Combined effects of blood pressure and glucose status on the risk of chronic kidney disease

This study aimed to assess the combined effects of blood pressure (BP) and glucose status on chronic kidney disease (CKD) incidence in young and middle-aged adults. We examined data from 1,297,341 Japanese individuals aged <60 years (60.1% men; mean age 41.4 ± 9.3 years) with no history of CKD at baseline. The interval-censored Cox proportional hazards model with covariates was used. During a median follow-up period of 2.1 years, new onset CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2 and/or proteinuria) occurred in 80,187 participants. In participants without antihypertensive treatment (AHT), the adjusted hazard ratios (95% confidence interval) per 1-standard deviation, that is, 15 mmHg increase in systolic BP for CKD incidence, were 1.08 (1.07-1.09), 1.12 (1.10-1.13), and 1.15 (1.12-1.18) in normoglycemia, borderline glycemia, and diabetes groups, respectively. These ratios were significantly higher in the borderline glycemia and diabetes groups compared with those in the normoglycemia group (interaction p < 0.0001). The interaction between BP and borderline glycemia was evident when the outcome definition was restricted to proteinuria. In participants under AHT, systolic BP was most strongly associated with CKD risk in the diabetes group, although no significant interaction was observed. High BP and high glucose status may synergistically increase the incidence of CKD. Strict BP management may play an important role in the early prevention of CKD in individuals with worse glucose status within the young and middle-aged population. This large-scale longitudinal cohort study showed high BP and diabetes synergistically increased the risk of CKD in individuals without AHT. Strict BP management may play an important role in the early prevention of CKD in individuals with worse glucose status within the young and middle-aged population.

Cross-classification by systolic and diastolic blood pressure levels and chronic kidney disease, proteinuria, or kidney function decline

Predicting and preventing new-onset chronic kidney disease (CKD) through blood pressure (BP) measurements is worthwhile. This study assessed the risk of CKD, which was defined as proteinuria and/or an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, according to cross-classification by systolic and diastolic BP (SBP and DBP). This retrospective population-based cohort study analyzed data from 1,492,291 participants without CKD and without antihypertensive treatment in the JMDC database, which contains the annual health check-up data of Japanese aged <75 years. During a mean follow-up of 3.2 years, CKD incidence, proteinuria, and eGFR <60 mL/min/1.73 m2 occurred in 92,587, 67,021, and 28,858 participants, respectively. When the SBP/DBP <120/<80 mmHg group was set as a reference, both high SBP and DBP were significantly associated with an elevated CKD risk. DBP tended to be more strongly associated with CKD risk than SBP; the hazard ratio of CKD was 1.44-1.80 in the group with SBP/DBP of 130-139/≥90 mmHg and 1.23-1.47 in the group with SBP/DBP of ≥140/80-89 mmHg. A similar result was observed for developing proteinuria and eGFR <60 mL/min/1.73 m2. SBP/DBP ≥150/<80 mmHg was strongly associated with an elevated CKD risk due to the increased risk of eGFR decline. High BP, especially isolated high DBP levels, is a significant risk factor for CKD among individuals around middle age without kidney disease. Moreover, attention should be paid to kidney function, particularly eGFR decline, in the case of low DBP with extremely high SBP levels.

Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system's stakeholders' perspectives

Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.

Design and content validation of a set of SMS to promote seeking of specialized mental health care within the Allillanchu Project

BACKGROUND

The aim of this study was to design and develop a set of, short message service (SMS) to promote specialized mental health care seeking within the framework of the Allillanchu Project.

METHODS

The design phase consisted of 39 interviews with potential recipients of the SMS, about use of cellphones, and perceptions and motivations towards seeking mental health care. After the data collection, the research team developed a set of seven SMS for validation. The content validation phase consisted of 24 interviews. The participants answered questions regarding their understanding of the SMS contents and rated its appeal.

RESULTS

The seven SMS subjected to content validation were tailored to the recipient using their name. The reminder message included the working hours of the psychology service at the patient's health center. The motivational messages addressed perceived barriers and benefits when seeking mental health services. The average appeal score of the seven SMS was 9.0 (SD±0.4) of 10 points. Participants did not make significant suggestions to change the wording of the messages.

CONCLUSIONS

Five SMS were chosen to be used. This approach is likely to be applicable to other similar low-resource settings, and the methodology used can be adapted to develop SMS for other chronic conditions.

Breeding timing and nest predation rate of sympatric scops owls with different dietary niche breadth

Breeding timing is one of the key life-history traits considered to be under strong stabilizing selection, such that offspring should be born when food resources are most abundant. Predation, however, may also affect the breeding timing because nest predation is a leading mortality for many species, although this possibility has been less considered. Here, we examined the possible effects of nest predation on breeding timing by comparing sympatric scops owls in a subtropical forest where only reptilian predators are present. The Japanese Scops Owl (Otus semitorques Temminck and Schlegel, 1844), a dietary generalist, bred one month earlier than the specialist Ryukyu Scops Owl (Otus elegans (Cassin, 1852)). The breeding timing of the Ryukyu Scops Owl matched with the emergence of their main prey species, but also matched with predator activity. Accordingly, the predation rate on eggs or nestlings was 7.5 times higher in the Ryukyu Scops Owl (13.9%; 21 out of 150 nests) than in the Japanese Scops Owl (1.9%; 1 out of 52 nests). Clutch size, on the other hand, was significantly larger in the Ryukyu Scops Owl than in the Japanese Scops Owl, possibly compensating loss from predation. Although alternative explanations still remain, our results suggest that the food generalist might have adjusted its breeding timing to avoid nest predation, whereas the breeding timing of the specialist might have been constrained by the availability of its main prey items.

Double patch technique for repairing postinfarction ventricular septal defect

We report 2 cases in which the double patch technique was used to repair an anterior postinfarction ventricular septal defect. To do this, we modified infarct exclusion as follows: In addition to a conventional patch excluding the infarcted muscle, another small patch is used to directly close the septal defect. Gelatin-resorcin-formal glue is applied between the double patches, which prevent the glue from being washed away and enhance it to polymerize stably, thereby rapidly stabilizing the infarcted myocardium with the endocardial patch. Echocardiography immediately after operation showed the infarcted septum had completely adhered to the endocardial patch. Both patients demonstrated satisfactory postoperative hemodynamics. Although 1 patient did well, the other died 6 months postoperatively due to complications of pneumonia and gastrointestinal bleeding secondary to colon carcinoma. This double patch technique appears useful, although further experience is needed to verify its safety and efficacy.

Involvement of high mobility group box 1 and the therapeutic effect of recombinant thrombomodulin in a mouse model of severe acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is accompanied by severe lung inflammation induced by various diseases. Despite the severity of the symptoms, therapeutic strategies have been ineffective. High mobility group box 1 (HMGB1), which was identified originally as a DNA binding protein, has been proposed as a mediator of acute lung injury. In addition to its anti-coagulant activity, recombinant thrombomodulin (rTM) possesses an ability to suppress the inflammatory response through neutralizing HMGB1. T regulatory (T(reg)) cells in the lungs are reported to modify innate immune responses during resolution of acute lung injury. In the present study, we investigated the therapeutic effect of rTM, and the contribution of T(reg) cells to this effect, in a mouse model of severe ARDS. C57BL/6 mice received sequential intratracheal administration of α-galactosylceramide (α-GalCer) and lipopolysaccharide (LPS), which resulted in the development of severe ARDS. HMGB1 levels in the lungs increased to a higher level in ARDS mice compared to those in mice treated with LPS alone. HMGB1 was expressed in the infiltrating neutrophils and macrophages in lungs. T(reg) cells were reduced significantly in the lungs of ARDS mice compared to those in mice treated with LPS alone. rTM administration prolonged the survival time and ameliorated the development of ARDS, which was associated with increased T(reg) cells and synthesis of interleukin (IL)-10 and transforming growth factor (TGF)-β in the lungs. These results suggest that HMGB1 is involved in the development of severe ARDS and rTM shows therapeutic effects through promoting the accumulation of T(reg) cells at the inflammatory sites.

[Pneumothorax and abdominal free air occurred after percutaneous tracheostomy (PCT)]

We report a case of pneumothorax and abdominal free air after percutaneous tracheostomy (PCT). A 80-year-old female was intubation for upper respiratory stenosis. We thought tracheal stenosis recurrence after extubation. PCT was performed. Respiratory insufficiency and subcutaneous emphysema appeared rapidly at face, neck and precordia Subcutaneous emphysema was pushed away. PCT was performed once more. Chest X-ray showed pneumothorax in right thoracic cavity. Thoracostomy tube was intubation. Chest computed tomography (CT) scan showed pneumothorax another thoracic cavity and abdominal free air. Vital signs was not worse, so observation. Postoperative course was uneventful. The patient was recovered. We thought that PCT was effective under bronchofiber.

Low-dose dobutamine radionuclide ventriculography for prediction of myocardial viability: quantitative analysis of regional left ventricular function

BACKGROUND

It is important to distinguish viable myocardium from necrotic tissue in order to decide upon therapy in patients with ischemic heart disease.

HYPOTHESIS

We verified the hypothesis that quantitative analysis of regional left ventricular function using low-dose dobutamine radionuclide ventriculography (RNV) can sensitively predict myocardial viability and compared its usefulness with thallium-201 (201Tl) single-photon emission computed tomography (201Tl-SPECT).

METHODS

Radionuclide ventriculography at rest and during low-dose dobutamine infusion (5 micrograms/kg/min), 201Tl-SPECT, and coronary angiography were performed in 51 subjects with severe ischemia-related stenosis of coronary arteries and 3 subjects without coronary artery disease. 201Tl uptake was assessed as normal (control), low perfusion (LP), or defect. We compared the response of regional function to dobutamine with the regional 201Tl uptake. The accuracy of both methods for identifying viable myocardium was investigated in 17 patients who underwent successful coronary revascularization, with a resulting improvement in wall motion.

RESULTS

The increase in regional ejection fraction (delta r-EF) in response to dobutamine was significantly greater in the control (12 +/- 6%) and LP (16 +/- 11%) regions than in the defect (5 +/- 10%) regions. The increase in one-third regional ejection fraction (delta r-1/3EF) was also significantly higher in the control (14 +/- 7%) and LP (10 +/- 8%) regions than in the defect regions (5 +/- 6%). We defined myocardial viability as a delta r-EF > 5% or a delta r-1/3EF > 2%. The sensitivity and specificity of the delta r-EF for identification of myocardial viability were 91.4 and 55.5%, respectively. The sensitivity and specificity of the delta r-1/3EF were 91.4 and 66.6%, respectively; the corresponding values for 201Tl SPECT were 74.2 and 77.8%.

CONCLUSION

Low-dose dobutamine RNV with quantitative analysis of regional left ventricular function was more sensitive for identification of viable myocardium than 201Tl-SPECT.

[Thoracoabdominal aortic aneurysm repair using a graft with prefabricated branches]

A 55-year-old male was referred to our hospital for abdominal examination and was diagnosed as Crawford type III thoracoabdominal aortic aneurysm by computed tomography (CT). Reconstruction of visceral vessels was performed using a Gealweave Coselli Thoracoabdominal Graft, which is currently clinically available. This vascular prosthesis, which is prefabricated 4 branches, requires no intraoperative preparation of the side branches, and the risk of postoperative recurrent aneurysm may be reduced following individual reconstruction of all 4 visceral vessels because of limited remaining aneurismal wall. Therefore, this graft is expected to be useful for this procedure.

[Extracorporeal membrane oxygenation for severe respiratory failure during thoracic aortic aneurysm repair]

We present a case of successful management for severe respiratory failure during thoracic aortic aneurysm repair by applying extracorporeal membrane oxygenation (ECMO). The patient was a 71-year-old man who was diagnosed as thoracic aortic aneurysm and coronary artery stenosis. Severe respiratory failure occurred during operation because of pulmonary hemorrhage, and it was difficult to wean from cardiopulmonary bypass. ECMO was provided for improvement of oxygenation and CO2 removal. Pulmonary hemorrhage was controlled by strict management of coagulation system, and ECMO was discontinued after improvement of oxygenation on the 4th postoperative day. It is considered that early application of ECMO was effective in this case.

MR features of masticatory muscles in adenoid cystic carcinoma involving the masticator space

Adenoid cystic carcinoma (ACC) is known for its slow-growing but severely infiltrative nature with little tissue reaction. Although the masticatory muscles are often involved, their imaging features have not been well elucidated. We hereby report three patients with widespread ACC, which initially appeared with trismus and/or temporomandibular symptoms and involved the masticator space. Possible features of masticator space involvement are presented on magnetic resonance (MR) images. Masticatory muscle changes on MR images consisted of two aspects, namely, denervation changes and direct tumour invasion.

[Minimally invasive video-assisted thoracic surgery using radially expanding trocars]

We report a new and safer access device for thoracoscopic operation. This radially expanding trocar provides a smaller incision of skin and a lesser visceral, vascular or neural injury than a conventional cannula. Therefore, most of patients undergoing this operation do not feel much pain. Moreover, this device system is more cost effective than a conventional one. We prefer and recommend this minimally invasive technique for video-assisted thoracic surgery.

[Re-do coronary artery bypass grafting with the descending branch of the lateral femoral circumflex artery in a patient with chronic hemodialysis]

A 52-year-old man with hemodialysis had undergone coronary artery bypass grafting (CABG); left internal thoracic artery (LITA) to left anterior descending artery (LAD), right gastroepiploic artery (RGEA) to posterolateral branch (PL), saphenous vein graft (SVG) to diagonal artery (Dx) 5 years previously. After 3 years, angiography was performed due to recurrence of angina pectoris and revealed RGEA and SVG was totally occluded. Since repeated intervention was unsuccessful, reoperation was necessary. Therefore, we performed re-do CABG without cardiopulmonary bypass using lateral femoral circumflex artery (LFCA) as an arterial conduit for myocardial revascularization via the 6th left intercostal posterolateral thoracotomy. Postoperative angiography showed that the LFCA bypass graft was patent and supplied sufficient blood to anastomosed vessel. The patient has had no angina pectoris subsequently. We believe this procedure is useful for re-do myocardial revascularization, and LFCA deserves to be taken into account as an alternative graft in a patient with chronic hemodialysis.

Ankylosis of the temporomandibular joint developing shortly after multiple facial fractures

A 41-year-old male patient was referred for treatment of extensive facial fractures and lateral condylar dislocations. The patient underwent open reduction and fixation under general anaesthesia. Intermaxillary fixation was released in 2 weeks and mouth opening was 21 mm. Despite postoperative physical exercises, the range of motion decreased to 10 mm at 5 weeks after the surgery. MR arthrography revealed a fibrous ankylosis in the bilateral TMJs. Coronal CT scans depicted a bony outgrowth of the left TMJ tuber. The patient underwent surgery for the ankylosis including discectomy and coronoidectomy, and removal of the bony outgrowth. An interincisal distance of 30 mm on maximal mouth opening has been maintained for 14 postoperative months. The importance of imaging assessment was emphasized for diagnosing the precise pathologic state of the ankylosis and selecting an appropriate surgical treatment of choice.

Computed tomography of odontogenic myxoma

OBJECTIVES

The purpose of this study was to clarify the CT features of odontogenic myxoma.

METHODS

CT appearances were analysed in 17 patients with histologically verified odontogenic myxoma collected from five dental hospitals in Japan.

RESULTS

On the CT images, tumour borders were generally well defined with a smooth margin both for bony and soft tissue structures in all patients. Cortical status was clearly evaluated using CT and the continuity was interrupted in nine patients. Intralesional trabeculations were observed in 13 patients. Of these 13, 6 patients showed the characteristic appearance of angular or straight trabeculations within the tumour. The trabeculations were frequently observed at the peripheral portion of the tumour. In three maxillary tumours, soft tissue margins were observed beyond the cortical margin and/or intralesional trabeculations. In 10 of the 13 lesions evaluated, the majority of the whole tumour area showed relatively lower density compared with surrounding muscles.

CONCLUSION

CT clearly demonstrated characteristic features of odontogenic myxoma. CT analysis may contribute to establishing a consensus regarding the interpretation of conventional radiographic appearances in odontogenic myxoma.

Measurement of ulnar flow is helpful in predicting ischemia after radial artery harvest

BACKGROUND

Despite a negative Allen test, some patients develop hand ischemia after radial artery harvesting. The presence of large interosseous collaterals may reduce the sensitivity of Allen test. To evaluate the combination of ulnar flow measurements and the Allen test as an effective screening technique, we performed Doppler ultrasonography during Allen's maneuver.

METHODS

The Allen test was used to select candidates for harvesting radial artery from 80 patients undergoing coronary bypass surgery.

RESULTS

Of 71 patients with a negative Allen test, one patient developed hand ischemia. This patient was one of six (7.5 %) possessing low ulnar flow levels (less than 40 ml/min/m(2) during compression of the radial artery). This low-flow group had a higher risk for ischemia of the 71 patients with a negative Allen test. The post-operative flow differed greatly from the pre-operative flow in eight patients (11.3 %), which was likely due to large sacrificed interosseous collaterals.

CONCLUSION

Combined use of ulnar flow measurement with the Allen test appears to increase the sensitivity of the Allen test. Neither test, however, is sufficient for a group of patients with large interosseous collaterals.

Chronic dental infections mimicking temporomandibular disorders

BACKGROUND

Trismus and jaw pain are not only caused by temporomandibular disorders (TMD), but also by various pathologies, namely infection, trauma, or neoplasms. TMD-like symptoms, as a result of the pathologies, may be confusing to a clinician. This paper reports two cases of chronic dental infection mimicking TMD.

METHODS

Two patients were initially diagnosed with, and treated for, TMD. However the patients did not respond to the treatment. Limited range of motion and jaw pain were then clinically evaluated for differential diagnoses. Laboratory examinations and computerized tomography (CT) scans were carried out to disclose any underlying lesion.

RESULTS

Laboratory examination, such as, C-reactive protein helped to detect latent infection. CT scans revealed insidious chronic dental infection imitating TMD. Surgical drainage and chemotherapy resolved the symptoms.

CONCLUSION

The importance of a rational diagnostic process, including clinical and laboratory examinations and radiologic imaging, cannot be over-emphasized in elucidating true cause of the symptoms.

Clinical studies of bioabsorbable poly-L-lactide sternal coaptation pins

BACKGROUND

Median sternotomy has become the most commonly used incision in cardiac surgery. Since sternal dehiscence, however, is a major complication, we used bioabsorbable poly-L-lactide (P-L-LA) sternal coaptation pins for sternal closure to prevent it.

METHODS

From February 1998 to October 1999, 99 patients (64 men, 35 women; mean age, 63+/-1.2 years) underwent median sternotomy for cardiac surgery using sternal coaptation pins. Nineteen patients had diabetes mellitus and seven had renal failure. In closure, two sternal pins were inserted into the bone marrow of the sternum, one into the manubrium, the other into the body, and the sternum was sutured with five stainless steel wires.

RESULTS

Five patients died in the hospital. The causes of death were cardiac failure in two patients, respiratory problem in two and perforation of the stomach in one. The average length of hospitalization was 2 4.5+/-2.5 days. Sternal dehiscence occurred in one patient and mediastinitis in four. There was no bleeding from the bone marrow and no complication related to the use of the sternal pins.

CONCLUSIONS

P-L-LA sternal pins were easy to insert and may be effective in preventing dehiscence of the sternum.

Colour Doppler sonographic analysis of blood-flow velocity in the human facial artery and changes in masseter muscle thickness during low-level static contraction

Muscle oedema, which can be seen as a thickness increment by ultrasonography, is important in provoking pain and fatigue during low-level contraction. Although oedema is related to the balance of inflow and outflow of blood, there are no data on the correlation between muscle thickness change and blood-flow. Blood-flow velocities in the facial artery and the muscle thickness changes were measured by colour Doppler ultrasonography in 30 healthy volunteers during 20 min contraction with 10% of maximum force. Thickness and velocity changes both reached a peak in the initial phase of contraction. The initial change of thickness did not correlate with the velocity in the facial artery, while those immediately after exercise showed a high correlation. The velocity changes in the facial artery might depend on both the general response to contraction and local metabolic or mechanical factors in the contracted masseters.

[Positive illusions in Japanese students]

The purpose of this study was to examine positive illusion phenomena among Japanese students. In Study 1, students were asked to rate themselves and the average same-sex student of their university or vocational school, in terms of their personality, optimism about the future, and belief in personal control. Results indicated that participants showed positive illusions in their ratings of agreeableness, conscientiousness, optimism for negative future events, and personal control. However, negative illusions were found in their ratings of extraversion, openness to experience, and appearance. In Study 2, participants were asked to compare themselves with the average same-sex student of their university or vocational school. Results were similar to those of Study 1. Cultural factors appeared to be responsible for those positive and negative illusions.

[Calf flow reserve measured by venous-occlusion near-infrared spectroscopy: relationship to exercise tolerance]

OBJECTIVES

The correlations between calf flow reserve evaluated with venous-occlusion near-infrared spectroscopy, air plethysmography or skin laser Doppler flowmetry were investigated in patients with cardiovascular diseases. The relationships to exercise tolerance during upright bicycle exercise were also examined.

METHODS

The calf flow reserve (blood flow after 5 min of arterial occlusion/basal blood flow) evaluated by the above three methods and peak oxygen uptake (peak VO2) on bicycle exercise were measured in 24 male patients (mean age 65.0 +/- 7.7 years, left ventricular ejection fraction 24-86%).

RESULTS

There was a good correlation between flow reserve by near-infrared spectroscopy (8.0 +/- 3.8) and air plethysmography (7.9 +/- 3.1; r = 0.90). However, there was a weak correlation between flow reserve by near-infrared spectroscopy and skin laser Doppler flowmetry (3.4 +/- 1.7; r = 0.42). There was a good correlation between flow reserve by near-infrared spectroscopy and peak VO2 (r = 0.69), or flow reserve by air plethysmography and peak VO2 (r = 0.53). However, there was no significant correlation between flow reserve by skin laser Doppler flowmetry and peak VO2 (r = 0.18).

CONCLUSIONS

Calf flow reserve evaluated by venous-occlusion near-infrared spectroscopy relates to the flow reserve in the muscle tissue and is minimally affected by the flow reserve in the skin. The flow reserve in the muscle tissue is related to exercise tolerance, but the flow reserve in the skin is not, in patients with cardiovascular diseases.

Clinical factors of recurrent chronic subdural hematoma

The clinical, radiological, and operative factors of recurrent chronic subdural hematoma (CSDH) were retrospectively analyzed in 116 patients with CSDH in 134 hemispheres, treated by one burr hole surgery. The correlation of recurrence was evaluated with personal and clinical factors such as age, sex, history of head injury, and interval from onset of initial symptoms to hospitalization; laboratory findings such as bleeding tendency and liver function; computed tomography (CT) findings such as hematoma density and brain atrophy; and operative findings such as additional procedures and postoperative residual air. The recurrence group (RG) included 10 hemispheres (7.5%) in 10 patients (8.6%). The interval from onset of symptoms to hospitalization was significantly shorter in the RG than in the nonrecurrence group (NRG). Headache was more frequently seen in the RG than in the NRG. Density of hematoma on CT was classified into five types: Low, iso, and high density, niveau, and mixed, and the incidence of recurrence was 0%, 2.3%, 17.2%, 12.5%, and 6.5%, respectively. Larger amounts of residual air in the postoperative hematoma cavity were associated with recurrence of CSDH. CSDH that progresses rapidly in the acute stage and appears as high density on preoperative CT is associated with a high incidence of recurrence. Intraoperative air invasion to the hematoma cavity should be avoided to prevent recurrence.

Scope-guided implantation of a stented elephant trunk in acute aortic dissection

A reliable guide is essential for implanting a stented graft safely into a recently dissected, fragile aorta. In 4 patients with acute aortic dissection, the implantation of a stented elephant trunk was done safely using an endoscope for direct visualization. In all patients, the operation went well. The placement of a stent appears to enhance the benefit of the elephant trunk, which itself reduces the complications of an arch replacement in acute dissection.

[Neuro-Behcet disease mimicking a thalamic tumor]

A case of neuro-Behcet disease presenting as a thalamo-lenticular expanding lesion is reported. A 41-year-old female was admitted with mental deterioration and right hemiparesis. She had been suffering from recurrent oral and genital ulcers and erythema nodosum for several years before admission. Neurological examination on admission revealed poor mental activity, dysarthria and right hemiparesis. Lumbar puncture showed CSF pleocytosis. CT and MRI revealed a thalamo-lenticular expanding lesion. CT showed a homogeneous hypodense lesion of the left lenticulothalamic region, which was enhanced in the central part, exerting a mild mass effect. MRI also revealed the lesion better. The T2 weighted images showed a high intensity signal in the left thalamo-lenticular region and the left peduncle. The T1 weighted images showed a low signal in the corresponding areas with a central enhancement with Gd-DTPA. EEG, SPECT and angiography indicated normal findings. Histologic study of the brain biopsy tissue ruled out a tumor but did not show any specific diagnosis. The patient improved with steroid therapy. In conclusion, the clinical and radiological presentation of neuro-Behcet disease can mimic a cerebral tumor. In such cases, stereotactic biopsy is useful to exclude suspicion of a cerebral tumor.

High yield expression and single step purification of human thionein/metallothionein

Human metallothionein (MT), isoform 2, was expressed in Escherichia coli as an intein (protein splicing element) fusion protein in the absence of added metals and purified by intein-mediated purification with an affinity chitin-binding tag (IMPACT system). This procedure constitutes a novel and simple strategy to prepare thionein (T), the metal-free form, or MT when reconstituting T with metals in vitro. The yield was 8 mg of T or 6 mg of pure Cd(7)- or Zn(7)-MT from a 1-L culture, significantly higher than yields from any other expression system. Purified recombinant protein is indistinguishable from the native protein on the basis of its metal-binding ability, titration of its sulfhydryls, and UV and CD spectra. The MALDI-TOF mass spectrum is consistent with that of T with a free N-terminus.

Thickened intima of the aortic arch is a risk factor for stroke with coronary artery bypass grafting

BACKGROUND

Perioperative stroke is one of the most serious complications of cardiac surgery.

METHODS

Using transesophageal echocardiography, we estimated the intimal thickness of the thoracic aorta as an index of the severity of aortic atherosclerosis to determine the risk of stroke in coronary artery bypass grafting (CABG) patients. The study population comprised 315 consecutive patients who underwent isolated CABG with cardiopulmonary bypass.

RESULTS

Five patients (1.6%) had perioperative cerebral stroke or systemic emboli. We compared the mean intimal thicknesses of the ascending aorta, aortic arch, and descending aorta. Mean thicknesses in patients without stroke were 2.07 +/- 0.76, 2.78 +/- 1.15, and 2.32 +/- 1.21 mm, respectively, and mean thicknesses in the stroke patients were 1.94 +/- 0.55, 6.94 +/- 3.79, and 3.39 +/- 1.85 mm, respectively. The patients with an intima of more than 5 mm at the aortic arch had a significantly greater incidence of perioperative stroke (p = 0.007).

CONCLUSIONS

These results suggest that patients who have an aortic arch intima thickened to more than 5 mm are at a significantly high risk for perioperative stroke, and thus, the CABG procedure should be carefully evaluated to prevent such complications.

Comparison of standard coronary artery bypass grafting and minimary invasive direct coronary artery bypass grafting. Early and mid-term result

OBJECTIVES

We studied indications and problems involved in minimally invasive coronary artery bypass grafting (MIDCAB).

METHODS

We compared patients profiles, graft patency, stenosis severity, morbidity, mortality, long-term survival and freedom from cardiac accidents in 174 patients undergoing elective standard coronary artery bypass grafting (CABG) and 128 undergoing between January 1996 and March 1999.

RESULTS

No statistically difference was seen in gender, diabetes mellitus, renal failure, cerebrovascular accident, multi-vessel disease ratios, or left main trunk stenosis between 2 groups. Internal thoracic artery graft patency was 97% (114/118) and the rate of anastomotic stenosis (> 50%) was 9% (10/118) compared to 96% (213/221) in the MIDCAB group. The 3-year survival rate was 91% in the MIDCAB group and 92% in the CABG group and freedom from cardiac accidents, most involving pericutaneus transluminal coronary angioplasty retreatment, was 66% in the MIDCAB group and 88% in the CABG group.

CONCLUSION

Although patency and stenosis incidence did not differ between 2 groups, freedom from cardiac accidents was lower in the MIDCAB group.

Magnetic resonance arthrography of the temporomandibular joint

PURPOSE

This study evaluated the usefulness of magnetic resonance arthrography (MRAr) in imaging the pathologic temporomandibular joint (TMJ).

PATIENTS AND METHODS

Thirteen TMJs of 11 patients with chronic TMJ pain and disability were examined with MRAr. T1-weighted and T2-weighted first spin-echo sequence with fat suppression images were obtained after the intra-articular injection of gadopentetate dimeglumine.

RESULTS

The disc, the posterior attachment, and the presence of perforations and adhesions were evaluated in each image. All of these anatomic and pathologic structures were clearly detected.

CONCLUSION

MRAr appears to be a promising imaging modality in detecting adhesions and perforations in the TMJ. The MRAr findings simplified the decision of whether a patient should undergo surgery.

[Clinical study of aortic root replacement]

From 1990 to 1999, 19 patients underwent aortic root replacement. Annulo-aortic ectasia was observed in 14 patients, aortic dissection in 4, and aortitis in 1. Mean aortic cross-clamp times and cardiopulmonary bypass times were 163 +/- 44 and 247 +/- 99 min, respectively. Concomitant procedures were coronary artery bypass grafting in 3 patients, aortic arch replacement in 1 and aortic arch replacement and elephant trunk method in 2. There were two hospital deaths due to cardiac failure. There was one late death because of pharyngeal cancer 1.7 years after the operation. Seventeen survivors were followed for a mean duration of 4.4 years (0.6-9.3 years). There were no complications during this period. In conclusion, good results were obtained by modified Bentall operation.

Inflammatory oedema induced by the lys-49 phospholipase A(2) homologue piratoxin-i in the rat and rabbit. Effect of polyanions and p-bromophenacyl bromide

Piratoxin-I (PrTX-I) is a Lys-49 phospholipase (PLA(2)) homologue, isolated from Bothrops pirajai snake venom, that has no phospholipase activity. In this study, we investigated the in vivo oedematogenic activity of PrTX-I in both the rat and the rabbit as well as the ability of PrTX-I to activate rat mast cells in vitro. In the rat paw and skin, PrTX-I (3-100 microg/paw) induced a dose-dependent oedema that was associated with extensive mast cell degranulation. The involvement of mast cells in PrTX-I-mediated oedema formation in the rat was further confirmed by the findings that this protein significantly activated rat peritoneal mast cells in vitro, causing the release of [(14)C]5-hydroxytryptamine ([(14)C]5-HT; 51 +/- 1%). In the rabbit, PrTX-I (10-100 microg/site) also induced dose-dependent skin oedema formation that was not affected by either mepyramine (a histamine H(1) receptor antagonist) or cyproheptadine (1.0 microg/site), indicating that mast cells do not play a role in this animal species. The bradykinin B(2) receptor antagonist Hoe 140 (0.5 microg/site) and the platelet-activating factor (PAF) receptor antagonist WEB 2086 (200 microg/site) also failed to affect the PrTX-I-induced rabbit skin oedema, ruling out the involvement of kinins and PAF. The PLA(2) inhibitor p-bromophenacyl bromide greatly reduced the PrTX-I-induced oedema in both the rat and the rabbit, and also inhibited the rat in vitro mast cell activation induced by this PLA(2) homologue. The polyanions heparin and dermatan sulphate efficiently prevented oedema formation in both species, and heparin inhibited PrTX-I-induced rat mast cell degranulation. Our results are consistent with the suggestion that the cationic charge of PrTX-I plays a major role in the inflammatory responses induced by this PLA(2) homologue.

Effect of crotapotin and heparin on the rat paw oedema induced by different secretory phospholipases A2

The effects of crotapotin (a non-toxic and non-enzymatic acid polypeptide naturally complexed with phospholipase A2) and heparin on rat paw edema induced by different secretory phospholipases A2 (sPLA2) have been investigated. The ability of crotapotin to affect the enzymatic activity of the sPLA2(s) have also been evaluated. Secretory PLA2(s) obtained from both snake (Naja naja, Naja mocambique mocambique, Crotalus adamanteus and Crotalus durissus terrificus) and bee (Apis mellifera) venoms as well as that from bovine pancreas were used in this study. Rat paw oedema was induced by a single subplantar injection of the sPLA2s (5-30 microg/paw) in absence and presence of either crotapotin (10-100 microg/paw) or heparin (50 U/paw). Paw volume was measured using a hydroplethysmometer. Phospholipase A2 from Naja naja, Naja mocambique mocambique, Apis mellifera venoms and the basic component of Crotalus durissus terrificus venom all induced dose-dependent rat paw oedema whereas those from Crotalus adamanteus venom and bovine pancreas were ineffective. Paw oedema induced by PLA2(s) from both Naja naja and Apis mellifera venoms was significantly (P < 0.05) inhibited by crotapotin (0.1-100 microg/site) whereas the Naja mocambique mocambique venom PLA2-induced oedema was significantly potentiated (P < 0.05) by this polypeptide (40 microg/site). On the other hand, heparin (50 U/paw) had no effect on the paw oedema induced by PLA2 from Naja naja and Apis mellifera venoms but significantly inhibited the Naja mocambique mocambique venom PLA2-induced oedema. The measurement of the in vitro phospholipasic activity revealed that crotapotin inhibited by 60-70% the enzymatic activities of PLA2(s) from Crotalus adamanteus, Naja mocambique mocambique, Apis mellifera venoms and bovine pancreas. Our results suggest that despite the great homology between the various types of sPLA2 they interact with crotapotin on cell surfaces in different ways leading to either inhibition or potentiation of the paw oedema by a mechanism unrelated to their enzymatic activities. Since heparin reduced paw oedema induced by PLA2 from Naja mocambique mocambique venom it is likely that this sPLA2 is similar to the novel heparin-sensitive PLA2 found in mast cells.

Decreased disk-eminence ratio is associated with advanced stages of temporomandibular joint internal derangement

OBJECTIVE

To examine the possible correlation between the stage of internal derangement and the antero-posterior length of the disk in relation to the length of the articular eminence.

STUDY DESIGN

Twenty asymptomatic volunteers with normal joints and 120 patients with TMJ dysfunction underwent MR imaging. The A-P length of the disk in relation to the length of the articular eminence (D/E ratio) was measured.

RESULTS

The D/E ratio was 0.95 in the asymptomatic volunteers, 0.83 in patients with disk displacement with reduction, 0.74 in those with disk displacement without reduction and 0.57 in the patients with disk displacement and osteoarthritis. The relationship between the D/E ratio and the stage of internal derangement was statistically significant (P<0.01).

CONCLUSION

The D/E ratio decreases with advancing internal derangement. We suggest that it is a reliable numerical method for staging the degree of the internal derangement.

Mitral valve thrombus attached to the intact mitral valve associated with distal embolism

A 61-year-old man was referred for cardiac investigation because embolism was suspected to be the cause of the sudden onset of severe pain in his right leg after a surgical procedure. The electrocardiogram revealed no atrial fibrillation. Transthoracic echocardiography demonstrated a tumor-like echo at the anterior mitral leaflet, and transesophageal echocardiography documented a mass 13x9mm in size, attached by a stalk to the left atrial side of the anterior mitral leaflet. The other parts of the mitral valve appeared to be intact. At emergency surgery, the mass was located in the center of the left atrial side of the anterior mitral leaflet. It mimicked a myxoma and had a stalk arising from the anterior leaflet. After resection of the mitral valve mass, catheter thrombo-embolectomy was performed and several long pieces of fresh thrombus were removed. On histological examination, the mass consisted of fresh thrombus tissue. No cellular component or myxoma tissue was documented. The distal embolus also consisted of fresh thrombus tissue. This is the first case of a thrombus of the intact mitral valve without atrial fibrillation.

Osmoregulation of vasopressin secretion in patients with the syndrome of inappropriate antidiuresis associated with central nervous system disorders

To clarify the characteristics of vasopressin (AVP) secretion in patients with the syndrome of inappropriate antidiuresis (SIAD) related to central nervous system disorders, we examined the response of AVP secretion to osmotic stimulus by hypertonic saline infusion and analyzed the possible causative factors in six patients with SIAD associated with head trauma or cerebral infarction. Hyponatremia developed after head trauma in four patients and cerebral infarction in two patients. In all patients the clinical state and laboratory findings fulfilled the criteria for SIAD, which was supported by either nonsuppressible plasma AVP levels or effectiveness of treatments with water restriction, demeclocycline, nonpeptide V2 AVP antagonist or diphenylhydantoin. Although patterns of plasma AVP response to the osmotic stimulus varied, plasma AVP concentrations neither increased nor decreased to undetectable levels with a rise in plasma osmolality. In one patient, plasma AVP levels responded to increasing plasma osmolality when plasma osmolality normalized; in which the threshold and the sensitivity of osmostat were normal. In two other patients, AVP secretion responded to plasma osmolality after the treatment. The changes in AVP secretion were not due to nonosmotic stimuli for AVP release. In conclusion, this study shows that patients with SIAD and central nervous system disorders may have persistent AVP secretion with a loss of hypotonic suppression such as found in patients with adrenal insufficiency or depletional hyponatremia in central nervous system disorders, indicating that careful evaluation is necessary to determine the relationship between persistent AVP secretion and the pathogenesis of hyponatremic disorders.

Concurrent infection with Legionella pneumophila and Pneumocystis carinii in a patient with adult T cell leukemia

A 48-year-old woman was admitted to our hospital with high fever, chills, cough, and exertional dyspnea. On admission, the chest roentgenogram and computed tomography scan showed bilateral alveolar infiltration in the middle and lower lung fields. Microscopic examination of the bronchial lavage fluid showed flower cells typical for adult T-cell leukemia (ATL) and cysts of Pneumocystis carinii, and Legionella pneumophila serogroup 1 grew on buffered charcoal yeast extract (BCYE)-alpha agar. The patient was successfully treated with antibiotics including trimethoprim/sulfamethoxazole, erythromycin, and sparfloxacin. Remission of ATL was achieved after three courses of antileukemic chemotherapy. Mixed infection of opportunistic pathogens should be considered in patients with ATL.

Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction

PURPOSE

This study was designed to evaluate the efficacy of arthroscopic lysis and lavage for patients with limited mouth opening. The relationship between preoperative mouth opening and the surgical outcome was determined.

METHOD

Fourteen patients with 16 internally deranged joints were treated by arthroscopic lysis and lavage. All had received 10.4 (7 to 19) months of nonsurgical treatment before arthroscopy. The preoperative magnetic resonance images showed anterior disc displacement without reduction in all treated joints.

RESULTS

Twelve of the 14 patients (86%) showed good reduction in pain and improved range of jaw movement on average follow-up of 28.5 (13 to 66) months. Two patients showed no improvement after arthroscopy and required open surgical procedures. The preoperative mouth opening of the successful group averaged 29.4 (22 to 35) mm, whereas the two failed cases had 10- and 19-mm openings, respectively (P < .05).

CONCLUSION

Persistent limitation of mouth opening of more than 22 mm after nonsurgical treatment has a good prognosis when treated by arthroscopic lysis and lavage. However, those with greater limitation should probably have earlier surgical intervention.

Separation of the two reactions, oxidation and isomerization, catalyzed by Streptomyces cholesterol oxidase

Site-directed mutagenesis was used to identify key amino acid residues of the cholesterol oxidase from Streptomyces sp., which catalyzes the oxidation of cholesterol and the isomerization of 5-cholesten-3-one. Eight mutant enzymes were constructed and the following amino acid substitutions were identified: N318A, N318H, E356A, E356D, H441A, H441N, N480A and N480Q. Mutants N318A and N318H retained both oxidation and isomerization activities. The mutant E356D retained oxidation but not isomerization activity. On the other hand, mutants N480A and N480Q showed no oxidation activity but retained their isomerization activities. The two catalytic reactions, oxidation and isomerization, in cholesterol oxidase were thus successfully separated. When the H441A or H441N mutation was introduced, both the oxidase and isomerase activities were completely lost. The H441, E356 and N480 residues thus appear to participate in the catalysis of cholesterol oxidase, whereas N318 does not. An analysis of the products of these mutant enzymes suggested that the previously proposed 6-hydroxylation reaction by cholesterol oxidase is actually autooxidation from 5-cholesten-3-one. Kinetic studies of the purified wild-type and mutant enzymes showed that the k(cat)/Km values for oxidation in E356D and for isomerization in N480A increased six- and threefold, respectively, over those in the wild-type. These mutational effects and the reaction mechanisms are discussed in terms of the three-dimensional structure of the enzyme constructed on the basis of homology modeling.

Primary uterine T-cell lymphoma

A uterine CD8-positive, HTLV-1-negative T-cell lymphoma associated with atypical endometrial hyperplasia was found in a 63-year-old Japanese woman. Primary T-cell lymphoma of the uterus has not been previously reported.