Association of trauma severity with antibody seroconversion in heparin-induced thrombocytopenia: A multicenter, prospective, observational study

BACKGROUND

Heparin administration can induce the production of anti-platelet factor 4 (PF4)/heparin antibodies with platelet-activating properties, causing heparin-induced thrombocytopenia (HIT). Previous studies have suggested that trauma severity influences HIT immune responses, but their relationship has not been fully explained. This study aimed to clarify this association by multicenter prospective observational study.

METHODS

Trauma patients who met the criteria of age 18 years or older and Injury Severity Scores (ISSs) of ≥9 from March 2018 to February 2019 were included. Patients who did not receive any heparin and those who received it as flushes or for treatment were also included. Patients were divided into three groups based on trauma severity (to mild [ISS 9-15], moderate [ISS 16-24], and severe injury groups [ISS ≥25]) and were compared by the seroconversion time and rate, as well as the disappearance rate of antibodies on day 30.

RESULTS

A total of 184 patients were included: 55, 62, and 67 patients were classified into the mild, moderate, and severe injury groups, respectively. Overall, the seroconversion rates of anti-PF4/heparin immunoglobulin G (IgG) and HIT antibodies by washed platelet activation assay were 26.6% and 16.3%, respectively. There was a significant difference in the seroconversion rates of anti-PF4/heparin IgG ( p = 0.016) and HIT antibodies ( p = 0.046) among the groups. Seroconversion rates in both assays increased with increasing trauma severity. The time required to achieve seroconversion was similar (between 5 and 10 days of trauma onset) regardless of heparin administration. Anti-PF4/heparin IgG and HIT antibodies were no longer detected on day 30 in 28.6% and 60.9% of seroconverted patients, respectively.

CONCLUSION

Development of HIT antibodies was observed commonly in severely injured trauma patients. Heparin-induced thrombocytopenia antibody development may be related to trauma severity, with a high disappearance frequency on day 30.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Effect of age on dexmedetomidine treatment for ventilated patients with sepsis: a post-hoc analysis of the DESIRE trial

Aim

There are no definitive data to determine whether age influences the effects of dexmedetomidine (DEX) treatment. Thus, we investigated whether older age was associated with more favorable sedative action by DEX in sepsis patients who required mechanical ventilation.

Methods

This study involved a post‐hoc analysis of data from the Dexmedetomidine for Sepsis in the ICU Randomized Evaluation (DESIRE) trial. The patients were categorized based on median age into elderly and younger groups. The two groups were then compared during the first 7 days after ventilation based on proportion of patients with well‐controlled sedation (Richmond Agitation–Sedation Scale score between −3 and +1), days free from delirium (based on the Confusion Assessment Method for ICU), and days free from coma (Richmond Agitation–Sedation Scale score between −4 and −5).

Results

One hundred and one patients were assigned to the elderly group and 100 patients were assigned to the younger group. In the elderly group, 50 patients received DEX treatment and 51 patients received non‐DEX treatment, with the DEX arm having significantly better‐controlled sedation (range, 14–52% versus 16–27%; P = 0.01). In the younger group, 50 patients received DEX treatment and 50 patients received non‐DEX treatment, with no significant difference in the proportions of well‐controlled sedation (range, 20–64% versus 24–60%; P = 0.73). There were no significant differences in the numbers of days free from delirium or coma between the groups.

Conclusion

In elderly sepsis patients who require ventilation, dexmedetomidine could be more effective than other sedative agents for achieving proper sedation.

Association of Body Weight Change and Fluid Balance With Extubation Failure in Intensive Care Unit Patients: A Single-Center Observational Study

PURPOSE

To elucidate whether fluid balance and body weight change are associated with failed planned extubation.

MATERIALS AND METHODS

Patients who received invasive mechanical ventilation for over 24 hours were enrolled and divided into extubation success and extubation failure groups. Fluid balance and body weight fluctuation within 24 and 48 hours before extubation and from admission to planned extubation were calculated. The primary outcome was extubation failure (ie, all-cause reintubation within 72 hours). The association of extubation failure with fluid balance and body weight change was assessed via logistic regression analysis.

RESULTS

Extubation failure occurred in 12(7.4%)/161 patients. The extubation success group had a significantly lower fluid balance within 24 hours before extubation than did the extubation failure group (-276 mL [-1111 to 456] vs 1217 mL [503 to 1875], P = .002). However, fluid balance within 48 hours before extubation, cumulative fluid balance, and body weight change were not significantly different between the 2 groups. The sensitivity and specificity of water balance +1000 mL within 24 hours before extubation for the extubation failure group were 0.54 and 0.84, respectively, based on the receiver operating characteristic curve. Logistic regression analysis showed that fluid balance within 24 hours before extubation was associated with extubation failure (odds ratio: 22.9, 95% confidence interval: 4.1-128.4).

CONCLUSIONS

A larger fluid balance within 24 hours before extubation is associated with extubation failure. Thus, fluid balance may be a good indicator of extubation outcome.

Mortality Effects of Prolonged Hemoperfusion Therapy Using a Polymyxin B-Immobilized Fiber Column for Patients with Septic Shock: A Sub-Analysis of the DESIRE Trial

BACKGROUND/AIMS

The optimal duration of hemoperfusion therapy with a polymyxin B-immobilized fiber column has not yet been verified.

METHODS

This analysis examined whether hemoperfusion therapy with a polymyxin B-immobilized fiber column lasting longer than 2 h (prolonged polymyxin) improved outcomes for patients with septic shock compared to 2-h polymyxin therapy (sub-analysis of data from the DESIRE trial).

RESULTS

The 2-h and prolonged polymyxin groups contained 22 and 14 patients, respectively. Both groups had similar characteristics. The polymyxin duration per session in the prolonged polymyxin group was significantly longer (median, 5.5 h) than in the 2-h polymyxin group (p < 0.01). The 28-day mortality rate was significantly higher in the 2-h polymyxin group (7, 31.8%) than in the prolonged polymyxin group (0, 0%; p = 0.019).

CONCLUSION

Prolonged polymyxin therapy might be associated with better clinical outcomes than 2-h polymyxin therapy in patients with septic shock. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=491744.

High-mobility group box 1 is associated with neurological outcome in patients with post-cardiac arrest syndrome after out-of-hospital cardiac arrest

BACKGROUND

Alarmins, including high-mobility group box 1 (HMGB-1), can be released from damaged tissues and activated cells as inflammatory mediators. We aimed to evaluate HMGB-1 and mitochondrial DNA dynamics and estimate the prognostic value for neurological outcome in patients with post-cardiac arrest syndrome after out-of-hospital cardiac arrest.

METHODS

We evaluated the dynamics of HMGB-1, mitochondrial DNA, and other variables in patients with return of spontaneous circulation after out-of-hospital cardiac arrest. Patients were divided into two groups according to the cerebral performance category at 30 days: the favourable outcome group (cerebral performance categories 1 and 2) and unfavourable group (≥3).

RESULTS

Twenty-one patients were included, and 11 demonstrated favourable outcomes. HMGB-1 levels and mitochondrial DNA on day 1 were significantly higher than on days 2, 3, 5, and 7. Plasma levels of HMGB-1 on day 1 correlated with prognostic parameters (estimated interval to return of spontaneous circulation, lactate, and NH3), tissue damage, systemic inflammation, and disease severity. HMGB-1 on day 1 in the unfavourable group was significantly higher than in the favourable group (median [interquartile range] 15.5 [6.65-18.7], 39.4 [17-69.5], P = 0.009). These findings were not observed regarding mitochondrial DNA. Regarding HMGB-1 prediction accuracy for a good neurological outcome, the area under the receiver operating characteristic curve was 0.864 (95 % confidence interval 0.702, 1.000).

CONCLUSIONS

HMGB-1 may be involved in acute-phase post-cardiac arrest syndrome pathophysiology, and an increase in plasma levels may be associated with a poor neurological outcome. The study was registered with the University Hospital Medical Information Network Clinical Trials Registry ID: UMIN000006714.

Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients

Early aggressive hemodynamic resuscitation using elevated plasma lactate as a marker is an essential component of managing critically ill patients. Therefore, measurement of blood lactate is recommended to stratify patients based on the need for fluid resuscitation and the risks of multiple organ dysfunction syndrome and death. Hyperlactatemia is common among critically ill patients, and lactate levels and their trend may be reliable markers of illness severity and mortality. Although hyperlactatemia has been widely recognized as a marker of tissue hypoxia/hypoperfusion, it can also result from increased or accelerated aerobic glycolysis during the stress response. Additionally, lactate may represent an important energy source for patients in critical condition. Despite its inherent complexity, the current simplified view of hyperlactatemia is that it reflects the presence of global tissue hypoxia/hypoperfusion with anaerobic glycolysis. This review of hyperlactatemia in critically ill patients focuses on its pathophysiological aspects and recent clinical approaches. Hyperlactatemia in critically ill patients must be considered to be related to tissue hypoxia/hypoperfusion. Therefore, appropriate hemodynamic resuscitation is required to correct the pathological condition immediately. However, hyperlactatemia can also result from aerobic glycolysis, unrelated to tissue dysoxia, which is unlikely to respond to increases in systemic oxygen delivery. Because hyperlactatemia may be simultaneously related to, and unrelated to, tissue hypoxia, physicians should recognize that resuscitation to normalize plasma lactate levels could be over-resuscitation and may worsen the physiological status. Lactate is a reliable indicator of sepsis severity and a marker of resuscitation; however, it is an unreliable marker of tissue hypoxia/hypoperfusion.

WRKY Transcription Factors Phosphorylated by MAPK Regulate a Plant Immune NADPH Oxidase in Nicotiana benthamiana

Pathogen attack sequentially confers pattern-triggered immunity (PTI) and effector-triggered immunity (ETI) after sensing of pathogen patterns and effectors by plant immune receptors, respectively. Reactive oxygen species (ROS) play pivotal roles in PTI and ETI as signaling molecules. Nicotiana benthamiana RBOHB, an NADPH oxidase, is responsible for both the transient PTI ROS burst and the robust ETI ROS burst. Here, we show that RBOHB transactivation mediated by MAPK contributes to R3a/AVR3a-triggered ETI (AVR3a-ETI) ROS burst. RBOHB is markedly induced during the ETI and INF1-triggered PTI (INF1-PTI), but not flg22-tiggered PTI (flg22-PTI). We found that the RBOHB promoter contains a functional W-box in the R3a/AVR3a and INF1 signal-responsive cis-element. Ectopic expression of four phospho-mimicking mutants of WRKY transcription factors, which are MAPK substrates, induced RBOHB, and yeast one-hybrid analysis indicated that these mutants bind to the cis-element. Chromatin immunoprecipitation assays indicated direct binding of the WRKY to the cis-element in plants. Silencing of multiple WRKY genes compromised the upregulation of RBOHB, resulting in impairment of AVR3a-ETI and INF1-PTI ROS bursts, but not the flg22-PTI ROS burst. These results suggest that the MAPK-WRKY pathway is required for AVR3a-ETI and INF1-PTI ROS bursts by activation of RBOHB.

Burn-associated delayed dilated cardiomyopathy evaluated by cardiac PET and SPECT: Report of a case

Dilated cardiomyopathy is a delayed-onset and rarely reported cardiac complication of burn injury although the mechanism remains unclear. We thus report a case of dilated cardiomyopathy following severe burn injury, in which technetium 99m sestamibi single-photon emission computed tomography (SPECT), iodine-123 beta-methyl-iodophenylpentadecanoic acid SPECT and ¹⁸F-fluorodeoxyglucose positron emission tomography (PET) were performed to evaluate the pathophysiologic condition in combination with cardiac catheterization and myocardial biopsy. The cardiac PET and SPECT images showed reduced myocardial blood flow, decreased fatty acid metabolism, and increased glucose utilization in the left ventricular lateral wall in spite of normal coronary angiography, no significant cardiac fibrosis, and inflammatory cell infiltration, which suggests that myocardial ischemia due to microcirculatory disturbance in hypermetabolic state associated with burn injury might be a causative mechanism of dilated cardiomyopathy in this case. A beta blocker, bisoprolol, was successfully introduced in this patient in combination with oral inotropic agents, pimobendan and digitalis after the prolonged use of intravenous dobutamine infusion, which might have been beneficial for this patient with burn-associated dilated cardiomyopathy not only to reduce regional myocardial ischemia but also to attenuate hypermetabolic state after severe burn injury. <Learning objective: Dilated cardiomyopathy complicated with burn injury has been reported to cause a sudden attack of dyspnea and death. This case report suggests that burn-associated dilated cardiomyopathy may be caused by relative myocardial ischemia due to microvascular disturbance in hypermetabolic state associated with burn injuries and can be treated effectively with beta blockers with or without oral inotropic agents.>.

Body temperature abnormalities in non-neurological critically ill patients: a review of the literature

Body temperature abnormalities, which occur because of several infectious and non-infectious etiologies, are among the most commonly noted symptoms of critically ill patients. These abnormalities frequently trigger changes in patient management. The purpose of this article was to review the contemporary literature investigating the definition and occurrence of body temperature abnormalities in addition to their impact on illness severity and mortality in critically ill non-neurological patients, particularly in patients with severe sepsis. Reports on the influence of fever on outcomes are inconclusive, and the presence of fever per se may not contribute to increased mortality in critically ill patients. In patients with severe sepsis, the impacts of elevated body temperature and hypothermia on mortality and the severity of physiologic decline are different. Hypothermia is significantly associated with an increased risk of mortality. In contrast, elevated body temperature may not be associated with increased disease severity or risk of mortality. In patients with severe sepsis, the effect of fever and fever control on outcomes requires further research.

Plasma mitochondrial DNA levels in patients with trauma and severe sepsis: time course and the association with clinical status

PURPOSE

This study aimed to investigate the serial changes in plasma levels of mitochondrial DNA (mtDNA) in patients with trauma and severe sepsis and the mechanism of increase in mtDNA levels and the association between the levels and severity.

MATERIALS AND METHODS

We conducted a prospective observational study of patients with trauma having injuries with an Abbreviated Injury Scale score of 3 or higher (n = 37) and patients with severe sepsis (n = 23). The mtDNA concentrations in clarified plasma were measured using real-time quantitative polymerase chain reaction.

RESULTS

Concentrations of mtDNA peaked on the day of admission (day 1) in patients with trauma, whereas they increased on day 1 and remained constant until day 5 in patients with sepsis. The mtDNA levels on day 1 correlated with the maximal levels of creatinine phosphokinase in patients with trauma (R(2) = 0.463, P < .05) but not in patients with sepsis (R(2) = 0.028, P = .43). The mtDNA levels on day 1 were significantly higher in nonsurvivors compared with survivors of trauma (P < .05) but not sepsis.

CONCLUSIONS

The levels of mtDNA were elevated during traumatic injury and severe sepsis, although time course and prognostic significance differed between the groups, suggesting that the mechanisms of mtDNA release into plasma differ.

Frequencies of HER-2/neu expression and gene amplification in patients with oesophageal squamous cell carcinoma

The utilisation of antitumour T cells induced by cancer vaccination with HER-2 peptides or antibodies (Herceptin) against HER-2, as immunotherapy for oesophageal cancer, is a novel and attractive approach. It is important to clarify the frequencies of HER-2 expression and gene amplification in patients with oesophageal squamous cell carcinoma (SCC) and to evaluate the relationship between HER-2 status and HLA haplotype, since the candidates for HER-2 peptide-based vaccination are restricted to a certain HLA haplotype. We determined the frequency of HER-2 expression using the HercepTest for immunohistochemistry and HER-2 gene amplification by fluorescence in situ hybridisation (FISH) assay in oesophageal SCC (n=66). HER-2-positive tumours (1+/2+/3+) analysed by a HercepTest were observed in 30.3% of all the patients and HER-2 gene amplification evaluated by FISH was observed in 11.0% of all the patients, in which all HercepTest (3+) tumours were found to have gene amplification and three of six moderately positive (2+) tumours showed gene amplification. Furthermore, HER-2-positive cells were present more diffusely and were larger within each tumour in the patients who were HercepTest 3+ than those who were HercepTest 1+. Moreover, the survival rate in HER-2-positive group was significantly worse than that in HER-2-negative group. Also, the survival rate in the patients with HER-2 gene amplification was significantly worse than that without HER-2 gene amplification. In addition, oesophageal SCC patients with both HLA-A24-positive and HER-2-positive tumours (1+/2+/3+) accounted for 26% of these cases, and both HLA-A2- and HER-2-positive tumours accounted for 18% of them.

A report of two cases of Werner's syndrome and review of the literature

Two cases of Werner's syndrome are reported. The first case is that of a man with grey hair since his 20s, and alopecia since aged about 50 years. At the age of 53 years, Werner's syndrome was diagnosed, along with a malignant soft tissue tumour of the hand. The patient underwent ray amputation for the tumour. The subsequent histopathological diagnosis was synovial cell sarcoma, and the patient died of lung metastasis at 15 weeks postsurgery. The second case is that of a woman diagnosed with diabetes mellitus when aged 34 years. At 39 years, a bilateral cataract was diagnosed and at 40 years, diabetic gangrene of the left calcaneal region and calcaneal osteomyelitis necessitated left below-knee amputation. The incidence of Werner's syndrome in Japan is extremely high (1000 of the around 1300 cases reported worldwide) compared to other countries. Most patients develop malignant tumour or arteriosclerosis, the most important complications of this syndrome. The average life expectancy for patients with Werner's syndrome is 46 years. The incidence of epithelial cancer and mesenchymal sarcoma is 10 times that of the general population. The onset of symptoms of Werner's syndrome generally precedes any later symptoms of associated conditions, such as malignant tumour. Therefore, early recognition of Werner's syndrome is important to assist identification of malignant tumours at an early stage in this patient group.

Acute occlusion of an abdominal aortic aneurysm--case report and review of the literature

Acute thrombosis of an abdominal aortic aneurysm (AAA) is a surgical emergency. Only 44 cases have been reported in the literature. The mechanism of the thrombosis has not been delineated. The proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, and dislodgment of a mural thrombus. Patients often present bilateral lower extremity ischemia, mimicking a saddle embolism. Systemic heparinization immediately after diagnosis and prompt surgical revascularization can reduce the mortality rate. The authors present a patient with sudden thrombosis of an AAA who was successfully treated with an axillobifemoral bypass graft. All published cases of thrombosed AAAs are analyzed.

Studies on feline CD8+ T cell non-cytolytic anti-feline immunodeficiency virus (FIV) activity

CD8+ T cells in FIV-infected cats inhibit feline immunodeficiency virus (FIV) replication by producing a soluble factor(s). In the present study, four SPF cats were experimentally infected with FIV. The period during which the anti-FIV activity of CD8+ T cells became detectable was investigated, and the presence or absence of this activity in the lymph nodes and spleen was examined. Furthermore, we investigated which step(s) of the FIV replication cycle are affected by this antiviral activity. This antiviral activity became detectable five weeks after FIV infection in early cases, and it was simultaneous with or one week after the induction of humoral immunity. All cats having CD8+ T cells with anti-FIV activity in the peripheral blood also possessed CD8+ T cells with anti-FIV activity in the lymph nodes. In contrast, CD8+ T cells from the spleens of some, but not all cats showed anti-FIV activity. CD8+ T cell-depleted peripheral blood mononuclear cells were cultured and reconstituted with CD8+ T cells on day 12 of culture after confirming FIV replication. The number of FIV proviral DNA copies in the cells did not change, but the amount of FIV p24 antigen production in the culture supernatant and the number of FIV mRNA copies in the cells decreased. These findings suggested that CD8+ T cell anti-FIV activity acts at the level of FIV mRNA synthesis from the FIV proviral DNA, inhibiting FIV replication by a non-cytolytic mechanism.

Spontaneously developed aneurysm of the ductus arteriosus in an adult

We report an unusual adult case of aneurysm associated with the ductus arteriosus. A 67-year-old female, who suffered recurrent nerve palsy, was diagnosed as having an aneurysm of the ductus arteriosus. The aneurysm, located in the medial aspect of the aortic ischimus and projected toward the pulmonary artery, was successfully repaired using a Dacron patch. A pathologic review of the aneurysm revealed the degeneration of the aortic media.

Coronary atherosclerosis with dual coronary artery fistulas

Coronary artery fistula (CAF) is an uncommon congenital anomaly. Bilateral CAFs, arising from both right and left coronary arteries are rare. Myocardial infarction is by far a less frequent complication of CAF than angina pectoris. Ligation of CAF and coronary artery bypass graft were performed in the treatment of coronary artery stenosis with CAF.

Coronary revascularization and abdominal aortic aneurysm repair in a patient with Behçet's diseases

Behçet's disease is a systemic disease characterized by oral aphta, genital ulcer, and ocular lesion. Arterial involvement is an uncommon complication of Behçet's disease, and it most frequently affects the abdominal aorta followed by the femoral artery and the pulmonary artery. Coronary lesions in Behçet's disease have been little reported in the literature. In this communication, we present a case with coronary artery stenosis and with subsequently developed supra-renal abdominal aortic aneurysm. The coronary lesions were revasculized with gastroepiploic artery, right internal mammary artery, and saphenous vein graft. Abdominal aortic repair was performed with partial cardiopulmonary stand by, because of the risk of coronary ischemia during the cross clamp including the celiac artery. To our knowledge, this is the first report of successful repair of combined lesions of the coronary and the abdominal aorta in a patient with Behçet's disease.

Genetic risk factor for abdominal aortic aneurysm: HLA-DR2(15), a Japanese study

PURPOSE

Autoimmunity has been proposed to play a role in the pathogenesis of the abdominal aortic aneurysm (AAA). Several autoimmune diseases are associated with specific HLA DR alleles. These experiments were carried out to determine whether the same HLA DR types that have been reported to be associated with AAA in a mixed North American population are similarly associated with AAA in a more homogeneous group of patients in Japan.

METHOD

HLA DR typing was performed by a serologic method on samples of peripheral blood of patients with nonspecific infrarenal AAA in Nagasaki University Hospital in Japan. The frequencies of HLA DR antigens were compared with those of volunteers approximately matched for age and sex from the same referral area.

RESULTS

HLA DR haplotypes were determined in 46 Japanese patients with AAA and in 50 patients in a control group. The HLA-DR2(15) antigen was observed in 27 (58.7%) patients (29 alleles 31.5%) with AAA and in 14 (28%) subjects (16 alleles 26.0%) in the control group (p < 0.005).

CONCLUSIONS

The data suggest that HLA-DR2(15) has an important role as a genetic risk factor for AAA in Japanese patients, as previously reported in a mixed North American population.

Hemodynamic effects of nicardipine and phentolamine in combination with norepinephrine in a canine low-output-state model

Norepinephrine (NE) is one of the most potent positive inotropic drugs available for the treatment of low-output state following open-heart surgery. However, its inotropic effect is often masked by a significant increase of peripheral vascular resistance due to marked vasoconstriction. The purpose of the present study was to investigate whether the use of nicardipine (Nc) and phentolamine (Ph) in combination with NE could ameliorate the adverse vasoconstrictive action of NE. A low-output-state (LOS) model was produced by global myocardial ischemia due to electrically induced intermittent ventricular fibrillations in open-chest dogs. Twenty-eight dogs were divided into 6 groups according to the drugs infused after producing LOS. In the control group, hemodynamic changes similar to the clinical low-output state were observed, e.g., a decrease in cardiac output (CO) and left ventricular dp/dt, and an increase in the systemic vascular resistance (SVR). The use of NE alone produced marked increases in the systemic arterial pressure (SAP), heart rate, and SVR, with a slight increase in CO. The infusion of Nc alone produced decreases in SVR and SAP with a slight increase in CO. The concomitant infusion of NE and Nc produced increases in SV and CO, and decreases in SAP and SVR. The infusion of Ph alone produced no significant hemodynamic changes. The combined use of NE and Ph produced increases in CO, SAP and heart rate, but not to a significant extent. These results suggest that there are major advantages in the concomitant use of NE and Nc for the control of LOS.

[Simultaneous mitral valve replacement and splenectomy in a patient with chronic idiopathic thrombocytopenic purpura]

A 57-year-old female with valvular heart disease and chronic idiopathic thrombocytopenic purpura (ITP) underwent successful open-heart surgery. Preoperative administration of steroids and high-dose gamma-globulin increased the platelet count from 3 x 10(4)/microgram at admission to 10 x 10(4)/microgram before the operation. Splenectomy followed by mitral valve replacement (SJM 27M) were performed simultaneously. No platelet transfusion needed during and after the operation owing to rapid increase in platelets that would occur following splenectomy. The postoperative course was uneventful. The present simultaneous splenectomy and open-heart operation appears to be a safe and effective procedure for minimizing perioperative blood loss in patients with ITP and heart disease.

The role of low-density lipoprotein apheresis as postoperative care of bypass grafting for chronic arterial occlusion

Since November 1989, low-density lipoprotein apheresis has been applied to patients with intractable hyperlipidaemia following bypass grafting for chronic arterial occlusion of the lower extremities. The treatment group comprised six patients (four men, two women) with arteriosclerosis obliterans. In five patients, the ankle pressure index deteriorated and intermittent claudication recurred due to atherosclerotic progression. Results of low-density lipoprotein apheresis were dramatic; the deteriorated ankle pressure index and intermittent claudication improved significantly after several applications of low-density lipoprotein apheresis. Significant angiographic improvement was obtained in two patients. It is concluded that low-density lipoprotein apheresis appears to be an efficient method to preserve graft patency and treat postoperative patients with deteriorated ankle pressure index.

Myocardial recovery during post-ischemic reperfusion: optimal concentrations of Na+ and Ca2+ in the reperfusate and protective effects of amiloride added to cardioplegic solution

The effects of Na+ and Ca2+ concentrations in the reperfusate on post-ischemic myocardial recovery were examined. Also, the myocardial protective effects of amiloride, an inhibitor of the Na+/Ca2+ and Na+/H+ exchange systems, added to cardioplegic solutions were assessed, using an isolated working rat heart perfusion system. Global myocardial ischemia was induced by 30-min normothermic cardioplegic arrest, using St. Thomas' solution. The concentration of Na+ in the reperfusate varied, stepwise, from 75 to 145 mM/l, and that of Ca2+, from 0.1 to 2.5 mM/l. In this study post-ischemic functional recovery was best at 110mM/l Na+ and 1.2-1.8 mM/l Ca2+ in the reperfusate. A significantly greater post-ischemic functional recovery and a lower creatine kinase release were observed when amiloride was added to the cardioplegic solution. Ca2+ overload via Na+/Ca2+ and Na+/H+ exchange systems would, thus, appear to be due, at least in part, to post-ischemic reperfusion injury.

Computational analysis of a holographic optical head configuration

The best configuration for holographic optical heads for compact disk players is discussed from the viewpoint of considering the misalignment allowance for head components. Focus-error and trackingerror signals of the proposed head configurations are simulated with a ray-tracing method and by using optical cross transfer function theory. The misalignment allowance for the head components, such as the objective lens, the holographic optical element, and the photodetector, are calculated for several configurations. The misalignment allowance is found to increase greatly when the holographic optical element is placed in close proximity to the objective lens and then when this assembly is moved as a unit.

Protective action of aromatic compounds against cold-shock injuries in boar spermatozoa

Butylated hydroxytoluene has been known to protect spermatozoa from cold shock injury. To determine whether such protective action is a common property of aromatic compounds, the effect of 14 hydrophobic and 2 hydrophilic aromatic compounds on the protection of boar spermatozoa from cold shock was investigated. The majority of the hydrophobic compounds tested provided protection; the hydrophilic compounds were ineffective. Of the aromatic compounds tested, naphthalene was most effective in reducing the effect of cold shock on motility and acrosomal integrity of boar spermatozoa.

Influence of melatonin on reproductive behavior in male rats

The influence of melatonin on reproductive behavior was examined by administering it to pinealectomized male rats for 30 consecutive days. After the 30-d administration of melatonin or vehicle, each male rat was introduced into a female rat's cage on the day of proestrus and allowed to mate overnight. All rats administered the vehicle and the pinealectomized rats copulated; five of the twelve melatonin (8.0 mg/kg)-treated rats did not copulate. These findings suggest that melatonin inhibits the reproductive behavior of male rats.

Studies on the relationship between serum colloidal reactions (ZTT and TTT) and IgG subclasses, especially IgG1 and IgG2

The relationship between zinc sulfate turbidity test (ZTT and thymol turbidity test (TTT), and IgG subclasses, especially IgG1 and IgG2, was studied. Serum colloidal reactions of specimens from patients with IgG-myeloma usually show abnormally high values in ZTT and low values in TTT. But in some cases, values in ZTT and TTT are both low, and in a few cases both values are abnormally high. In order to see the reason why IgG-myelomas are classified into these three groups according to serum colloidal reactions. IgG subclasses of monoclonal proteins (MPs) isolated by zone electrophoresis were determined by immunodiffusion with anti IgG-subclasses. Results revealed that IgG1-myeloma showed high ZTT and low TTT and IgG2-myeloma showed low ZTT and TTT. Only two out of our 29 cases with IgG-myeloma showed high ZTT and TTT. MP from one of them belonged to IgG1-kappa and that from the other to IgG2-lambda. We checked the relationship between turbidity tests and electrophoretic mobility of MP and also that between these tests and L-chains' type of MP, but did not find any relationship between them. These findings suggest that IgG1 innately reacts with ZTT but not with TTT, while IgG2 does not react with any of these tests. MP from cases showing high values in both ZTT and TTT may have a special idiotype.

[A double monoclonal IgG1-kappa and IgG3-lambda with electrophoretically same mobility in a single patient]

The serum from a 78-year-old male (SY) with abdominal aneurysm was shown to contain monoclonal protein (MP) of IgG. Immunoelectrophoresis (IEP) and immunofixation electrophoresis (IFE) of SY serum revealed MP reacted with both of anti kappa and anti lambda antisera. To see whether the monoclonal IgG molecule possesses both types of light chains, an attempt to separate MPs isolated by zone electrophoresis was made by affinity chromatography using anti kappa and anti lambda Sepharose 4 B conjugates. Immunodiffusion (ID) of these separated MPs showed that kappa type of MP (MP-kappa) was IgG1, while lambda type of MP (MP-lambda) was IgG3. For preparation of anti-idiotype antibodies (Aid) against MP-lambda, antisera against MP-lambda raised in rabbits by immunization with affinity-chromatographic purified MP-lambda was absorbed with solid phase normal human serum. ID and IFE of these MPs (original MP, MP-lambda and MP-kappa) revealed MP-kappa did not react with Aid, suggesting idiotype of MP-kappa was different from that of MP-lambda. These results indicate that two types of MPs derived from different B cell clones happen to have same mobility electrophoretically.

Serum CA125 level is a good prognostic indicator in lung cancer

The serum CA125 level was determined by a one-step immunoradiometric assay method in patients with lung cancer. Increased serum CA125 levels were observed in 37.8% of patients with squamous cell cancer, in 30.0% of those with adenocarcinoma and in 60.0% of those with small call cancer. Most patients with increased serum CA125 levels were in stages 3 or 4. Patients with pleural effusions or ascites showed high serum CA125 levels. The survival time was significantly shorter in patients with increased serum CA125 levels than in those within normal limits. Among patients with advanced disease (stages 3 and 4), an increased serum CA125 level was again a poor prognostic factor (P less than 0.01). The existence of a pleural effusion did not correlate with the survival time. We conclude that CA125 is a good indicator of disease extent and serum levels correlate to the length of survival.

Idiotypical identity of IgG myeloma protein with monoclonal IgM, Bence Jones protein, and Fv derived from one patient

Serum from a patient (KK) with IgG2-lambda myeloma was shown to contain multiple paraproteins corresponding to an IgM-lambda monoclonal protein (MMP), a lambda-type Bence Jones protein (BJP), and a 30 kDa component in addition to the IgG2 myeloma protein (GMP). These proteins possessed common idiotypic determinants, as judged by their monoclonal reactivity with rabbit anti-GMP idiotype antibody (aId) in the immunofixation electrophoresis. Analysis with aId absorbed with either H or L chain of GMP revealed that the 30 kDa component shared both VH and VL with GMP and MMP, while BJP carried only the VL idiotype. The 30 kDa component, however, failed to react with antibody to either the mu, gamma, alpha, kappa, or lambda isotype, indicating that it had an Fv-like molecular composition. These results suggest that myeloma cells of KK had diverged from the same precursor B cell clone to produce MPs of different isotypes and altered molecular constructions.

[A case of a gastric cancer patient with high serum pepsinogen levels at relapse]

A rare case of a 68-year-old female cancer patient with an extremely high serum level of pepsinogens (PG) at relapse is presented. She had stage 3 Borrmann 3 type gastric cancer which was a poorly differentiated adenocarcinoma. Her postoperative serum PG levels had been within normal limits (23.0 ng/ml for PG-I and 3.2 ng/ml for PG-II), but at the time of the peritoneal relapse they were 5,630 ng/ml and 3,380 ng/ml, respectively. After was chemotherapy initiated, her serum PG levels decreased in parallel with an improvement of her clinical status. Immunohistochemical examination with monoclonal antibodies revealed PG-I and PG-II production in the primary and the metastatic lesions.

[Evaluation of serum pepsinogen I and II of patients with gastric cancer]

Serum pepsinogen levels were examined by immunoradiometric assay method for evaluating its clinical usefulness in gastric cancer. In patients with gastric cancer, serum PG-I tended to decrease but PG-II stayed normal level, resulting in low PG-I/PG-II ratio. Combination of PG-I and PG-I/PG-II discriminated 53.7% of gastric cancer, 70.6% of scirrhous type gastric cancer, and 66.7-100% of those arisen in the upper portion of the stomach, but 13.7% of normal subjects. As the aged normal subjects tended to show decreased PG-I/PG-II ratio (about 30% of the normal subjects aged over 40 years were discriminated as abnormal), the usefulness for detection of gastric cancer seems to be limited, but some types of gastric cancer such as scirrhous type or one arisen in the upper portion may be discriminated by this method. It is also suggested that this method may detect the recurrence of the cancer in some patients.

[A case of acute spinal epidural hematoma in a patient with antiplatelet therapy]

The authors report a case of acute spinal epidural hematoma occurring in a patient receiving antiplatelet drugs. A 76-year-old man with a history of cerebral infarction had been taking antiplatelet agents for one year. He suddenly developed severe back pain which woke him from sleep, and numbness of his lower extremities was then noted. He was hospitalized 15 hours later. Neurological examination revealed flaccid paralysis of both lower extremities with negative Babinski's reflex, and sensory disturbance below the level of L1. The bleeding time and prothrombin time were prolonged. Computed tomographic (CT) scan revealed a biconvex, relatively hyperdense mass in the posterior spinal canal at the level of T12. Metrizamide myelography disclosed an incomplete blockage caused by an epidural mass at the level of T11. Post-myelographic CT scan demonstrated a sharply demarcated extradural filling defect at the level of T11. Seventeen hours after the onset of symptoms, an emergency laminectomy was performed extending from T12 to L3, and the epidural clot was totally evacuated. Histological examination of the capsule of the hematoma revealed no vascular anomalies. The patient made a good postoperative recovery. To the authors' knowledge, this is the first reported case of spontaneous intraspinal hemorrhage in a patient taking antiplatelet drugs. Acute onset of persistent pain anywhere along the spinal axis and the development of spinal neurological deficits in a patient on antiplatelet therapy should raise the suspicion of a spinal epidural hematoma. It should be stressed that prompt neuroradiological diagnosis and rapid surgical decompression are essential to allow good recovery. The present case illustrates that neurological emergencies can occur in patients receiving antiplatelet therapy.

Effect of C-reactive protein on peritoneal macrophages. I. Human C-reactive protein inhibits migration of guinea pig peritoneal macrophages

The effect of human C-reactive protein (CRP) isolated and purified from pooled patients' sera on macrophage function, especially on macrophage migration, was studied. Peritoneal exudate cells (PEC) from guinea pigs were used for macrophage migration inhibition (MMI) test of capillary method. Migration of either PEC or adherent purified macrophages exposed to CRP were inhibited dose-dependently. These findings indicate that CRP inhibits macrophage migration directly, not via activation of lymphocytes contained in PEC. As control, we examined the effect of normal human serum, anti C-polysaccharide antibodies isolated from patients' sera, and free endotoxin at the dose contaminated in CRP preparation on macrophage migration and found that none of them were effective. The effect of CRP on MMI of sensitized PEC exposed to antigen was also studied. Large amounts of CRP inhibited MMI induced by antigen, indicating the possibility that CRP may act on macrophages competitively with migration inhibitory factor (MIF) and may modulate MMI. CRP possesses MIF-like activity and may play a functional role at the site of tissue injury by causing the accumulation of macrophages.

Effect of C-reactive protein on peritoneal macrophages. II. Human C-reactive protein activates peritoneal macrophages of guinea pigs to release superoxide anion in vitro

The effect of human C-reactive protein (CRP) on macrophage function was studied in an assay of superoxide anion (O2-) production. Peritoneal exudate macrophages (PEM) of guinea pigs exposed in vitro to various doses of CRP for 72 hr resulted in the development of O2- production dose-dependently, measured by increases in superoxide dismutase-inhibitable nitro blue tetrazolium reduction. The O2--producing activity of PEM cultured without CRP, used as a control, decreased markedly in proportion to incubation time. The O2- production by PEM exposed to CRP for 18 hr when control PEM were still high in O2- production, was decreased by larger doses of CRP, while PEM cultured without CRP for 72 hr, when O2- production by control PEM was very low, followed by incubation with CRP for another 18 hr, produced O2- CRP-dose-dependently as in the case of that observed after 72-hr incubation with CRP. These results indicate that CRP is capable of activating macrophages and acts on macrophage function as a modulator. CRP possesses migration inhibitory factor (MIF)-like activity (as reported in the preceding paper) and also macrophage-activating factor (MAF)-like activity, indicating that CRP may play a functional role at the site of inflammation and tissue damage by accumulating and activating macrophages.

[A case of leukoencephalopathy caused by HCFU]

After a hysterectomy, a bilateral salpingo-oophorectomy, two courses of intra-peritoneal chemotherapy of Cisplatinum, Carmofur (HCFU, 600 mg/day [per os]) were given a patient who had ovarian granulosa cell tumor (malignant, stage Iai). Dizziness and loss of consciousness developed about 60 days after administration of HCFU, and leucoencephalopathy was diagnosed. A CT revealed a diffuse low density area in the white matter of the cerebrum. Myelin Basic Protein in the spinal fluid was found to amount to 9.8 mg/dl, which in norm. person is less than 4.0 mg/dl. Also, it showed parallel changes with the course of the clinical findings. HCFU easily dissolves to fat and changes to 5-FU without enzymes in the liver cell. Further HCFU also passes through Blood Brain Barrier to Produce 5-FU and its derivatives, in which the alpha-Fluoro-beta-Alanine is thought to be the culprit that brings on leucoencephalopathy. Even so, HCFU should be dosed when needed in spite of this risk. Other 5-FU modifiers also have been reported to produce the same effect in several cases.

[Clinico-pathological analysis of stage IIIa carcinoma of the cervix uteri]

We have reviewed cervical carcinoma IIIa cases treated at the University of Hirosaki Hospital from 1970 to 1984 and at the Metropolitan Komagome Hospital from 1975 to 1984. In this period, 32 cases were staged at IIIa, and this group accounts for less than 2% of all cervical cancer cases at these two institutions. The age of the 32 patients ranged from 33 to 86 years with a mean age of 66. In treatment methods, 3 cases were operated on and other cases were irradiated by a combination of intracavitary therapy and external beam therapy. The actuarial 5-year survival rate was 78.3%, and the relative 5-year survival rate was 86%. Our results suggest that FIGO stage IIIa carcinoma of the cervix has a much better prognosis than FIGO stage IIIb cervical cancer.