and 3-week-old biofilms, respectively. The infected samples were subjected to nonequilibrium plasma, 2% chlorhexidine digluconate (CHX) and saline for 3, 10 and 30 minutes, respectively. After treatment, the killing effectiveness of nonequilibrium plasma was analyzed by using laser scanning confocal microscopy (LSCM) and colony forming unit (CFU) counting. Results: The 3-dimentional reconstruction LSCM images showed that about 48.3%-79.8% of 1-week-old Ef biofilm cells and 40.0%-67.4% of 3-week-old biofilm cells were killed by nonequilibrium plasma and 2% CHX compared to saline (P<0.05). The proportion of killing activity was lower after 3 minutes (40.0%-50.9% killing) than after 10 minutes (65.3%-77.8% killing) and 30 minutes (66.4%-79.8% killing) (P<0.05). And the killing of biofilm bacteria was fastest during the first 3 minutes (13.3%-17.0% killing per minute) and slow down greatly after 10 minutes. Remarkably more bacteria were killed in 1-week-old Ef biofilms (48.3%-79.8% killing) than in 3-week-old biofilms (P<0.05). Conclusions: The nonequilibrium plasma killed more Ef biofilm cells in infected root canals showed promotional as an additional approach against bacterial biofilms during root canal disinfection.

Experimental upper bound and theoretical expectations for parity-violating neutron spin rotation in 4He

Neutron spin rotation is expected from quark-quark weak interactions in the standard model, which induce weak interactions among nucleons that violate parity. We present the results from an experiment searching for the effect of parity violation via the spin rotation of polarized neutrons in a liquid 4He medium. The value for the neutron spin rotation angle per unit length in 4He, d ϕ / d z = [ + 2.1 ± 8.3 (stat.) - 0.2 + 2.9 (sys.) ] × 10 - 7 rad/m, is consistent with zero. The result agrees with the best current theoretical estimates of the size of nucleon-nucleon weak amplitudes from other experiments and with the expectations from recent theoretical approaches to weak nucleon-nucleon interactions. In this paper we review the theoretical status of parity violation in then → + 4He system and discuss details of the data analysis leading to the quoted result. Analysis tools are presented that quantify systematic uncertainties in this measurement and that are expected to be essential for future measurements.

A slow neutron polarimeter for the measurement of parity-odd neutron rotary power

We present the design, description, calibration procedure, and an analysis of systematic effects for an apparatus designed to measure the rotation of the plane of polarization of a transversely polarized slow neutron beam as it passes through unpolarized matter. This device is the neutron optical equivalent of a crossed polarizer/analyzer pair familiar from light optics. This apparatus has been used to search for parity violation in the interaction of polarized slow neutrons in matter. Given the brightness of existing slow neutron sources, this apparatus is capable of measuring a neutron rotary power of dϕ/dz = 1 × 10(-7) rad/m.

Effects of activating NK cell receptor expression and NK cell reconstitution on the outcomes of unrelated donor hematopoietic cell transplantation for hematologic malignancies

Inhibitory NK cell receptors are recognized as important determinants of NK cell activity in hematopoietic cell transplantation (HCT). The role of activating receptors and their acquisition after HCT is less certain. Therefore, we comprehensively evaluated both inhibitory and activating receptors in 59 patients receiving unrelated donor HCT. NK cell numbers normalized quickly relative to B and T cells; however, the expression of both inhibitory and activating isoforms of killer immunoglobulin-like receptors (KIRs) was delayed. Most NK cells expressed an immature phenotype during the first 6 months post-HCT; however, we found high expression of activating NKp46 and NKp44 natural cytotoxicity receptors (NCRs), and cytotoxicity was preserved. Early reconstituting NK cells from unmanipulated grafts showed lower cytotoxicity than those from T-cell-depleted grafts. Differences in NK cell reconstitution had significant effects on clinical outcomes. Patients whose NK cells reconstituted earlier had better survival and lower relapse rates. The best survival group was recipients who possessed HLA-C2 but their donor lacked the cognate-activating KIR2DS1. Collectively, our data underscore the clinical relevance of reconstituting NK cells and their activating KIRs and NCRs. In addition to NK cell quantification and genotyping, comprehensive assessment of NK cell functions and phenotypes, including activating receptors, is essential.

Modelling the isotope enrichment of leaf water

Farquhar and Gan have proposed a model for the spatial variation in the isotopic enrichment of H(2)(18)O across a leaf, which is specifically formulated for monocotyledoneous leaves. The model is based on the interaction between mass fluxes longitudinally within the xylem, and fluxes laterally through veinlets into the lamina mesophyll, where moisture leaves the leaf through transpiration. The lighter, more abundant, molecule H(2)(16)O escapes preferentially with the evaporating water, resulting in the enrichment of H(2)(18)O at these sites. Enriched water diffuses throughout the leaf, and it is this spatial distribution of enriched water which the model seeks to capture. In this paper we present a general formulation of the model in terms of mass flux, extending it to include variable transpiration rates across the leaf surface, as well as a tapering xylem. Solutions are developed for the general case and, since the solutions present in the form of Kummer functions, properties are established as well as methods for estimating the solutions under certain conditions relevant to the biology. The model output is compared with Gan's data collected from maize plants.

Evidence of progressive delay of motor development in children with sensorineural hearing loss and concurrent vestibular dysfunction

Gross motor development, and the effect of age, sex and vestibular function on it, was examined in 39 24- to 83-mo.-old children with sensorineural hearing impairment. Repeated testing was completed on 18 children. Delayed gross motor development was evident regardless of age, but only children less than 5 years of age had developmental balance deficits on initial testing. Both gross motor and balance development scores were lower on repeated testing. Furthermore, vestibular function scores facilitated identification of those children with a deficit in balance development as well as those with a progressive delay in motor or balance development. Implications for practice are discussed.

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.

Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction

BACKGROUND

Time limits for neuroprotection by retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) in aortic arch aneurysm repair or dissection are undergoing definition.

METHODS

Using near-infrared optical spectroscopy, changes in regional cerebrovascular oxygen saturation (rSO2) were compared between the two perfusion methods.

RESULTS

Immediately before cardiopulmonary bypass, baseline rSO2 was 63.9%+/-6.9% for the RCP and 66.1%+/-5.3% for the SCP group (no significant difference). As patients were core-cooled to 20 degrees C, rSO2 increased to 73.1%+/-8.8% and 74.1%+/-7.9% in the RCP and SCP groups, respectively. With circulatory arrest, rSO2 suddenly decreased. After starting cerebral perfusion, rSO2 returned to prearrest values in the SCP group but continued decreasing steadily in the RCP group, to levels below baseline after about 25 minutes. At the end of perfusion, rSO2 was 57.4%+/-12.2% for the RCP group and 71.7%+/-6.9% for the SCP group, and the ratio of rSO2 to baseline value was 0.89 for RCP and 1.08 for SCP despite a shorter brain perfusion time for RCP (38.8+/-18.0 versus 103.3+/-43.3 minutes). Three of 5 patients whose ratios of rSO2 to baseline at the end of brain protection were 0.7 or less had neurologic deficits.

CONCLUSIONS

Although SCP showed no clinically important time limitation, rSO2 continued to decrease with time during RCP. An rSO2 ratio less than 0.7 could represent a critical lower limit.

[Results of surgical treatment for pT3 primary lung cancer]

We reviewed pT3 lung cancer for 86 cases (13.1%) out of 659 cases treated surgically for primary lung cancer between 1985 and march 1998. Five-year and ten-year survival rates for all pT3 cases were 48% and 40% respectively and those for pT3N0M0 cases were 67.2%. The operative mortality between 1990 and 1998 (2.4%) was better than that between 1985 and 1989 (6.7%). The extensive resection for pT3 lung cancer was evaluated to be appropriate. However, the prognosis of the patients who underwent combined resection of mediastinal pleura, pericardium or diaphragm was very poor. Five-year survival rate was significantly worse in patients with N2 disease (17.3%) than in patients with N0 disease (65.8%) (p < 0.05). Although the surgical indication for the patients with mediastinal pleura, pericardium or diaphragm disease and N2 disease is still controversial, there is not the extensive surgical indication.

Emergency percutaneous cardiopulmonary bypass support for acute myocardial infarction

We assessed the efficacy of emergency percutaneous cardiopulmonary bypass support (PCPS) in the treatment of patients with acute myocardial infarction complicated by cardiogenic shock. Emergency PCPS was instituted in 21 consecutive patients beginning in 1991. After the stabilization of the hemodynamics, coronary reperfusion was performed by means of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Of the seven patients with acute myocardial infarction involving either the left main or two-vessel territories, five survived more than 1 month, but only one patient remained alive and well after 20 months. The main cause of death for this group was low output syndrome. Four of 12 patients with acute left main trunkal occlusion in the catheter laboratory survived and showed a preserved cardiac function (mean followup 28.5 months). The main cause of death for this group was brain damage. Two patients with single-vessel territory acute myocardial infarction underwent PCPS to treat refractory ventricular fibrillation. Both patients were still alive and well at a 12-month followup. Percutaneous cardiopulmonary bypass support successfully stabilized the hemodynamics, allowing time to perform revascularization for all three groups of patients with life-threatening acute myocardial infarction. Recanalization was nevertheless unable to salvage the damaged myocardium in cases of prolonged ischemic time.

Statistical evaluation of in vitro dissolution of different brands of ciprofloxacin hydrochloride tablets and capsules

The in vitro dissolution of ciprofloxacin from commercially available tablets and capsules in China was studied using the USP apparatus I to compare the product performance from nine different manufacturers. Cumulative release greater than 75% was obtained from all of the products tested within 45 min. However, statistically significant differences were found between some of the products when in vitro data were analyzed using the Weibull function, similarity factor (f2), and multivariate analysis of variances.

Leriche syndrome. Surgical procedures and early and late results

During the past thirteen years, 29 patients underwent surgical intervention for Leriche syndrome. Fifteen patients (aged forty-two to seventy-two years, average 60.7 years) underwent anatomical bypass, and 9 of them whose thrombus was confined to the infrarenal aorta received a routine graft insertion. In the other 6 whose thrombus extended to the level of the renal arteries, an open thrombectomy of the juxtarenal aorta was first performed through a transection of the infrarenal aorta under renal ischemia (4-14 minutes, average 7). Twelve elderly or high-risk patients (aged sixty-eight to eighty-four years, average 75.3 years) underwent an axillobifemoral bypass, and another 2 (fifty-eight and sixty years old, respectively) who had been operated on at an earlier time received an ascending aortobifemoral bypass. In cases of anatomical bypass, no graft has occluded and all patients but 1, who died of cerebral infarction, have an active life now. In cases of extraanatomical bypass, 5 of the 28 grafts occluded and only 6 patients have survived. The other 8 patients died of malignancy, atherosclerotic complications, or unknown causes. The 10-year survival rate was 92.9% and 29.5% in the anatomical bypass and extraanatomical bypass group, respectively. In Leriche syndrome, anatomical bypass is preferred to extraanatomical bypass if conditions permit. In the juxtarenal type, an open thrombectomy under renal ischemia is mandatory for anatomical bypass, and a transection of the infrarenal aorta facilitates this procedure. Because the patients with Leriche syndrome are elderly and harbor arteriosclerotic lesions, a careful follow-up is mandatory.

Roles of histidine-103 and tyrosine-235 in the function of the prolipoprotein diacylglyceryl transferase of Escherichia coli

Phosphatidylglycerol:prolipoprotein diacylglyceryl transferase (Lgt) is the first enzyme in the posttranslational sequence of reactions resulting in the lipid modification of lipoproteins in bacteria. A previous comparison of the primary sequences of the Lgt enzymes from phylogenetically distant bacterial species revealed several highly conserved amino acid sequences throughout the molecule; the most extensive of these was the region 103HGGLIG108 in the Escherichia coli Lgt (H.-Y. Qi, K. Sankaran, K. Gan, and H. C. Wu, J. Bacteriol. 177:6820-6824, 1995). These studies also revealed that the kinetics of inactivation of E. coli Lgt with diethylpyrocarbonate were consistent with the modification of a single essential histidine or tyrosine residue. The current study was conducted in an attempt to identify this essential amino acid residue in order to further define structure-function relationships in Lgt. Accordingly, all of the histidine residues and seven of the tyrosine residues of E. coli Lgt were altered by site-directed mutagenesis, and the in vitro activities of the altered enzymes, as well the abilities of the respective mutant lgt alleles to complement the temperature-sensitive phenotype of E. coli SK634 defective in Lgt activity, were determined. The data obtained from these studies, in conjunction with additional chemical inactivation studies, support the conclusion that His-103 is essential for Lgt activity. These studies also indicated that Tyr-235 plays an important role in the function of this enzyme. Although other histidine and tyrosine residues were not found to be essential for Lgt activity, alterations of His-196 resulted in a significant reduction of in vitro activity.

Surgical treatment of infective endocarditis complicated by annular infection and cerebral infarction

The surgical treatment of nine patients with infective endocarditis (IE) complicated by annular infection and five with IE complicated by cerebral infarction is described herein. In those with annular infection, after thorough débridement of the infected tissues, valve replacement was performed at the original position in five, at the supraannular position in three, and one underwent a translocation procedure. Aortic valve replacement was able to be performed at the original position in two patients by closing the defect at the aortic annulus with a patch after through débridement. The five patients who underwent original valve position replacement recovered well. Of the three who underwent supraannular position replacement, two died of septicemia after a redo operation, and one received pacemaker implantation. The patient undergoing the translocation procedure died of intestinal infarction. In the five patients who suffered cerebral infarction due to embolus of the vegetation, valve replacement was performed between 40 h and 5 months after its onset. Although one patient died of the rapid progression of brain damage, the other four are alive and well, including two who developed mycotic cerebral aneurysm in the infarcted areas. In conclusion, early surgery for IE is mandatory irrespective of active infection, due to the high mortality and morbidity associated with serious sequelae such as annular abscess or cerebral infarction.

Delayed primary repair of intrathoracic esophageal perforation: is it safe?

The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older (p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome.

[Graft replacement of a thoracic aneurysm and coronary artery bypass grafting using retrograde cerebral perfusion through left thoracotomy--a case report]

A 67-year-old woman having descending thoracic aneurysm and 90% stenosis of the obtuse marginal artery underwent a concomitant operation of graft replacement of a thoracic aneurysm and coronary artery bypass grafting. The operation was performed through left posterolateral thoracotomy with total cardiopulmonary bypass using femoral artery, femoral vein and the pulmonary artery cannulation, deep hypothermia and retrograde cerebral perfusion (RGCP). RGCP was performed by high central venous pressure (17-18 mmHg) resulted from low flow perfusion of the lower body under clamping of the descending aorta. Distal coronary anastomosis was done during an initial 100ling period and proximal anastomosis was put on the replaced thoracic graft after coming off extracorporeal circulation (ECC). ECC time was 167 minutes, and RGCP time was 27 minutes. The patient did well after the operation. Postoperative coronary angiography showed the patent coronary bypass graft. We conclude that this method provides good exposure of the thoracic aorta and the coronary artery, and satisfactory brain protection.

[A comparison of changes of cerebrovascular oxygen saturation in retrograde and selective cerebral perfusion during aortic arch surgery]

To evaluate the effect of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) on brain protection, changes of cerebrovascular oxygen saturation (rSO2) were studied in 14 patients with aortic arch reconstruction during the procedure. The rSO2 was monitored with spectroscopy instrument (Invos 3100, Somanetics). The mean value of rSO2 measured just before cardiopulmonary bypass was 65.9 +/- 6.2% in 7 patients with RCP, and was 64.9 +/- 4.7% in 7 patients with SCP. The value of rSO2 during core cooling of cardiopulmonary bypass was increased step by step. Although RCP time with a mean of 38.9 +/- 9.7 min was statistically shorter than SCP time (80.7 +/- 45.1 min), the mean value of rSO2 during cerebral protection in RCP group was decreased from 80.3 +/- 8.1% to 63.4 +/- 10.2%, lowest 46% with a ratio of 21.1%. In contrast, the mean value of rSO2 in SCP group was well maintained from 79.9 +/- 6.5 to 75.6 +/- 6.8%, lowest 63% with a ratio of 5.4%. Although no neurological deficits were recognized after operation in both groups, rSO2 in SCP group was sustained above the control value (65% just before cardiopulmonary bypass) but rSO2 in RCP group was decreased below the control value after 35 min. So we conclude that with regard to brain protection assessed from rSO2 measured by Invos 3100 cerebral oximeter, there is no time limitation of SCP during the procedure but RCP had a limit of the duration.

Structure-function relationship of bacterial prolipoprotein diacylglyceryl transferase: functionally significant conserved regions

The structure-function relationship of bacterial prolipoprotein diacylgyceryl transferase (LGT) Has been investigated by a comparison of the primary structures of this enzyme in phylogenetically distant bacterial species, analysis of the sequences of mutant enzymes, and specific chemical modification of the Escherichia coli enzyme. A clone containing the gene for LGT, lgt, of the gram-positive species Staphylococcus aureus was isolated by complementation of the temperature-sensitive lgt mutant of E. coli (strain SK634) defective in LGT activity. In vivo and in vitro assays for prolipoprotein diacylglyceryl modification activity indicated that the complementing clone restored the prolipoprotein modification activity in the mutant strain. Sequence determination of the insert DNA revealed an open reading frame of 837 bp encoding a protein of 279 amino acids with a calculated molecular mass of 31.6 kDa. S. aureus LGT showed 24% identity and 47% similarity with E. coli, Salmonella typhimurium, and Haemophilus influenzae LGT.S. aureus LGT, while 12 amino acids shorter than the E. coli enzyme, had a hydropathic profile and a predicted pI (10.4) similar to those of the E. coli enzyme. Multiple sequence alignment among E. coli, S. typhimurium, H. influenzae, and S. aureus LGT proteins revealed regions of highly conserved amino acid sequences throughout the molecule. Three independent lgt mutant alleles from E. coli SK634, SK635, and SK636 and one lgt allele from S. typhimurium SE5221, all defective in LGT activity at the nonpermissive temperature, were cloned by PCR and sequenced. The mutant alleles were found to contain a single base alteration resulting in the substitution of a conserved amino acid. The longest set of identical amino acids without any gap was H-103-GGLIG-108 in LGT from these four microorganisms. In E. coli lgt mutant SK634, Gly-104 in this region was mutated to Ser, and the mutant organism was temperature sensitive in growth and exhibited low LGT activity in vitro. Diethylpyrocarbonate inactivated the E. coli LGT with a second-order rate constant of 18.6 M-1S-1, and the inactivation of LGT activity was reversed by hydroxylamine at pH 7. The inactivation kinetics were consistent with the modification of a single residue, His or Tyr, essential for LGT activity.

One-stage primary repair of distal esophageal perforation using fundic wrap

Esophageal leak following primary repair of esophageal perforation is a serious complication that can lead to severe mediastinitis and sepsis. Complete diversion with esophageal exclusion or resection is designed to minimize further mediastinal contamination. However, this approach is not necessarily associated with less morbidity or mortality. Furthermore, a second stage operation is required to restore esophageal continuity. From 1986 to 1994, we performed a one-stage primary repair of the distal esophagus in seven patients with either iatrogenic (n = 5) or spontaneous (n = 2) perforations and reinforced the repair by a fundic wrap. One patient underwent an additional modified Heller myotomy for achalasia. Delay between perforation and operation was less than 6 hours in 3 patients, 6 to 24 hours in 2 patients, and greater than 24 hours in 2 patients. Only one patient (14%) developed a small esophageal leak that spontaneously resolved with adequate mediastinal drainage, intravenous antibiotics, and aggressive nutritional support. One patient (14%), whose repair was delayed by 12 hours, died postoperatively of profound sepsis. This patient was moribund from sepsis preoperatively, and postmortem examination of the esophagus revealed no evidence of esophageal leak. Esophageal continuity was maintained in all patients. The median length of stay was 21 days (range, 15-58 days). We conclude that primary reinforced repair of esophageal perforation using a fundic wrap is an effective method of treatment for distal esophageal perforation, even when the repair is delayed by more than 24 hours.

[Mitral valve repair for the treatment of ischemic mitral regurgitation]

Twenty-six patients with moderate and severe ischemic mitral regurgitation due to papillary muscle dysfunction underwent mitral valve replacement (MVR) or mitral annuloplasty (MAP) using modified Kay method. Emergent operation was performed in 12 patients of whom 11 had severe congestive heart failure even under IABP, 5 had cardiogenic shock and 9 needed respiratory care with intubation preoperatively. Elective operation was performed in 14 patients of whom 6 had history of congestive heart failure and 1 had episodes of ventricular tachycardia. As intraoperative findings of mitral valve, mural annular dilatation in 84.6%, prolapse of anterior leaflet in 23.1%, papillary muscle scar in 15.4%, chordal elongation in 15.4% and chordal rupture in 3.8% were seen separately or in combination. In 22 patients MAP using modified Kay method and CABG were performed, but in 4 patients MVR was needed because of the prominent prolapse of the anterior leaflet. Fourteen patients who underwent MAP with CABG and one MVR with CABG survived. Hospital mortality was higher in emergent (58.5%) than elective operation (28.6%). In the 15 survivors, mitral regurgitation decreased below Sellers 2, pulmonary wedge pressure decreased significantly (p < 0.01) and NYHA functional class improved to I or II postoperatively. During the follow up period of 15-100 (mean 38.7 +/- 21.6) months, 2 MAP+CABG patients died suddenly, but the remaining 13 patients were in NYHA class I or II and no progression of MR was seen. These results indicated that MAP+CABG is recommendable in the treatment of ischemic mitral regurgitation due to papillary muscle dysfunction, in order to preserve cardiac function and to reduce valve related complications.

Respiratory-related heart rate variability persists during central apnea in dogs: mechanisms and implications

The aim of this study was to determine the mechanism(s) responsible for the persistence of respiratory sinus arrhythmia (RSA) during central apnea. In five awake dogs, heart rate (HR) was recorded during constant mechanical ventilation (MV) and during central apneas produced by cessation of MV. For each of 10 control ventilator cycles before MV was stopped, instantaneous HR was plotted against the time from the onset of lung inflation; the fundamental and first harmonic of a sine wave (at the ventilator frequency) was then fitted to the HR data. For the control cycles, the mean r2 from the curve fits was 0.57 +/- 0.07, showing that a significant component of the HR variability was linked to the ventilator cycle. After MV was stopped, RSA persisted and only by the third "phantom" ventilator cycle during apnea had the degree of fit consistently decreased compared with control dogs (P < 0.02). The persistence of ventilator-linked RSA at the onset of central apnea supports the concept of a "memory" in the respiratory system. Toward the end of central apnea, HR variability reappeared and had the periodicity and rhythmic profile of RSA on 81% of occasions. The presence of RSA-like activity toward the end of central apnea suggests that subthreshold rhythmic respiratory-related activity may be present even before the onset of detectable lung volume changes.

The umpA gene of Escherichia coli encodes phosphatidylglycerol:prolipoprotein diacylglyceryl transferase (lgt) and regulates thymidylate synthase levels through translational coupling

Using a combination of biochemical, physical, and genetic techniques, we have shown that the umpA gene of Escherichia coli is allelic with the lgt (phosphatidylglycerol:prolipoprotein diacylglyceryl transferase) of Salmonella typhimurium. These genes are essential for the viability of the respective organism and exhibit 92.8% sequence identity at the amino acid level. In E. coli, lgt and thyA (thymidylate synthase) form an operon. Thymidylate synthase levels are regulated by transcription from the lgt promoter and by translational coupling.

Mitral valve repair using an annuloplasty ring made of artificial woven Dacron graft

A woven Dacron ring made of artificial graft was successfully used in combination with a modified Kay's annuloplasty for mitral valve repair. In this procedure, after excision and repair of the redundant prolapsed leaflets, Kay's annuloplasty was performed at both commissures to reduce the posterior annulus and to coapt the leaflets. A woven Dacron ring was then seated and tied to the annulus to provide long-term stabilization and prevent its further dilatation. The mitral orifice of the patient was reduced from 33 mm to 21 mm in diameter, and neither mitral regurgitation nor stenosis was found in the postoperative evaluation.

Tidal ventilation at low airway pressures can augment lung injury

Intermittent positive pressure ventilation with large tidal volumes and high peak airway pressures can result in pulmonary barotrauma. In the present study, we examined the hypothesis that ventilation at very low lung volumes can also worsen lung injury by repeated opening and closing of airway and alveolar duct units as ventilation occurs from below to above the infection point (Pinf) as determined from the inspiratory pressure-volume curve. We ventilated isolated, nonperfused, lavaged rat lungs with physiologic tidal volumes (5 to 6 ml/kg) at different end-expiratory pressures (above and below Pinf) and studied the effect on compliance and lung injury. In the groups ventilated with positive end-expiratory pressure (PEEP) below Pinf compliance fell dramatically after ventilation. It did not change in either the control group or the group ventilated with PEEP above Pinf. Lung injury assessed morphologically was significantly greater in the groups ventilated with a PEEP below Pinf, and in these groups the site of injury was dependent on the level of PEEP. The group ventilated without PEEP had significantly greater respiratory and membranous injury to bronchioles, while the group ventilated with PEEP of 4 cm H2O had significantly greater alveolar duct injury. In conclusion, ventilation at lung volumes below those found at Pinf caused a significant decrease in lung compliance and progression of lung injury. Therefore, in addition to high airway pressures, end-expiratory lung volume is an important determinant of the degree and site of lung injury during positive-pressure ventilation.

On-line determination of pulmonary blood flow using respiratory inert gas analysis

An inert gas analysis method has been developed to perform on-line real time determination of pulmonary blood flow using a nonrebreathing approach. This technique is based on a mathematical model describing mass balance of two inert gases which are breathed using an open gas circuit. The measurements using this method are noninvasive, easy to peform, and do not disturb normal physiological processes. As well, since data are collected on a breath-by-breath basis, it is possible to estimate other respiratory, cardiopulmonary, and metabolic parameters simultaneously in a breath-by-breath manner. Special consideration was given to developing effective data processing algorithms to minimize the influence of measurement noise and respiratory variations. Experimental studies to compare this method with other accepted techniques were conducted to validate the present technique.

[A case of left atrial ball thrombus]

A 76-year-old man admitted to one hospital complaining of transient left hemiparesis. Because of arrhythmia, he was examined by an echocardiogram and found to have an oval free-floating thrombus in his left atrium concomitant with mitral stenosis. He was transferred to our hospital for emergency surgery. On operation, a 3 x 4 cm ball thrombus was removed and diseased mitral valve was replaced with a SJM prosthetic valve. His postoperative course was relatively uneventful. Though left atrial ball thrombus is rarely found among the patients with mitral valve disease, when left atrial ball thrombus is found, immediate surgical intervention is recommended to avoid sudden death.

Characterization of a temperature-sensitive mutant of Salmonella typhimurium defective in apolipoprotein N-acyltransferase

On screening 440 temperature-sensitive (ts) mutants of Salmonella typhimurium, a mutant strain SE5312 which accumulated apolipoprotein (ALP) at 42 degrees C was identified. In vitro assay of apolipoprotein N-acyltransferase activity indicated that the mutant cell envelope contained reduced activity as compared to the wild-type strain. Transduction with a Mud-P22 mapping set placed the ts mutation to 14-17 min region of the S. typhimurium chromosome. P22 transduction using transposon insertions in this region revealed a linkage of the ts mutation to cobD (6%), nag (8%), and corC68 (99%). The ts phenotype was complemented by a 2.3-kilobase EcoRI subclone derived from lambda-phage 170 of Kohara's bank of Escherichia coli. Restriction enzyme analysis of the cloned DNA revealed that this 2.3-kilobase EcoRI fragment included the copper transport (cutE) gene in E. coli. The mutant strain SE5312 was copper-sensitive at 30 degrees C, and the complementing clone conferred copper resistance and restored the ALP N-acyltransferase activity in the mutant cell. Wild-type strain of S. typhimurium harboring this clone exhibited elevated levels of ALP N-acyltransferase activity. These results suggest that the cloned gene encodes the ALP N-acyltransferase. Upon shift to the non-permissive temperature, the viability of the mutant cells decreased, and the mutant cells assumed anomalous morphology. Temperature-resistant revertants could be readily isolated, and a subset of tr revertants contained no detectable lipoprotein. A lpp::Tn10 derivative of the mutant SE5312 was also temperature-resistant. These observations suggest that ALP N-acyltransferase is essential for the growth and viability of S. typhimurium, and this requirement is decreased in the absence of major outer membrane lipoprotein.

Isolation and characterization of a temperature-sensitive mutant of Salmonella typhimurium defective in prolipoprotein modification

A temperature-sensitive (ts) mutant of Salmonella typhimurium that accumulated unmodified murein prolipoprotein at 42 degrees C but not at 30 degrees C was identified. In vivo and in vitro studies of the biosynthesis of Braun's lipoprotein revealed that this mutant (SE5221) was defective in the glyceryl modification of prolipoprotein. The ts mutation was mapped to 60.6 min of the S. typhimurium chromosome and was linked to argA and cysH. A clone with a 1.4-kilobase S. typhimurium DNA insert that complemented the ts mutation and restored the prolipoprotein modification activity both in vivo and in vitro was isolated. DNA sequencing of the complementing region revealed an open reading frame encoding a protein with 291 amino acids lacking NH2-terminal signal sequence. This open reading frame is immediately 5' to the thyA gene and is allelic to umpA of Escherichia coli. Wild-type strains harboring the cloned gene exhibited elevated levels of prolipoprotein modification activity. At the non-permissive temperature, the mutation affected both growth and viability, and the mutant cells exhibited anomalous cell morphology. The ts phenotype was suppressed by the introduction of a lpp::Tn10 mutation. These results suggest that the cloned gene encodes prolipoprotein glyceryl transferase (lgt), and in the wild-type background, this prolipoprotein modification enzyme is essential for the growth and viability of S. typhimurium.

[A successful VA bypass treatment in patient with severe pulmonary hypertension]

Report of a case of a patient with pulmonary hypertension associated with pericardial effusion who was treated by VA bypass during life-threatening right ventricular failure. A 63-year-old man was admitted to our hospital complaining of chest pain and dyspnea. Echocardiography revealed the patient had severe pulmonary hypertension and pericardial effusion. Though there were deep Q waves in ECG, his coronary angiography revealed normal coronary arteries. Pulmonary scintigraphy showed no evidence of pulmonary thromboembolism. As he developed hypotension and anuria, emergency pericardial drainage was carried out without any beneficial effect. Because no effective drugs were found to control his systemic hypotension and pulmonary hypertension, he was treated by VA bypass to save his life. Although his systemic pressure rose to normal level following institution of VA bypass, his pulmonary pressure remained high constantly, around 60-70mmHg. The VA bypass was discontinued on the 6th day because of bleeding tendency. 3 months after VA bypass, though he had not been given any drugs to control pulmonary hypertension, his pulmonary arterial pressure dropped down to within normal range. Though the exact mechanism or etiology of pulmonary hypertension remained unclear, this may be a rare case treated by VA bypass successfully for life-threatening right ventricular failure caused by pulmonary hypertension.

[A successful case of tricuspid valvulectomy for Ebstein's anomaly with severe tricuspid stenosis]

A 44-year-old male was admitted to our hospital complaining of general fatigue and dyspnea on exertion with congestive heart failure (NYHA IV). Cardiac catheterization and angiogram revealed Ebstein's anomaly with severe tricuspid stenosis and functioning small right ventricle. Because of tiny right ventricular chamber, the usual surgical treatment for Ebstein's anomaly i.e. tricuspid valve replacement or valvuloplasty were deemed to be inappropriate. Tricuspid valvulectomy was performed to relieve the inflow stenosis of the right ventricle and excellent symptomatic relief was achieved. It is very rare to seen an adult case of Ebstein's anomaly with severe tricuspid stenosis and functioning small right ventricle. Tricuspid valvulectomy may be justified to use in this rare condition.

[A case of pulmonary paraganglioma]

A pulmonary paraganglioma that was discovered incidentally as a solitary coin lesion on abdominal CT was successfully resected. Though this type of paraganglioma is extremely rare, it needs to be differentiated from certain other pulmonary neoplasms.

Murine monoclonal antibodies to human pancreatic cancer: specificity and sensitivity

Pancreatic carcinoma (n = 7), pancreatitis tissue (n = 4), normal pancreas tissue (n = 5), colonic adenocarcinoma (n = 4) and in vitro human pancreatic cancer cell lines (n = 6) were studied with the murine monoclonal antibodies (MAbs) 3DS2A, AR1-28, AR2-20, Ca19-9 and CA17-1A to determine their immunohistologic specificity and sensitivity for use as radiolabeled diagnostic imaging agents. Using the avidinbiotin-immunoperoxidase staining technique, MAbs 3DS2A and AR1-28 stained 86 and 100% of pancreatic cancer specimens, respectively. MAbs 3DS2A and AR1-28 are suitable agents for use as radiolabeled diagnostic imaging agents in patients with pancreatic cancer.

A case of postnephrectomy arteriovenous fistula

A rare case of a postnephrectomy arteriovenous fistula involving the major renal vessels is presented herein. This type of postnephrectomy arteriovenous fistula is very unusual; in fact, since first documented in 1934, only 65 cases have been reported in the world literature, including 2 cases from Japan. Even though postoperative arteriovenous fistulae are rare, one should bear this complication in mind when unknown causes of bruit or heart failure develop following surgery.

[Thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis. A case report of successful surgical repair]

A case of thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis is reported. A cyanotic boy with omphalocele was brought to our hospital soon after his birth and was diagnosed as thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis. A conservative treatment of omphalocele was performed successfully and a plastic chest shield had been made for him which protected the anterior surface of his chest. He continued to develop in a fairly satisfactory condition and operation was delayed until he was 8 years old when he had severe cyanosis and frequent episodes of headache. The operative procedures were; 1) ascending aorta to main pulmonary artery shunt with EPTFE tube; 2) to bring the heart into the thoracic and abdominal cavity by developing widely the pericardial and diaphragmatic defect behind the heart's preoperative position; 3) to reconstruct the new pericardial sac lying from thoracic to abdominal cavity by covering the heart using EPTFE sheet. This trial of making a new pericardial sac for thoracoabdominal ectopia cordis is not reported so far in the literature. It is expected that the heart has being raised to the thoracic cavity with patient's physical growth after this operation.

[Advantages and limits on the surgical therapy of esophageal cancer]

During a 11-year period, 315 patients of squamous cell carcinoma of the thoracic esophagus were treated. Notwithstanding the great majority of the patients had advanced cancer and operative contra-indications were very limited, the percentage of the operation of total patients was 94% (297/315) and that of operative mortality was 7.0% (20/297). As a standard surgical procedure, subtotal esophagectomies were performed through a right thoracotomy, followed by a laparotomy with simultaneous reconstruction via the posterior mediastinal route. On the 181 cases of the squamous cell carcinoma of the thoracic esophagus resected and reconstructed by this method before 1977, the survival rate of 1-year was 50%, that of 3-years was 19% and that of 5-years was 10%. Post operative T-shaped irradiation was performed in about a half of the total 181 patients. The efficacy of the postoperative irradiation was discernible in patients of each stage. It is expected that a precise schedule of chemotherapy and immunotherapy combined with post-operative irradiation might improve the prognosis of the esophageal cancer.