Rapid in vivo evaluation system for cholestasis-related genes in mice with humanized bile acid profiles

BACKGROUND

Pediatric cholestatic liver diseases (Ped-CLD) comprise many ultrarare disorders with a genetic basis. Pharmacologic therapy for severe cases of Ped-CLD has not been established. Species differences in bile acid (BA) metabolism between humans and rodents contribute to the lack of phenocopy of patients with Ped-CLD in rodents and hinder the development of therapeutic strategies. We aimed to establish an efficient in vivo system to understand BA-related pathogenesis, such as Ped-CLD.

METHODS

We generated mice that express spCas9 specifically in the liver (L-Cas9Tg/Tg [liver-specific Cas9Tg/Tg] mice) and designed recombinant adeno-associated virus serotype 8 encoding small-guide RNA (AAV8 sgRNA) targeting Abcc2, Abcb11, and Cyp2c70. In humans, ABCC2 and ABCB11 deficiencies cause constitutional hyperbilirubinemia and most severe Ped-CLD, respectively. Cyp2c70 encodes an enzyme responsible for the rodent-specific BA profile. Six-week-old L-Cas9Tg/Tg mice were injected with this AAV8 sgRNA and subjected to biochemical and histological analysis.

RESULTS

Fourteen days after the injection with AAV8 sgRNA targeting Abcc2, L-Cas9Tg/Tg mice exhibited jaundice and phenocopied patients with ABCC2 deficiency. L-Cas9Tg/Tg mice injected with AAV8 sgRNA targeting Abcb11 showed hepatomegaly and cholestasis without histological evidence of liver injury. Compared to Abcb11 alone, simultaneous injection of AAV8 sgRNA for Abcb11 and Cyp2c70 humanized the BA profile and caused higher transaminase levels and parenchymal necrosis, resembling phenotypes with ABCB11 deficiency.

CONCLUSIONS

This study provides proof of concept for efficient in vivo assessment of cholestasis-related genes in humanized bile acid profiles. Our platform offers a more time- and cost-effective alternative to conventional genetically engineered mice, increasing our understanding of BA-related pathogenesis such as Ped-CLD and expanding the potential for translational research.

Influence of food on pharmacokinetics and pharmacodynamics of 4-phenylbutyrate in patients with urea cycle disorders

Urea cycle disorders (UCDs), inborn errors of hepatocyte metabolism, cause hyperammonemia and lead to neurocognitive deficits, coma, and even death. Sodium 4-phenylbutyrate (NaPB), a standard adjunctive therapy for UCDs, generates an alternative pathway of nitrogen deposition through glutamine consumption. Administration during or immediately after a meal is the approved usage of NaPB. However, we previously found that preprandial oral administration enhanced its potency in healthy adults and pediatric patients with intrahepatic cholestasis. The present study evaluated the effect of food on the pharmacokinetics and pharmacodynamics of NaPB in five patients with UCDs. Following an overnight fast, NaPB was administered orally at 75 mg/kg/dose (high dose, HD) or 25 mg/kg/dose (low dose, LD) either 15 min before or immediately after breakfast. Each patient was treated with these four treatment regimens with NaPB. With either dose, pre-breakfast administration rather than post-breakfast administration significantly increased plasma PB levels and decreased plasma glutamine availability. Pre-breakfast LD administration resulted in a greater attenuation in plasma glutamine availability than post-breakfast HD administration. Plasma levels of branched-chain amino acids decreased to the same extent in all tested regimens. No severe adverse events occurred during this study. In conclusion, preprandial oral administration of NaPB maximized systemic exposure of PB and thereby its efficacy on glutamine consumption in patients with UCDs.

A randomized trial to examine the impact of food on pharmacokinetics of 4-phenylbutyrate and change in amino acid availability after a single oral administration of sodium 4-phenylbutyrarte in healthy volunteers

Urea cycle disorders (UCDs), inborn errors of hepatocyte metabolism, result in the systemic accumulation of ammonia to toxic levels. Sodium 4-phenylbutyrate (NaPB), a standard therapy for UCDs for over 20 years, generates an alternative pathway of nitrogen deposition through glutamine consumption. Administration during or immediately after a meal is the accepted use of NaPB. However, this regimen is not based on clinical evidence. Here, an open-label, single-dose, five-period crossover study was conducted in healthy adults to investigate the effect of food on the pharmacokinetics of NaPB and determine any subsequent change in amino acid availability. Twenty subjects were randomized to one of four treatment groups. Following an overnight fast, NaPB was administered orally at 4.3 g/m² (high dose, HD) or 1.4 g/m² (low dose, LD) either 30 min before or just after breakfast. At both doses, compared with post-breakfast administration, pre-breakfast administration significantly increased systemic exposure of PB and decreased plasma glutamine availability. Pre-breakfast LD administration attenuated plasma glutamine availability to the same extent as post-breakfast HD administration. Regardless of the regimen, plasma levels of branched-chain amino acids (BCAA) were decreased below baseline in a dose-dependent manner. In conclusion, preprandial oral administration of NaPB maximized systemic exposure of the drug and thereby its potency to consume plasma glutamine. This finding may improve poor medication compliance because of the issues with odor, taste, and pill burden of NaPB and reduce the risk of BCAA deficiency in NaPB therapy.

Modeling Human Bile Acid Transport and Synthesis in Stem Cell-Derived Hepatocytes with a Patient-Specific Mutation

The bile salt export pump (BSEP) is responsible for the export of bile acid from hepatocytes. Impaired transcellular transport of bile acids in hepatocytes with mutations in BSEP causes cholestasis. Compensatory mechanisms to regulate the intracellular bile acid concentration in human hepatocytes with BSEP deficiency remain unclear. To define pathways that prevent cytotoxic accumulation of bile acid in hepatocytes, we developed a human induced pluripotent stem cell-based model of isogenic BSEP-deficient hepatocytes in a Transwell culture system. Induced hepatocytes (i-Heps) exhibited defects in the apical export of bile acids but maintained a low intracellular bile acid concentration by inducing basolateral export. Modeling the autoregulation of bile acids on hepatocytes, we found that BSEP-deficient i-Heps suppressed de novo bile acid synthesis using the FXR pathway via basolateral uptake and export without apical export. These observations inform the development of therapeutic targets to reduce the overall bile acid pool in patients with BSEP deficiency.

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Human isogenic iPSCs were generated by CRISPR to study a truncating mutation of BSEP

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iPSC-derived hepatocytes recapitulate pathophysiology of BSEP deficiency in patients

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BSEP-deficient hepatocytes induce alternative basolateral bile acid export

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Activation of FXR suppresses de novo bile acid synthesis in BSEP-deficient hepatocytes

Efficacy of neutrophil elastase inhibitor on type A acute aortic dissection

BACKGROUND

Surgery for type A acute aortic dissection (AAD) is associated with a high mortality and incidence of postoperative complications, including acute respiratory failure and coagulopathy. Aim of the study was to investigate the effects of sivelestat on pulmonary function and coagulopathy in patients undergoing surgery for AAD.

METHODS

Sixty patients undergoing emergency ascending replacement for AAD were divided into two groups. Group I was administered sivelestat intravenously from the beginning of surgery until extubation. Group II was not treated with sivelestat. The platelet count, antithrombin III (AT III) level, leukocyte count, C-reactive protein (CRP) level, prothrombin time (PT), activated partial thrombin time (APTT), and prothrombin time-international normalized ratio (PT-INR) were measured.

RESULTS

The postoperative decrease of AT III and the platelet count on admission to the intensive care unit (ICU) and 3 hours later were significantly less in group I. The leukocyte count and the values of CRP, PT, APTT, and PT-INR did not differ significantly between the groups. The duration of mechanical ventilation after surgery tended to be shorter in group I.

CONCLUSIONS

Sivelestat significantly reduced the postoperative decreases in AT III and platelet count in patients undergoing emergency surgery for AAD.

Clinical and immunohistochemical characteristics of benign giant cell tumour of bone with pulmonary metastases: case series

PURPOSE

Giant cell tumour of bone with pulmonary metastases is rare. However, some patients die of pulmonary metastases, and histological examination cannot distinguish between benign tumour and malignant metastases. In this study, we present clinical and immunohistochemical findings associated with giant cell tumour of bone with pulmonary metastases.

METHODS

Five patients with benign giant cell tumour of bone with pulmonary metastases (one man and 4 women) were studied. Patients' ages ranged between 20 and 23 years (mean age, 21.8 years). Tumours were in the distal femur in 2 cases, and in the proximal tibia, distal tibia, and lumbar spine in one case each. The tissue specimens from primary tumours, recurrent tumours, and pulmonary metastases were studied using immunohistochemical techniques.

RESULTS

Three of the 5 primary tumours were of the spontaneous regression or growth cessation type, or the continuously slow-growing type, showing 4.2% to 6.2% of positive cells for Ki-67 after immunohistochemical staining. However, 2 patients with the rapid-growing type of disease died of pulmonary metastases; their primary, recurrent, and metastatic tumour specimens contained 9.0% to 11.5% of positive cells for Ki-67.

CONCLUSION

Three of the 5 primary tumours had a benign clinical pattern and immunohistochemistry. Two of the 5 patients died of pulmonary metastases, which had an aggressive clinical pattern and a high prevalence of positive cells in Ki-67. Examination of Ki-67 should be carried out for aggressive type of giant cell tumour.

Surgical management of malignant soft tissue tumours in patients aged 65 years or older

OBJECTIVE

With the aim to determine the most effective treatment for primary malignant musculoskeletal tumours in patients aged 65 years or older, we reviewed cases of low- and high-grade neoplasms, surgical margins, surgical methods, and the prognoses of elderly and aged patients at our institution.

METHODS

Records of 25 patients aged 65 years or older who had malignant soft tissue tumours from December 1986 to February 1997 were reviewed. Low- and high-grade neoplasms accounted for 8 and 17 patients, respectively. 11 patients were aged 65 to 69 years, while 14 were 70 years or older. Surgical margins were wide in 19 cases, marginal in 4, and intralesional in 2. Reconstruction was done using 6 musculocutaneous flaps and/or 4 vessel grafts. As adjuvant therapy, radiotherapy was used in 5 cases and chemotherapy in 3. There was no recurrence in patients with wide surgical margins (determined on the basis of gross inspection of the excised tumour and the cut surface); but there was recurrence in 4 patients with marginal margins, and one patient with intralesional margin. Two patients with intralesional, 4 with marginal, and 2 with wide margins, died from recurrence at the primary site and metastasis, or from metastasis without recurrence at the primary site.

RESULTS

Follow-up periods ranged from 4 months to 180 months (mean, 91.6 months). The overall 5-year survival rate was 79.6%; for low- and high-grade neoplasms, the figures were 100% and 69.7%, respectively; for those aged 65 to 69 years and in their 70's or older, the figures were 90.9% and 70.1%, respectively.

CONCLUSION

For geriatric patients, wide surgical margins are required to manage both low- and high-grade neoplasms, in order to avoid multiple surgeries.

Off-pump Coronary Artery Bypass Grafting in patients on chronic hemodialysis

BACKGROUND

Off-pump Coronary Artery Bypass Grafting(CABG) has gained much support but has been scarcely reported in patients on chronic hemodialysis (HD). The details of CABG for such patients on chronic HD are presented.

METHODS

Between January 1998 and December 1999, off-pump CABG was performed in 5 patients on chronic HD. All patients presented with unstable angina pectoris. The indication for off-pump CABG was suitable coronary anatomy (N = 5) and expected high risks associated with cardiopulmonary bypass due to reoperation (N = 1) and impaired cerebral blood flow (N = 2). The approach was median sternotomy (N = 4) and left anterior short thoracotomy (N = 1). The mean graft number was 2.0 +/- 1.0 (range, 1-3). In situ arterial grafts were mainly used: the in situ left internal thoracic artery was used in four patients, the in situ right gastroepiploic artery in two, the in situ right internal thoracic artery in two, and the saphenous vein in two patients.

RESULTS

There were no deaths or complications. Nine of 10 grafts were confirmed fully patent by postoperative angiography before hospital discharge. In a mean follow-up of 17.2 months, no patients had developed recurrence of angina or any cardiac symptom.

CONCLUSION

Off-pump CABG using in situ arterial grafts can be performed on patients on chronic hemodialysis subject to suitable anatomy of the target coronary arteries.

[A case of quadricuspid aortic valve associated with coronary artery disease]

A 65-year-old man with aortic regurgitation was found to have a quadricuspid aortic valve. Surgical correction consisted of aortic valve replacement with a 21 mm Hyper dynamic plus St. Jude Medical valve and coronary revascularization of LAD and the first diagonal branch. During the operation, a quadricuspid aortic valve with 1 smaller and 3 larger cusps and normal coronary orifice were noticed. Accurate information by the transesophageal echo proved to be quite valuable. Our case is one of 43 cases which have been reported in Japan.

Effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde for decreasing risk of transmission of hepatitis C virus

OBJECTIVES

The effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde in decreasing the risk of transmission of hepatitis C virus (HCV) was examined.

METHODS

Gastroendoscopes used for treatment of endoscopic esophageal variceal ligation in patients with HCV infection were manually cleaned and disinfected with 3% glutaraldehyde (n = 25), 2% glutaraldehyde (n = 17), or 0.1% benzethonium chloride (n = 25). Samples were obtained by pouring 20 ml of 0.9% NaCl solution into the biopsy-suction channel of the scope before and after cleaning and disinfection. HCV was detected with the polymerase chain reaction.

RESULTS

Of the 25 scopes in 3% glutaraldehyde group, nine (36%) were positive for HCV before cleaning and disinfection, but all became negative after cleaning and disinfection; the difference was statistically significant (p < 0.01). In contrast, in 2% glutaraldehyde group and in the routine cleaning group, there were no significant differences in the number of positive samples between before and after cleaning and disinfection.

CONCLUSION

Manual cleaning and disinfection of gastroscopes with 3% glutaraldehyde is useful for decreasing the risk of transmission of HCV among patients.

Immediate and long-term results of coronary artery bypass operation in hemodialysis patients

This study evaluated the early and late results of coronary artery bypass grafting (CABG) in patients on long-term maintenance hemodialysis (chronic HD) at Teikyo University Ichihara Hospital between January 1996 and June 2000. Thirty-six patients on chronic HD underwent CABG. There were 26 males (72%) and 10 females (28%) ranging from 41 to 81 years (mean +/- SD, 61.8 +/- 9.2 years) of age. Twenty-one patients (58%) had unstable angina, 14 (39%) stable angina, and 1 acute myocardial infarction. Eleven patients (31%) had urgent or emergency CABG. The average graft number was 2.5 +/- 0.8 (arterial graft 1.3 +/- 0.7/patient). Six patients had concomitant cardiac operations. Three patients underwent re- or a second re-CABG. Five patients underwent off-pump CABG. Principally, HD was performed during cardiopulmonary bypass and was followed by continuous hemodiafiltration in the early postoperative period. The early mortality was 11%; 25% in emergency and urgent CABG and 4% in elective CABG. In the follow-up period between 1 and 53 months (mean +/- SD 21.9 +/- 15.1 months), 4 patients died, and 9 patients developed recurrence of angina pectoris (6, occlusion of saphenous vein graft and 3, native coronary progression). Six patients had coronary intervention. The postoperative angiogram showed that all arterial grafts were patent, but the patency of the vein grafts was only 61.5%. The early results of CABG in patients on chronic HD was satisfactory. The late recurrence of angina pectoris mostly was caused by occlusion of the saphenous vein graft. In conclusion, the aggressive use of arterial grafts is crucial in CABG for patients on chronic HD.

Hemipelvic allograft reconstruction after periacetabular bone tumor resection

We reviewed the results of 19 patients with hemipelvic allograft reconstructions after periacetabular tumor resection at Massachusetts General Hospital from 1977 to 1996. Histological diagnosis showed chondrosarcoma (in 7 patients), osteosarcoma in 5, and other tumors in 7. Seventeen patients were continuously disease-free for 12-228 months (mean, 57 months). One patient died of sepsis caused by wound infection after surgery for local recurrence. Results of evaluation (by the Mankin scale) in the 19 patients were: excellent in 1, good in 6, fair in 5, and failure in 7. Of the 19 patients, 5 (28%) had wound infection, and 3 patients had local recurrence. Allograft fracture was observed in 1 patient. Allograft and bipolar prosthesis were used in 11 patients, and migration of the bipolar prosthesis was observed in 4 of these patients. In 7 patients the femoral head was preserved; 2 patients received total hip arthroplasty because of osteoarthrosis in the hip joint or collapsed allograft. Migration of the bipolar prosthesis, with eventual osteoathrosis in the hip joint was also observed. However, hemipelvic allograft was thought to be an alternative useful reconstruction method despite the unresolved problems of loosening, dislocation, and breakage of the custom-made prosthetic hemipelvis.

Interleukin-1 alpha producing synovial sarcoma with prolonged fever: a case report

The patient had a synovial sarcoma of the monophasic fibrous type accompanied by prolonged spike fever. Wide excision of the tumor resulted in the disappearance of her fever. The tumor cells showed interleukin-1 alpha (IL-1 alpha) expression immunohistochemically. IL-1 alpha cDNA was detected in the tumor by RT-PCR, the sequences of which were identical with those of normal human IL-1 alpha molecules. These results indicated that IL-1 alpha, one of the fever-inducing cytokines, was expressed by sarcoma cells in the present case, which were thought to be a causative factor of the fever.

Detection of Epstein-Barr virus-encoded small RNA 1 and latent membrane protein 1 in synovial lining cells from rheumatoid arthritis patients

Several investigators have demonstrated an association between Epstein-Barr virus (EBV) and the pathogenesis of rheumatoid arthritis (RA). However, there is no direct evidence that this virus exists in the synovial cells of patients with RA. We attempted to detect EBV in synovial cells from RA patients. Specimens of synovial tissues from 34 patients with RA and from 20 patients with osteoarthritis (OA), and from one patient with psoriatic arthritis as controls, were examined for evidence of the EBV by in situ hybridization. The specimens were also tested by immunoperoxidase staining for expression of the CD21 molecule (EBV receptor), EBV nuclear antigen (EBNA)-2 and latent membrane protein (LMP)-1. EBV-encoded small RNA-1 (EBER) was demonstrated in synovial lining cells from eight (23.5%) out of 34 RA patients but in none of 20 OA patients (P < 0.05) nor in the one psoriatic arthritis patient. Interestingly, EBER localized in synovial lining cells that were located at the apex of villus proliferating lesions. Furthermore, LMP-1 was also detected in synovial lining cells at the top of villus lesions. Nevertheless, CD19 and CD21 molecules, and EBNA-2 were not demonstrated in such lesions. The incidence of EBV-positive in synovial lining cells with severely infiltrated lymphocytes tended to be higher than that in moderately infiltrated ones. This is the first evidence that EBV exists in chronically inflamed synovial lining cells of human joints in RA.

Analysis of giant cell tumor of bone with pulmonary metastases

The authors reviewed 6 cases of giant cell tumor of bone with pulmonary metastases, analyzed the growth rate of the metastases, and performed flow cytometry on paraffin blocks from primary and metastatic lesions. Surgery on the pulmonary metastases was done in 3 cases. Chemotherapy was administered in all 6 cases. If the doubling time of the pulmonary metastases was more than 80 days, the case was considered to be slow growing or in regression. However, if the doubling time was approximately 30 days, the prognosis was poor. The cases were divided into 3 types according to the prognosis. After chemotherapy (cyclophosphamide), the pulmonary metastases decreased in size in 2 cases. In 2 other cases, the metastases were slow growing, and the remaining 2 patients died early. Flow cytometric analysis was performed on primary and metastatic lesions, which showed a diploid pattern in most cases, but a tetraploid pattern in 1 recurrent case. Pulmonary metastatic lesions displayed a diploid pattern in 4 cases from which materials were taken either at surgery or autopsy.

Description of new composite tissue transfer for salvage of a complex hand defect

Leiomyosarcoma of the soft tissue involving bones is an extremely rare tumor. In the past, a hand tumor of this type required amputation. Presently, with improved chemotherapy and reconstruction, the hand and its dexterity sometimes can be saved. In this case, after chemotherapy, the authors opted for wide excision including the skin, tendons, muscles, and bones. The large defect was reconstructed with an iliac crest autograft and a dorsalis pedis free flap including tendons. Functional result was excellent in this patient. The pathologic results also were reviewed by histology, immunohistochemistry for muscle marker, and electron microscopy.

[The effects of preoperative drinking and H2 blocker on gastric acid secretion]

We studied the effects of preoperative drinking and H2 blocker on gastric acid secretion in 63 patients (ASA I-II, > 18yrs) scheduled for afternoon surgery. Group A (n = 20), as a control, was not permitted to eat and drink from 9 pm, the day before surgery, and was then given 500 ml of maintainance fluid before anesthesia. Group B (n = 20) fasted from 9 pm the day before surgery, and was allowed to drink clear fluids until 2hs before anesthesia. Group C (n - 23) followed the same guidelines as group B, and was given famotidine (20mg) orally at 9 pm the day before and 2hs before anesthesia. After induction, a Salem sump tube was inserted into the stomach and a gastric fluid aspiration was performed. The fluid volume and pH were measured after collection. Gastric pH was significantly higher (P < 0.001) in group C (6.4 +/- 0.9) than in groups A (3.1 +/- 1.8) and B (2.7 +/- 1.8). Fluid volume was similar in each group (A; 11 +/- 9/B; 12 +/- 9/C; 12 +/- 13ml). The dilution of gastric acid by the ingested fluid was not observed. We conclude that preoperative drinking does not affect gastric contents in elective operative patients. To reduce the risk of developing aspiration pneumonia, we recommend that every patient should receive an oral H2 blocker.

Human T-lymphotropic virus type I associated myelopathy treated effectively with lymphocytapheresis using a leukocyte removal filter

The patient, a 61-year-old woman, received a blood transfusion at the age of 33 years. Weakness of the lower extremities developed at the age of 42 and the diagnosis of human T-lymphotropic virus type I (HTLV-I) associated myelopathy was made. Somatosensory evoked potential examination showed that the latency of P27 evoked by peroneal nerve stimulation was 44 msec. Lymphocytapheresis was performed 3 times with one-week intervals using a leukocyte removal filter. The muscle weakness began to improve on the second day after the second lymphocytapheresis and the sensory impairment began to improve on the third day after the third lymphocytapheresis. The delayed latency of P27 improved after the lymphocytapheresis. The effectiveness of lymphocytapheresis in this case suggests that lymphocytes are involved in the pathogenesis of HTLV-I associated myelopathy.

Uptake of liposomes surface-modified with glycyrrhizin by primary cultured rat hepatocytes

Previously, we synthesized 30-stearyl glycyrrhizin (GLOSt) and reported that small unilamellar liposomes containing GLOSt (GLOSt-SUV) accumulated in the liver several times more than the control liposomes (control-SUV). In the present study, to determine the interaction between GLOSt-SUV and hepatocytes, in vitro uptake experiments were achieved with primary cultured rat hepatocytes. The uptake amount of GLOSt-SUV by rat hepatocytes was considerably higher compared to the control-SUV, while GLOSt-SUV showed about a 10-fold higher uptake level than the control-SUV during 2 h of incubation. It was assumed that GLOSt-SUV not only bind to the surface of the hepatocytes but are internalized and degraded in the cells, because at 37 degrees C, GLOSt-SUV were taken up and the level of the degradable marker was lower than the inert marker, and this did not occur at 4 degrees C. Since the uptake of GLOSt-SUV was inhibited by glycyrrhizin (GL), it was suggested that a binding-site for GL is present on the surface of hepatocytes, and GLOSt-SUV are likely to be internalized via this site by the hepatocytes. Furthermore, it was confirmed that the efficacy of GLOSt on liposomes is not affected by the fluidity of the liposomal membrane.

Addition of cisapride shortens colonoscopy preparation with lavage in elderly patients

METHODS

The effect of pre-treatment with cisapride on colonoscopy preparation with lavage solution was compared in 120 out-patients less than 60 years and 73 out-patients 60 years or older, who were scheduled for total colonoscopy. By random allocation, patients were assigned to receive cisapride 10 mg or placebo 30 minutes before ingesting the magnesium citrate lavage solution.

RESULTS

The cleansing results and patients' acceptance did not differ significantly in the two treatment groups in either age group. The time from the start of ingesting magnesium citrate until the rectal effluent became clear was significantly shorter in cisapride-treated patients of 60 years or more. Moreover, the residual fluid volume removed by suction during colonoscopy was significantly less in the patients above aged 60 years who received cisapride.

CONCLUSION

These findings indicate that the combination of cisapride and magnesium citrate is more effective than magnesium citrate alone in cleansing the colon for colonoscopy in elderly patients.

[Growth rate analysis of pulmonary metastases in giant cell tumor of bone]

We reviewed six cases with pulmonary metastases in giant cell tumor of bone. The growth rate and the doubling time of pulmonary metastases was measured and compared to the clinical course. The six cases were classified into two each of the following three types: 1) spontaneous remission, 2) continuously slow growing and 3) rapid growing. A favorable factor was a doubling time of more than 80 days in pulmonary metastases. A poor prognosis was indicated by a doubling time of around 30 days. Aggressive primary lesions should be excised widely.

Nasu-Hakola disease. A case accompanied by abnormalities in fatty acid composition of serum total lipids and amino acid analysis

A case of Nasu-Hakola disease (membranous lipodystrophy) was reported. The patient is a 33-year-old man who started to have pathological fractures at the age of 24 years. Then, neurological symptoms such as dementia appeared gradually. A biopsy specimen of the bone showed membranocystic changes of the adipose tissue. T2-weighted magnetic resonance images of the head showed low intensity in bilateral putamens, internal capsules, globi pallidi and caudate nuclei. One of his brothers has the same disease. In both patients, fatty acid composition of serum total lipids showed increased nervonic acid and plasma amino acid analysis showed decreased glutamine.

[Malfunction of mitral and tricuspid Ionescu-Shiley pericardial xenografts]

We report a case of the malfunction of Ionescu-Shiley pericardial xenografts (ISPX) in the mitral and tricuspid positions at 6 years after implantation. The patient underwent an emergency operation successfully despite his high age (75 years) and extremely poor preoperative condition. The valve extracted from the mitral position showed spontaneous disruption of the leaflet, while the tricuspid valve graft was entangled with the preserved native septal leaflet around the stents. This former complication is now widely recognized, but the latter one appears to be rare. Care should be taken in replacing the atrioventricular valve with a bioprosthesis when the native valve leaflets are not removed. Although the ISPX is no longer in clinical use, careful follow-up is mandatory in patients with this prosthesis especially when it was implanted in the mitral position.

[Effects of enflurane, isoflurane, and sevoflurane on renal tubular functions]

Twenty-seven patients without renal disease were divided randomly into three groups of each nine patients. Each group received either enflurane, isoflurane or sevoflurane. The renal tubular functions were examined during anesthesia and on the first postoperative day. By inhalation of 1.49 MAC hours of enflurane, 2.17 MAC hours of isoflurane or 1.29 MAC hours of sevoflurane, creatinine clearance, Na excretion rate, urine beta 2-microglobulin and urine N-acetyl-beta-D-glucosaminidase showed no significant changes during anesthesia and the during postoperative period among anesthetic agents used. These results indicate that enflurane, isoflurane or sevoflurane does not affect renal tubular function specifically under anesthesia when each was given for less than four hours.

Targeting of liposomes surface-modified with glycyrrhizin to the liver. I. Preparation and biological disposition

We consider glycyrrhizin to be a new ligand for liposomes to the liver because it is known that about 80% of glycyrrhizin is excreted into the bile after intravenous administration in rats. In order to modify the liposomal surface with glycyrrhizin, 30-stearyl glycyrrhizin (GLOSt), one of the lipophilic glycyrrhizin derivatives, was synthesized. The structure of this new compound was identified by nuclear magnetic resonance (NMR), infrared (IR) and mass spectra (MS). Sonicated liposomes were prepared from hydrogenated egg phosphatidylcholine-cholesterol-GLOSt or dicetyl phosphate (DCP) (4:4:1) and were labelled with [3H]inulin as an aqueous marker. It was confirmed by measuring the encapsulation efficiencies and the mean diameters that GLOSt-containing sonicated liposomes (GLOSt-SUV) were SUV-type as well as DCP-containing control liposomes (control-SUV). Four hours after intravenous injection into rats at a dose of 90 mumol as total lipid per kg of rat body weight, GLOSt-SUV showed 4-fold more accumulation (42.4%) in the liver than control-SUV. Therefore, glycyrrhizin is considered to be a useful new ligand on liposomes for targeting to the liver.

[Treatment and prognosis of giant cell tumor in the sacrum--study of Bone Tumor Registry in Japan]

The prognosis of giant cell tumors arising in the sacrum is difficult to ascertain. Because of the low incidence in Japan there are scanty statistics. We selected 14 cases from the Bone Tumor Registry in Japan. Questionnaires were sent to hospitals which had submitted cases, regarding Enneking's staging, surgical approach, surgical procedure, radiotherapy, chemotherapy, complications and prognosis of this tumor. The results of the questionnaire show that surgery alone gives better results than combined surgery and radiotherapy. Good prognosis called for surgery alone. Curettage resulted in no evidence of disease (NED) in four cases. Bad prognosis called for combined surgery, radiotherapy and chemotherapy. If we surmise from the biological behavior of the giant cell tumor, that the tumor mass extends out extraosseously en-bloc excision with nerve roots is indicated. Extensive curettage will be adequate if the tumor is confined intraosseously. Radiotherapy should not be selected except for inoperative cases.

[A case report of coronary artery bypass grafting with the left internal mammary, the right gastroepiploic, and the inferior epigastric arteries]

We performed coronary artery bypass grafting with the left internal mammary artery, right gastroepiploic artery, and inferior epigastric artery on a 60-year-old male. The inferior epigastric artery used as a free graft was placed between the in situ left internal mammary graft proximally and the obtuse marginal branch distally. Both the left internal mammary graft to the left anterior descending artery and the right gastroepiploic artery to the right coronary artery were used as an in situ graft. All grafts were patent two weeks after the operation and the patient was free from angina at three months follow-up period.

[Surgical treatment of postinfarction left ventricular free wall rupture--experience of 12 cases including 2 successful repairs of acute (blow out) rupture]

Left ventricular free wall rupture (LVFWR) complicating myocardial infarction is still a lethal complication. Although there have been reports of successful repair of LVFWR, most of them were of subacute type in which main symptom was cardiac tamponade and the surgical repair was undertaken several hours after the onset of rupture. Between March, 1984 and June, 1987. We treated 12 cases of LVFWR surgically, thoracotomy and open drainage in 2 cases, thoracotomy and direct closure of rupture in 8 cases, median sternotomy and patch closure of rupture in 2 cases. We used cardiopulmonary bypass (CPB) only in 3 cases, because most of the cases except two developed electromechanical dissociation abruptly, requiring an emergency thoracotomy and there was no time for establishing CPB. In the cases of electromechanical dissociation, cardiopulmonary resuscitation and an emergency thoracotomy were performed simultaneously. There were three early survivors (greater than 30 days) by emergency thoracotomy and direct closure of rupture and one survivor (double rupture case) by patch closure on CPB. We believe that acute type of LVFWR in which initial symptom is electromechanical dissociation without any preceding symptoms can be rescued by emergency thoracotomy and direct closure of rupture with no aid of CPB if rupture is a small tear of anterior or lateral left ventricle. For this purpose, prompt diagnosis is mandatory and this is possible by two dimensional echocardiogram even during cardiopulmonary resuscitation.

[Successful re-reconstruction for complete disruption of the right main bronchus by blunt chest trauma]

A 22 year-old man was brought to our hospital about twenty-three minutes following a high-speed motorbicycle accident in which he had blunt chest trauma. He was in severe respiratory distress with marked dyspnea and restless with extensive subcutaneous emphysema involving anterior chest wall, cervical and bilateral inguinal regions. A chest X-ray revealed bilateral pneumothorax involving mediastinal emphysema and also fracture of right submandibular and clavicula. In spite of orotracheal intubation and insertion of bilateral chest tube, continuous air leak and pneumothorax did not improve. Bronchoscopy revealed the disruption of mucosa of the right main bronchus at the bifurcation. Emergency right thoracotomy was performed and there was the complete disruption of the right main bronchus. Anastomosis of the right main bronchus with circumferential resection was undertaken on May 30, 1987 about two hours after trauma. About three months after reconstruction, bronchoscopic examination revealed stomal stenosis with deformation of tracheobronchial cartilage and granulation. The stenosis showed severe irregularity by deformed cartilage and thickened scar, so widening by Nd-YAG laser vaporization was inadequate in effect. Seven months after first reconstruction, we performed re-reconstructive operation, right upper sleeve lobectomy with partial resection of carcina and right wall of trachea for scar with severe deformation of cartilage. Following the operation, the patient suffered from sepsis with pneumonitis accompanied by lung edema. This complication was treated successfully. We considered that acute pneumonitis was caused by reventilation with increase of perfusion after tracheobronchial reconstruction. Consequently, we thought it important to treat such patients with long term IPPB postoperatively with adequate medication for respiratory system.

[Sternotomy wound closure with polyester tapes]

We developed the special polyester tape with Tetron coating for sternal closure. Fifty consecutive open heart cases had the sternum closed with the tapes in the past six months at Nippon Medical School Hospital. There was no sternal infection or mediastinitis postoperatively. The tape closure method was more effective in approximation of sternum than the ordinary wire closure, especially in the case with fragile sternum. Although a long term follow-up is necessary, the result of sternal closure with the polyester tape has been satisfactory.

[Historical improvement in the treatment of osteosarcoma]

In the past decade, advances in chemotherapeutic agents and in diagnostic devices have led to improvement in the results of treatment for osteosarcoma. To evaluate the factor which brought about such improvement, historical therapeutic regimens were analysed. Eighty-three osteosarcoma cases were treated in our institute from 1955 to 1988 and categorized into six groups with the following therapeutic regimens: N-0: No treatment (including biopsy) N-1: Surgery alone N-2: Post surgery adjuvant therapy N-3: Intra-arterial continuous infusion N-4: Distal arterial blockade infusion N-5: Balloon-occluded arterial infusion. (N-3, 4 and 5 imply neo-adjuvant chemotherapy). Overall five-year survival rate was 48.8% (included Enneking's stage III). The survival rate improved from N-1 to N-5 in stepwise fashion, and N-5 reached 80% at two-year survival. We concluded that neo-adjuvant chemotherapy was not only effective to control the local lesion but also to prevent lung metastasis.

[Treatment and prognosis of sacrococcygeal chordoma--study of bone tumor registry in Japan]

Prognosis of chordoma arising in the sacrococcygeal area is difficult to assess because of the small number cases and lack of statistics in Japan. From the bone tumor registry we selected records on sacrococcygeal chordoma cases and sent a questionnaire to many hospitals regarding staging, surgical approach, surgical procedure, radiotherapy, chemotherapy, complications and prognosis of this tumor. The results of the questionnaire (32 cases) showed that combined surgery and radiotherapy were the best methods. This survival rate was 85% in five years and 43% in ten years. In the surgical procedure the extralesional excision resulted in a high recurrence rate (73%) three years after operation, and in the case of intralesional excision an even higher rate (91%). We assume this is a problem of the excisional method. In the staging system, the intracompartment tumors have a better prognosis. Early stage discovery and surgical treatment is of vital importance.

Early and late results of re-operation for coronary artery disease: a 13-year experience

A second coronary artery bypass grafting procedure was performed for recurrent angina in 119 patients between 1970 and mid-1983. Angiographic findings were assessed and computerized using the Brandt myocardial scoring system. The myocardial score was similar prior to the first and second operations. Graft failure was the most common indication for re-operation, either alone (48%) or in combination with progression of coronary artery disease (29%) or incomplete revascularization (10%). Progression of coronary artery disease alone was an indication in 9% and previous incomplete revascularization alone in 4%. The completeness of revascularization at the end of operation was analysed using a new index, the myocardial score/graft coverage rate. This showed that revascularization was less complete at the second operation than at the first (P less than 0.0001). The hospital mortality at re-operation was 2.5% and the peri-operative myocardial infarction rate was 9.2%. The follow-up period was 54 months (range 10-160 months). Actuarial survival was 94% at 5 years and 74% at 10 years. The average onset of recurrent angina was earlier after the second operation than after the first (P = 0.001). Using a cumulative actuarial curve, survival at 8 years was 85%, a further 6% of patients had undergone a third or fourth operation, and a further 25% were in NYHA Classes III or IV. Therefore 54% achieved a good or excellent result. It was concluded that re-operation is a worthwhile procedure.

[Surgical treatment of bone and soft tissue tumors in the sacroiliac area--low- and high-grade neoplasms]

Operative treatment of tumors in the sacroiliac area is very difficult for the orthopedic surgeon. We reviewed low- and high-grade neoplasms in the sacrum and part of the ilium. Primary bone tumors were giant cell tumor, chondrosarcoma and others; invading bone tumors were carcinoma, rhabdomyosarcoma and others; soft tissue tumors were liposarcoma, metastasis of extraskeletal chondrosarcoma and others; total, 19 cases. The preoperative treatment performed was embolization, intra-arterial infusion (chemotherapy) and radiation therapy. The surgical approach used were the posterior, posterolateral, anterior and posterior, anterior and lateral combined approach. The transiliac procedure using the posterolateral approach gives better visualization adjacent to the sacroiliac area. The gap between the sacrum and the ilium is bridged by grafting the resected ilium. The anterior and lateral combined approach was used in the resection of large iliac tumors, and the abdominoinguinal approach was selected for large retroperitoneal tumors. The surgical treatment performed ranged from simple to wide excision, including the external iliac vessels or rectum, and also palliative surgery. Reconstructive surgery was done for reconstruction of the pelvic ring, spinal fusion using instrumentation and replacement of artificial vessels. Many complications and functional loss requiring treatment were encountered.

Surgical treatment of giant cell tumors of the pelvis

There are many problems concerning management of giant cell tumors in the pelvis: diagnosis, surgical approach, adequacy of treatment, reconstruction, and prognosis. Of 58 cases of giant cell tumor of bone from 1962 to 1985, five cases arose in the pelvis, two in the ilium, two in the ischium, and one in the pubis. Surgical procedures included en bloc excision in four cases and intralesional excision in one. Reconstruction included sacroiliac fusion in one, iliofemoral fusion in one, and pelvic prosthetic replacement in another. Recurrence and metastasis did not occur in any of the cases. All patients were able to walk without crutches. A good surgical approach isolates major vessels and nerves, and permits excision to prevent recurrence and control bleeding. Reconstructive surgery may be required for treatment of a pelvic giant cell tumor.

Clinical usefulness of intraaortic balloon pumping in acute myocardial infarction complicated with cardiogenic shock, ventricular septal perforation and mitral regurgitation

The effects of intraaortic balloon pumping (IABP) were studied in 91 patients with acute myocardial infarction complicated with cardiogenic shock (75 pts), ventricular septal perforation (VSP) (12 pts), and/or mitral regurgitation (MR) (4 pts). Out of 44 pts with cardiogenic shock in whom IABP was performed, 14 pts could not recover from cardiogenic shock, 6 pts became dependent on IABP and 13 pts survived (29.5%). In contrast, out of the remaining 31 pts with cardiogenic shock who did not undergo IABP because of inability to insert IABP catheter or other reasons and were treated medically, only 3 pts survived (9.7%, p less than 0.05). After the initiation of IABP, BPd, CI, SVI, SWI, TMG increased significantly, and HR, CVP, PCWP, TPR decreased significantly. Comparison of hemodynamic parameters after the initiation of IABP showed that SVI and SWI at 24 hours were higher and CVP lower in survivors. Out of 7 pts with VSP who underwent IABP 2 pts were operated and survived.

IN CONCLUSION

short-term mortality in pts with cardiogenic shock was significantly lower in IABP-treated group, hemodynamic parameters improved after IABP, survivors from cardiogenic shock had higher SVI, SWI, BPd, and lower CVP than non-survivors, patients with VSP and MR had worse prognosis in spite of IABP.

Effects of intraaortic balloon pumping on acute myocardial infarction in 64 cases of cardiogenic shock, severe heart failure and mechanical heart failure

Of the patients treated in the CCU of Nippon Medical School for acute myocardial infarction in the past 5 years and 8 months, 44 with cardiogenic shock, 11 with severe heart failure, 7 with ventricular septal perforation and 2 with mitral regurgitation were treated by IABP. The peak effect of IABP on the hemodynamics of patients with cardiogenic shock was noted 24 hours after starting on IABP. When hemodynamics were compared between surviving and dead groups, there was a significant difference in stroke volume index between the two groups. When left ventricular function was compared between them, it was suggested that patients whose left ventricular function does not respond to IABP for 48 hours or longer are more likely to die than responders. Twenty-four of 44 patients became independent of IABP, but no more than 13 patients (30%) survived for 6 months or longer. Isosorbide dinitrate (ISDN) was combined with IABP in 7 patients who had a persistence of heart failure in spite of IABP. Combination therapy with IABP and ISDN elicited a significant increase in cardiac index, a significant decrease in pulmonary capillary wedge pressure, mean pulmonary arterial pressure and total peripheral resistance and a pronounced improvement in left ventricular function, and all 7 patients became independent of IABP. In the patients with acute myocardial infarction complicated with ventricular septal perforation, the mean systolic arterial pressure was 87.7 +/- 8.3 mmHg, mean pulmonary capillary wedge pressure, 20.3 +/- 7.4 mmHg and pulmonary-to-systemic flow ratio, 3.12 +/- 0.95 before starting on IABP. When the hemodynamics at 3 hours of IABP were compared to the pre-IABP values, the right atrial pressure, pulmonary capillary wedge pressure and pulmonary-to-systemic flow ratio had a tendency to decline, but the changes were not statistically significant, except for the peak arterial pressure which showed a significant elevation at 3 hours of IABP. Three of the 7 patients became dependent on IABP, and 2 of the 3 patients were saved by emergency operation.