Frailty and use of treatment in patients with heart failure and reduced ejection fraction

Background

In heart failure with reduced ejection fraction (HFrEF), drugs including angiotensin-converting enzyme inhibitors (ACEi)/ angiotensin receptor blockers (ARB), beta-blockers, and mineralocorticoid receptor antagonists (MRA) have been shown to have robust survival benefits. However, these guideline-recommended therapies remain underutilized in clinical practice. Frailty is common in HFrEF and may lead to underprescription of life-saving therapy.

Purpose

We aimed to investigate the association between physical frailty and the use of evidence-based pharmacological therapy for HFrEF, and the impact of this on prognosis

Methods

The FLAGSHIP study included patients hospitalized for acute HF and data on physical frailty were collected prospectively. Of the total 3,272 patients registered in the FLAGSHIP study, 1,041 HFrEF patients (70 years; 73% male) with left ventricular ejection fraction ≤40% were analyzed and were divided into 4 groups by severity of frailty: category I (n=371) [least frail], II (n=275), III (n=224), and IV (n=171) [most frail].

Results

An ACEi/ARB was prescribed in 76% of category I and 53% of category IV patients; for a beta-blocker these proportions were 94% and 76%, respectively; for an MRA they were 55% and 46%, respectively. The proportion of patients using receiving all 3 drugs decreased as frailty increased, with approximately twice the rate of use of triple therapy in category I patients (40.2%) compared to category IV patients (23.4%) [p<0.001] (Figure 1). In adjusted analyses, the severity of frailty was an independent predictor for non-use of an ACEi/ARB (Odds ratio (OR): 1.23, 95% CI: 1.05–1.43, per 1 category increase) and a beta-blocker (OR: 1.32, 95% CI: 1.06–1.64), but not an MRA (OR: 0.97, 95% CI: 0.84–1.12). Risk of the composite outcome of all-cause death or HF rehospitalization increased with decreasing use of treatment across frailty categories: category I-II (Hazard ratio (HR): 1.80, 95% CI: 1.08–2.98, in 0–1 drug with 3 drugs as reference) and III–IV (HR: 1.53, 95% CI: 1.01–2.32). The relationship between the number of HF drugs prescribed and the composite outcome did not differ across frailty categories (p-interaction=0.86). The HRs for all 12 groups, reflecting frailty categories and a number of HF drugs is depicted in Figure 2. The HRs for composite outcome increased with increasing frailty category and with decreasing number of drugs, with an almost 4-fold difference in risk between the least frail patients receiving all three evidence-based therapies and the most frail receiving only 0–1 drug.

Conclusions

Prescription of guideline-recommended therapy decreased as the severity of frailty increased in patients with HFrEF. Sub-optimal medical therapy was associated with a worse outcome and underprescription of guideline-recommended therapy may contribute to the poor prognosis associated with frailty. An effective strategy is needed to improve the medical treatment of frail patients with HFrEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study issupported by a Grant-in-Aid for Scientifi c Research (A) from the Japan Society for the Promotion of Science (16H01862). ToruKondo receives grants from the Uehara Memorial Foundation and the Japanese Heart Failure Society Tsuchiya Foundation forthe research activities at the University of Glasgow.

ACE values in the diagnosis of sarcoidosis

Background

In clinical practice, we often encounter the patients with sarcoidosis showing relatively high in the normal range of serum angiotensin-converting enzyme (ACE) value.

Purpose

We aimed to examine the serum ACE value of the patients with sarcoidosis and determine the new cut-off value for detecting the patients with sarcoidosis.

Methods and results

We retrospectively examined all 3781 subjects (51.1% men, 60.1±17.0 y.o.) in whom ACE was measured for any reasons including suspected sarcoidosis between 2009 and 2020 in our hospital. Of 293 patients with sarcoidosis, 101, 212, 84, and 88 were diagnosed as sarcoidosis in heart, lung, skin, and eyes, respectively. After excluding 477 patients taking ACE inhibitor and/or immunosuppression agent or those with any diseases affecting serum ACE levels, we analyzed 3304 subjects including 215 with sarcoidosis. Serum ACEs were 19.6 IU/L [IQR, 15.1–31.5] in the subjects with sarcoidosis and 10.7 [8.4–16.5] in those without (P<0.01). In ROC curve analysis of ACE for diagnosis of sarcoidosis, the cut-off point was 14.7 IU/L and the AUC was 0.865. When we used the current cut-off of 21.4 or new cut-off value of 14.7, sensitivity, specificity, PPV, NPV, and accuracy were shown in Table. Finally, they were divided into four groups based on the presence of cardiac and/or extra cardiac sarcoidosis, ACE values in Group A, B, C, and D were 17.9, 20.9, 18.6, and 10.7, respectively (Figure 1).

Conclusion(s)

In the current cut-off value of serum ACE, sensitivity for detecting sarcoidosis was comparatively low, though positive predictive value was low when the new-cut-off value was used in our study. Further examinations may be needed for the patients suspected sarcoidosis with relatively high ACE in the normal range.

Funding Acknowledgement

Type of funding sources: None.

Comparison between optical frequency domain imaging and intravascular ultrasound in PCI guidance for Biolimus A9 eluting stent implantation

Background

It has been reported that intravascular ultrasound (IVUS) guided PCI reduced a risk of major adverse cardiac event compared to conventional angiography guided PCI, while comparison between IVUS-guided and optical frequency domain imaging (OFDI)-guided PCI specifically in long-term clinical outcomes (>1 year) has been unexplored.

Purpose

We sought to compare imaging surrogates at 8 months and clinical outcomes beyond 1 year after drug-eluting stent implantation between IVUS and OFDI guidance.

Methods

The MISTIC-1 is a prospective, multi-centre, single-blinded, randomised-controlled, non-inferiority trial comparing OFDI-guided and IVUS-guided PCI using Biolimus A9 eluting Nobori stent. We enrolled patients with stable coronary artery disease who have symptoms or clinically relevant myocardial ischemia. Stent landing zones were selected in the most normal looking sites with largest lumen and without percentage plaque area >50% in IVUS group while without lipidic plaque of >2 quadrants or suggestive thin-cap fibroatheroma in OFDI group. Stent sizing was based on external elastic lamina (EEL) in IVUS group, while by taking 10% or 0.25mm larger than mean lumen diameter at reference sites in OFDI group. Stent optimisation with in-stent minimum lumen area ≥80% of the average lumen area at proximal and distal reference sites was encouraged in both groups. Primary efficacy endpoint is in-segment minimum lumen area (MLA) assessed by OFDI at 8 months. Secondary safety endpoint is a composite of cardiovascular death, target vessel myocardial infarction, or target lesion revascularisation. Based on the assumption that mean in-segment MLA at follow-up was 4.5mm2 with a standard deviation of 2.0mm2 in the control (IVUS) group and a non-inferiority limit of 1.2mm2 for OFDI group, sample size was estimated as 48 cases in each group with 5% type I error and 90% statistical power.

Results

Since June-2014 and August-2016, we prospectively enrolled 109 patients (mean age 70 years, male 78%) with 126 lesions. Baseline patient and lesion characteristics were well balanced and average nominal size and length of stent used did not differ between OFDI-guided and IVUS-guided PCI (3.0 and 19.1mm vs. 3.1 and 19.3mm, respectively). Post-procedural minimum stent area was 6.24mm2 in OFDI group and 6.72mm2 in IVUS group (p=0.20). At 8-month follow-up, in-segment MLA was 4.56mm2 in OFDI group and 4.13mm2 in IVUS group (P for non-inferiority <0.001). During the follow-up (median 4.5 years [1654 days]), incidence rates of major adverse cardiac event were comparable between the two groups (7.4% in OFDI group and 7.3% in IVUS group, hazard ratio 0.96, 95% CI 0.24–3.83, p=0.95). No definite or probable stent thrombosis were documented in both groups.

Conclusion

OFDI-guided PCI demonstrated comparable results in achieving satisfactory imaging surrogates as well as long-term clinical outcomes after newer generation DES implantation as compared to IVUS-guided PCI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Suzuken Memorial Foundation

Five-year major adverse cardiac and cerebrovascular events of patients with lipid core abutting lumen (LCAL) on integrated-backscatter intravascular ultrasound undergoing PCI with current DES

Background

Percutaneous Coronary Intervention (PCI) using the new generation drug-eluting stent (DES) has been extremely reduced target lesion revascularization (TLR) in recent years. However, a high incidence of non-target lesion-related cardiovascular events in patients undergoing PCI is an important problem to be solved. According to the previous findings, patients with vulnerable plaques particularly have a high recurrence of cardiovascular events. Little studies, however, has been done to examine the relationship between plaque characteristics on intravascular imaging in a target lesion and non-target lesion-related cardiovascular events.

Purpose

The main objective of this study is to investigate the five-year major adverse cardiac and cerebrovascular events (MACCE) of patients with lipid core abutting lumen (LCAL) on integrated backscatter intravascular ultrasound (IB-IVUS) in a target lesion undergoing PCI with current DES.

Methods and results

Between February 2010 and September 2013, in total 780 patients with ischemic heart disease undergoing PCI, 166 target lesions in 166 consecutive patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and stable angina pectoris (SAP) undergoing IVUS-guided PCI were studied.

Plaque characteristics in all target lesions were analyzed by three-dimensional IB-IVUS system using the mechanical IVUS catheter. Our previous study has found that LCAL which is defined as a lipid pool directly in contact with the lumen visualizes the thin fibrous cap of less than 75μm on optical coherence tomography (OCT). On the basis of this data, LCAL at minimal lumen area (MLA) site was identified.

In total, 39 patients had lesions with LCAL at MLA site (LCAL(+)), and 127 patients had those without LCAL (LCAL(−)).

The primary endpoint was defined as MACCE, including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and non-TLR for the new lesion during a median follow up of five years. The MACCE occurred significantly higher in the LCAL(+) than in the LCAL(−) (38.5% vs. 17.3%; p<0.005). And the Kaplan-Meier estimates have shown that the cumulative incidence of MACCE was significantly higher in the LCAL(+) than in the LCAL(−) (log rank test, p=0.041). Additionally, after adjustment for confounders, gender, prior PCI and LCAL was the independent predictors for the MACCE of patients undergoing PCI with current DES.

Furthermore, after adding LCAL to a baseline model with established factors consisting of age, gender, diabetes mellitus, prior PCI and percentage lipid volume on IB-IVUS, the net reclassification (p<0.002) and integrated discrimination improvement (p<0.004) significantly improved compared to baseline model alone.

Conclusions

In this study, it has become clear that LCAL on IB-IVUS is likely to be a surrogate marker of MACCE in patients undergoing PCI with current DES.

Funding Acknowledgement

Type of funding source: None

Factors associated with silent cerebral events during catheter ablation for atrial fibrillation in the era of uninterrupted oral anticoagulation therapy

Background

A silent cerebral event (SCE), detected by brain magnetic resonance imaging (MRI), is defined as an acute new brain lesion without clinically apparent neurological deficit, and is frequently observed after catheter ablation in atrial fibrillation (AF) patients. Although the small number of SCEs does not cause neurocognitive dysfunction, the greater volume and/or larger number of SCE lesions are reportedly related to neuropsychological decline; SCE incidence may be a surrogate marker for the potential thromboembolic risk. Thus, strategies to reduce SCEs would be beneficial. Uninterrupted oral anticoagulation strategy for peri-procedural period reportedly reduced the risk of SCEs, but the incidence hovers at 10% to 30%. We sought factors associated with SCEs during catheter ablation for AF in patients with peri-procedural uninterrupted oral anticoagulation (OAC) therapy.

Methods

AF patients undergoing catheter ablation were eligible (n=255). All patients took non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonist (VKA) for peri-procedural OAC (>4 weeks) without interruption during the procedure. Brain MRI was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure-related parameters were compared between patients with and without SCEs.

Results

SCEs were detected in 59 patients (23%, SCE[+]) but not in 196 patients (77%, SCE[-]). Average age was higher in SCE[+] than SCE[-] (66±10 years vs. 62±12 years, p<0.05). Persistent AF prevalence, CHADS2/CHA2DS2-VASc scores, and serum NT-ProBNP levels increased in SCE[+] vs. SCE[-]. In transthoracic/transesophageal echocardiography, left-atrial dimension (LAD) was larger and AF rhythm/spontaneous echo contrast were more frequently observed in SCE[+] than SCE[-]. SCE[+] had lower initial activated clotting time (ACT) before unfractionated heparin (UFH) injection and longer time to reach optimal ACT (>300 sec) before trans-septal puncture than SCE [-]. In multivariate analysis, LAD, initial ACT before UFH injection, and time to reach optimal ACT were predictors for SCEs.

Conclusions

LAD and intra-procedural ACT kinetics affect SCEs during the procedure in patients with uninterrupted OAC for AF ablation. Shortening time to achieve optimal ACT during the procedure may reduce the risk of SCEs.

Funding Acknowledgement

Type of funding source: None

Circulating presepsin (soluble CD14 subtype) as a novel marker of mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocyte activation. The association between presepsin levels and mortality in patients treated at medical cardiac intensive care units (CICUs) remains poorly known.

Objective

We aimed to understand the prognostic value of presepsin levels on admission to medical CICUs for mortality.

Methods

We prospectively studied 1636 heterogeneous patients (median age; 71 years) treated at medical (non-surgical) CICUs. Patients with stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m2) were excluded. Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Upon admission, baseline plasma presepsin levels were measured. The primary endpoint was all-cause death.

Results

During a mean follow-up period of 44.6 months after admission, there were 323 (19.7%) deaths. Patients who died were older (median: 75 vs. 71 years, P<0.0001); had higher levels of presepsin (194 vs. 110 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 520 vs. 144 pg/mL, P<0.0001), high-sensitivity C-reactive protein (hsCRP: 4.7 vs. 2.0 mg/L, P<0.0001), and sequential organ failure assessment (SOFA) score (3 vs. 2, P<0.0001); and had lower levels of eGFR (55 vs. 69 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (46% vs. 52%, P<0.0001) than those of the survivors. Multivariate Cox regression analyses revealed presepsin levels as independent predictors of all-cause deaths when assessed as either continuous variables (relative risk [RR] 3.33 per 10-fold increment; P<0.0001) or variables categorized according to quartiles (RR quartile 4 vs. 1, 3.60; P<0.0001). Quartiles of presepsin levels were significantly (P<0.0001) associated with increased risk of mortality (Figure). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsCRP further enhanced reclassification (P=0.009) and discrimination (P=0.0008) beyond that of the baseline model alone.

Conclusions

Circulating concentration of presepsin on admission may be a potent and independent predictor of mortality, and it may improve the risk stratification of patients admitted at medical CICUs.

Presepsin quartiles and mortality

Funding Acknowledgement

Type of funding source: None

Honeycomb-like porous chitosan films prepared via phase transition of poly(N-isopropylacrylamide) during water evaporation under ambient conditions

Honeycomb-like porous chitosan (CS) films are attractive tools for developing functional materials for filters, catalyses, adsorbents, biomaterials, etc. A simple method for fabricating honeycomb-like porous CS films without special reagents, facilities, and techniques would make them accessible. Here we introduce an easily available method for fabricating honeycomb-like CS films without a strong acid/base, toxic reagents, or special facilities/techniques. An aqueous solution containing CS and poly(N-isopropylacrylamide) (PNIPAm) was allowed to stand at 25 °C to evaporate water. After 3 days, CS–PNIPAm composite films with homogenously phase-separated PNIPAm particles were obtained. The PNIPAm particles were removed by immersion in methanol, and the resulting films dried under reduced pressure to become honeycomb-like porous CS films. The pore size could be varied in the range of 0.5–3.0 μm by altering the CS concentration and the molecular weight of CS where the pore size was reduced under conditions with stronger interaction between CS molecules. We reveal that the key to success with this system is the decrease of lower critical solution temperature (LCST) of PNIPAm with water evaporation. In addition, we confirmed the removed PNIPAm was recyclable in this system. Furthermore, we found this method was also applicable to alginate. The proposed facile method for fabricating honeycomb-like porous polymeric films could provide various functional porous materials.

A simple method for fabricating honeycomb-like porous chitosan films without special reagents, facilities, and techniques was achieved by using poly(N-isopropylacrylamide).

P1806Diagnosis of isolated cardiac sarcoidosis using FDG-PET/CT on the basis of new guidelines

Introduction

Sarcoidosis is a systemic inflammatory disease which can involve any organs. The reported prevalence of isolated cardiac sarcoidosis (CS) varies widely because of the lack of an agreed definition of isolated CS (iCS). ICS was newly defined in the new guidelines for CS by Japanese Circulation Society.

Purpose

We aimed to examine the diagnostic accuracy of 18F-FDG PET/CT and the ratio of iCS in the whole CS by reviewing the patients with suspected CS undergoing the whole-body and cardiac FDG PET/CT scans.

Methods

We retrospectively reviewed 74 consecutive patients undergoing 18F-FDG PET/CT from 2013 to 2018 (mean age 60±14 years, 37 male) without the initiation of corticosteroid. Myocardial FDG uptake in CS was defined as a “focal” or “focal on diffuse” pattern. Systemic sarcoidosis (sCS) and iCS were diagnosed according to guidelines for the diagnosis and treatment of CS by Japanese Circulation Society. In short, iCS was diagnosed clinically when no clinical findings of sarcoidosis in any other organs and FDG uptake in heart were shown in addition to the following three of four criteria: high-grade atrioventricular block or fatal ventricular arrhythmia, structural abnormality, left ventricular contractile dysfunction, and delayed Gadolinium enhancement of myocardium on MRI.

Results

Of 31 patients with extra-cardiac sarcoidosis, 10 already met the diagnostic criteria of sCS before undergoing 18F-FDG PET/CT and 11 was newly diagnosed as sCS after FDG PET/CT. Of the remaining 43 without extra-cardiac sarcoidosis, 18 had FDG uptake in heart. Of 18 with FDG uptake in heart, iCS was diagnosed in 7, and sCS in 3 with extra-cardiac uptake of FDG as well as myocardium. Finally, 24 and 7 patients met the criteria of sCS and iCS based on the guideline, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG PET/CT for CS including sCS and iCS were 90, 87, 88, 85, and 92%, respectively.

Conclusion

The ratio of iCS on the basis of new guidelines for diagnosis and treatment of CS was 22% of the whole CS.

P4620Circulating concentration of presepsin improves early prediction of short-term mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocytic activation. Presepsin appears to be an accurate diagnostic marker of sepsis, but its clinical significance remains unclear in cardiovascular disease.

Purpose

This prospective study aimed to investigate the predictive value of plasma presepsin levels on admission to medical (non-surgical) cardiac intensive care units (MCICUs) for short-term mortality.

Methods

We examined 1560 patients hospitalized in MCICUs and measured the baseline plasma presepsin levels at admission.

Results

Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Before MCICUs admission, emergent coronary angiography or percutaneous coronary intervention was performed in 36%, mechanical ventilation was required for respiratory insufficiency in 2.1%, and intraaortic balloon pumps were needed for hemodynamic instability in 8.9%. During 6 months after admission, there were 113 (7.2%) deaths. Patients who died were older (median: 77 vs. 71 years, P<0.0001); had higher levels of presepsin (263 vs. 119 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 696 vs. 186 pg/mL, P<0.0001), high-sensitivity troponin T (hsTnT: 81 vs. 47 pg/mL, P=0.004), and high-sensitivity C-reactive protein (13.8 vs. 2.2 mg/L, P<0.0001); and had lower levels of estimated glomerular filtration rate (50 vs. 65 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (43% vs. 51%, P<0.0001) than those of the survivors. In the multivariate Cox regression analysis, higher levels of presepsin (P=0.0002), BNP (P=0.04), and hsTnT (P=0.009) were all independent predictors of 6-month deaths. Quartiles of presepsin levels were associated with higher mortality rates within 6 months after admission (Table). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsTnT further enhanced reclassification (P=0.004) and discrimination (P=0.003) beyond that of the baseline model.

Mortality rates according to presepsin Presepsin quartile 1st 2nd 3rd 4th P value ≤80 pg/mL 81–124 pg/mL 125–232 pg/mL >232 pg/mL 1-month mortality 0.8% 2.0% 3.3% 8.0% <0.0001 6-month mortality 0.8% 3.8% 8.2% 16.3% <0.0001

Conclusions

Presepsin levels at admission could improve the prediction of short-term mortality in patients hospitalized at MCICUs.

Preparation of polybenzoxazole nanofibers by a downsizing process

Poly(p-phenylene benzobisoxazole) (PBO) nanofibers were prepared from commercially available PBO fiber by a simple downsizing process for the first time.

Facile preparation of aramid nanofibers from Twaron fibers by a downsizing process

We introduce a simple preparation procedure for aramid nanofibers from Twaron fibers by using a downsizing process.

Supramolecular approaches for drug development

Various supramolecular systems can be used as drug carriers to alter physicochemical and pharmacokinetic characteristics of drugs. Representative supramolecular systems that can be used for this purpose include surfactant/polymer micelles, (micro)emulsions, liposomes, layer-by-layer assemblies, and various molecular conjugates. Notably, liposomes are established supramolecular drug carriers, which have already been marketed in formulations including AmBisome(®) (for treatment of fungal infection), Doxil(®) (for Kaposi's sarcoma), and Visudyne(®) (for age-related macular degeneration and choroidal neovascularization). Microemulsions have been used oral drug delivery of poorly soluble drugs due to improvements in bioavailability and predictable of absorption behavior. Neoral(®), an immunosuppressant used after transplant operations, is one of the most famous microemulsion-based drugs. Polymer micelles are being increasingly investigated as novel drug carriers and some formulations have already been tested in clinical trials. Supramolecular systems can be functionalized by designing the constituent molecules to achieve efficient delivery of drugs to desired sites in the body. In this review, representative supramolecular drug delivery systems, that may improve usability of candidate drugs or add value to existing drugs, are introduced.

Plasma resistin concentration determined by common variants in the resistin gene and associated with metabolic traits in an aged Japanese population

AIMS/HYPOTHESIS

Resistin is a cytokine derived from adipose tissue and is implicated in obesity-related insulin resistance and type 2 diabetes mellitus. Polymorphisms of the resistin gene (RETN) have been shown to affect the plasma resistin concentration. The aims of this study were to identify polymorphisms of RETN that influence plasma resistin concentration and to clarify the relation between plasma resistin level and metabolic disorders in an aged Japanese cohort.

METHODS

The study participants comprised 3133 individuals recruited to a population-based prospective cohort study (KING study). Plasma resistin concentration, BMI, abdominal circumference, blood pressure, fasting plasma glucose and serum insulin concentrations, HbA(1c) content and serum lipid profile were measured in all participants. The HOMA index of insulin resistance (HOMA-IR) was also calculated. Eleven polymorphisms of RETN were genotyped.

RESULTS

A combination of ANOVA and multiple linear regression analysis in screening and large-scale subsets of the study population revealed that plasma resistin concentration was significantly associated with rs34861192 and rs3745368 polymorphisms of RETN. Multiple linear regression analysis with adjustment for age and sex also showed that the plasma resistin level was significantly associated with serum concentrations of HDL-cholesterol, triacylglycerol and insulin, as well as with BMI.

CONCLUSIONS/INTERPRETATION

Our results implicate the rs34861192 and rs3745368 polymorphisms of RETN as robust and independent determinants of plasma resistin concentration in the study population. In addition, plasma resistin level was associated with dyslipidaemia, serum insulin concentration and obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00262691.

Granulomatous hypophysistis associated with rathke's cleft cyst: a case report

OBJECTIVE

The value of surgical intervention in the management of hypophysitis remains controversial.

PATENT

We describe a 57-year-old man presenting with general fatigue persisting for three months. Endocrine examination revealed hypopituitarism and diabetes insipidus. Magnetic resonance (MR) imaging showed a dumbbell-shaped pituitary mass lesion without a cystic component. We partially removed the lesion via a transsphenoidal approach. Histological examination yielded the diagnosis of granulomatous hypophysitis associated with Rathke's cleft cyst. No deterioration of pituitary function was observed postoperatively. Twenty months after the surgery, the lesion has spontaneously regressed on MR imaging, and he is doing well with continuing replacement therapy of hydrocortisone, levothyroxine and desmopressin acetate.

CONCLUSION

The diagnosis of hypophysitis, apart from typical lymphocytic hypophysitis, is difficult even with a surgical biopsy. Because a small specimen may lead to a diagnosis of non-specific hypophysitis, partial removal of the lesion is less invasive and recommended for preservation of the pituitary function.

Heterogeneity of regional systolic function detected by tissue Doppler imaging is linked to impaired global left ventricular relaxation in hypertrophic cardiomyopathy

OBJECTIVE

To evaluate regional and global left ventricular (LV) function and LV wall thickness (LVWT) in patients with hypertrophic cardiomyopathy (HCM).

DESIGN AND SETTING

Observational study at the National Cardiovascular Centre and Nagoya University Hospital in Japan.

PARTICIPANTS

Thirty-six patients with HCM and 16 patients with hypertensive LV hypertrophy (LVH).

MAIN OUTCOME MEASURES

Conventional echocardiography and strain rate (SR) imaging derived from tissue Doppler imaging were performed. Systolic strain (epsilon(sys)), peak systolic SR (SR(sys)), peak early diastolic SR (SR(dia)) and LVWT were obtained from eight LV segments. LV pressure was simultaneously recorded with a high-fidelity micromanometer.

RESULTS

The regional epsilon(sys) and SR(sys) were correlated with LVWT in patients with HCM (r = 0.50, p<0.001 and r = 0.63, p<0.001, respectively) but not in patients with hypertensive LVH. The standard deviations of LVWT, epsilon(sys) and SR(sys) obtained from the eight LV segments of each subject were greater for patients with HCM than for patients with hypertensive LVH. The standard deviation of LVWT was correlated with those of epsilon(sys) and SR(sys) (r = 0.55, p<0.001 and r = 0.56, p<0.001, respectively). The standard deviations of LVWT, epsilon(sys) and SR(sys) were correlated with tau (r = 0.35, p<0.05; r = 0.47, p<0.001; and r = 0.39, p<0.005, respectively).

CONCLUSIONS

Heterogeneity of regional LV systolic function detected by SR imaging is in part attributable to heterogeneity of LVH and may be linked to impaired global LV relaxation in HCM.

Combined study with FDG PET and Tl SPECT in patients with idiopathic dilated cardiomyopathy

This study aimed to determine whether combined examinations of myocardial 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) and stress-redistribution 201Tl single-photon emission computed tomography (Tl SPECT) were useful in clarifying myocardial ischaemia and evaluating the prognosis in patients with idiopathic dilated cardiomyopathy (IDCM). Twenty-two patients with IDCM underwent echocardiography, cardiac catheterization, FDG PET, and Tl SPECT. In scintigraphic analysis, the total defect score (TDS) was semiquantitatively determined as the sum of scores of the 17 left ventricular (LV) segments with a 5-point scale (0 as normal to 4 as absent). Patients were classified according to the scintigraphic findings as follows: eight patients with small defects on Tl and FDG (TDS < or = 20) (group I), eight patients with small defects on FDG (TDS < or = 20) with FDG uptake increased relative to Tl or 'mismatch' (group II), and six patients with large defects on FDG and Tl (TDS >20) (group III). Eleven patients (50%) showed reversible defects on Tl and all showed preserved FDG uptake. The patients in group III had significantly lower LV ejection fraction (LVEF) (P<0.05, respectively) and a poorer prognosis as shown by the Kaplan-Meier event-free curve compared with those in groups I and II (P<0.01, respectively). Although patients in group II had significantly greater TDS on Tl compared with those in group I (P<0.01), no significant differences in LVEF and prognosis were found between patients in groups I and II. In multivariate analysis, a TDS on FDG revealed an independent predictor of subsequent cardiac events. In conclusion, such mismatched areas can be assumed to consist of impaired but viable myocardium, and may be associated with ischaemia of the microvasculature. Impaired myocardial glucose metabolism is a more powerful predictor of future cardiac events than perfusion abnormality in patients with IDCM.

Association of a G994 --> T (Val279 --> Phe) polymorphism of the plasma platelet-activating factor acetylhydrolase gene with myocardial damage in Japanese patients with nonfamilial hypertrophic cardiomyopathy

Plasma platelet-activating factor acetylhydrolase (PAF-AH) acts as a key defense against oxidative stress by hydrolyzing PAF and oxidized phospholipids. Deficiency of the activity of this enzyme may thus potentially result in predisposition to myocardial damage. The possible role of the G994 (V allele) --> T (F allele) polymorphism of the PAF-AH gene in modulating cardiac function was investigated in 142 Japanese subjects with nonfamilial hypertrophic cardiomyopathy (HCM). Logistic regression analysis adjusted for age, sex, height, and body weight revealed that the frequency of the F allele was significantly higher in HCM patients than in 284 healthy controls. Echocardiographic examination revealed that left ventricular (LV) end-diastolic and end-systolic dimensions were significantly greater in HCM patients with the FF genotype than in those with the VV genotype. Cardiac catheterization revealed that LV end-diastolic pressure was significantly higher, whereas the LV ejection fraction was significantly smaller, for HCM patients with the F allele than for those with the VV genotype. Interstitial fibrosis was significantly more severe in HCM subjects with the FF genotype than in those with the VV genotype. These results suggest that the G994 --> T (Val279 --> Phe) polymorphism in the plasma PAF-AH gene may exacerbate cardiac damage in Japanese individuals with nonfamilial HCM, although this polymorphism is unlikely to be a causative factor for this condition.

Carboxy-terminal region involved in activity of Escherichia coli TolC

The Escherichia coli TolC acts as a channel tunnel in the transport of various molecules across the outer membrane. Partial-deletion studies of tolC revealed that the region extending from the 50th to the 60th amino acid residue from the carboxy terminus plays an important role in this transport activity of TolC.

Syntheses and properties of ditelluroxanes and oligochalcogenoxanes: hypervalent oligomers with Te-O apical linkages in the main chain

The reaction of ditelluroxanes [Ar2Te-O-TeAr]2+[X]2- (2) (Ar = p-tolyl) with a telluroxide 1, a selenoxide 7, or a carboxylate 10 to produce oligochalcogenoxanes with hypervalent Te-O apical linkages in their main chain is described. The 125Te NMR chemical shifts of 2 (2a: X- = CF3SO3-, 2b: X- = CF3CO2-, 2c: X- = CH3CO2-, 2d: X- = Cl-) are shifted downfield with decreasing nucleophilicity of the counteranions. This result reflects both the cationic character and the reactivity of the Te atoms of 2. The reaction of 2a with one, two, three, or four equivalents of telluroxide 1a (Ar = p-tolyl) selectively gave a tritelluroxane 3a, tetratelluroxane 4a, pentatelluroxane 5a, and hexatelluroxane 6a, respectively. In contrast, the reaction of 2b with an excess of 1a produced only tritelluroxane 3b. An equilibrium between the oligotelluroxanes was confirmed by crossover experiments of the reactions of 2a with 4a and of 2a with 1b (Ar = Ph). The selective equilibrium formation of a selenoxaditelluroxane 8 or a bis(selenoxa)ditelluroxane 9 was achieved by the reaction of 2a with one or two equivalents of selenoxide 7, respectively. The association constant of 2a with 7 to form 8 was estimated to be Ka = (2.18+/-0.12) x 10(4) M(-1) in CD3CN at -40 degrees C. The reaction of 2a with two equivalents of carboxylates 10a-d gave a mixture of bis(carboxylate)ditelluroxanes and diaryldicarboxytelluranes 12b-d, respectively, in which the product ratio of these depended upon the electron-withdrawing ability of 10. The reaction of 3a with two equivalents of 10a-d afforded 11a-d in all cases. The present results suggest that the sigma*-n orbital interaction plays an essential role in the reactivity of ditelluroxanes and in the formation of self-assembled oligochalcogenoxanes, and that a hypervalent bond via a sigma*-n orbital interaction is viable as a new supramolecular synthon for molecular assembly.

The effect of heat-treated human bone morphogenetic protein on clinical implantation

For the clinical usage of human-derived bones, it is necessary to treat bones to reduce the risk of contamination by microorganisms. Bone morphogenetic protein is vulnerable to chemicals, but shows resistance to thermal heat to 70 degrees C in a short time. In this experiment, crude human bone morphogenetic protein was extracted from heat-treated bones at 60 degrees C for 10 hours and from nonheated bones. Sodium dodecyl sulfate polyacrylamide gel electrophoresis for these specimens was done. Gelatin capsules containing 5 mg of crude human bone morphogenetic protein extracted from heated and nonheated bones were implanted into thigh muscle pouches of five mice. At 20 days after implantation, the heterotopic bone formation was compared by evaluating the radiographic and histologic analyses. The sodium dodecyl sulfate polyacrylamide gel electrophoresis pattern of the human bone morphogenetic proteins showed five main bands (16, 22, 28, 35, and 67 kDa) that were almost identical. Heterotopic bone formation observed on the radiograph was induced by crude human bone morphogenetic protein from heated bones in a manner similar to that used for nonheated bones. The results from this study show that heat-treated bone preserves osteoinduction.

Reduced myocardial sarcoplasmic reticulum Ca(2+)-ATPase mRNA expression and biphasic force-frequency relations in patients with hypertrophic cardiomyopathy

BACKGROUND

The relationship between left ventricular (LV) contractile functional reserve and gene expression of Ca(2+)-handling proteins in patients with hypertrophic cardiomyopathy (HCM) remains to be clarified.

METHODS AND RESULTS

We calculated the maximum first derivative of LV pressure (LV dP/dt(max)) and the LV pressure half-time (T(1/2)) during pacing in 14 patients with nonobstructive HCM (LV ejection fraction >55%) and 7 control subjects. Endomyocardial tissue was obtained, and mRNA levels of sarcoplasmic reticulum Ca(2+)-ATPase (SERCA2), ryanodine receptor-2, phospholamban, calsequestrin, and Na(+)/Ca(2+) exchanger were quantified by use of a real-time quantitative reverse transcription-polymerase chain reaction method. Group A consisted of 7 HCM patients who showed a progressive rise in the LV dP/dt(max) with increased heart rate. Group B consisted of 7 HCM patients in whom the heart rate-LV dP/dt(max) relation was biphasic at physiological pacing rates. Both the mean maximal wall thickness and the LV hypertrophy score in group B were greater than in group A (20+/-5 versus 15+/-3 mm and 7+/-1 versus 5+/-2 points, respectively). SERCA2 mRNA levels were significantly lower in group B (SERCA2/GAPDH ratio 0.34+/-0.15) compared with group A (0.72+/-0.27) and control subjects (0.85+/-0.47), whereas the mRNA expression of ryanodine receptor-2, phospholamban, calsequestrin, and Na(+)/Ca(2+) exchanger were similar in all groups.

CONCLUSIONS

These results suggest that downregulation of SERCA2 mRNA, resulting in altered Ca(2+) handling, may contribute to impaired LV contractile reserve in HCM patients with severe hypertrophy, even in the absence of detectable baseline systolic dysfunction.

Biphasic changes in left ventricular end-diastolic pressure during dynamic exercise in patients with nonobstructive hypertrophic cardiomyopathy

OBJECTIVES

The aim of this study was to clarify the serial changes in left ventricular (LV) end-diastolic pressure (LVEDP) during dynamic exercise in patients with hypertrophic cardiomyopathy (HCM).

BACKGROUND

Although HCM is characterized by impaired resting LV diastolic function, serial changes in LVEDP during exercise have not been characterized.

METHODS

We simultaneously measured LV pressure and LV dimensions during symptom-limited supine bicycle exercise in 5 healthy individuals and 20 patients with HCM. Exercise thallium-201 scintigraphic studies were also performed.

RESULTS

The LVEDP (baseline: 12 +/- 5 mm Hg) progressively increased to a maximum value at peak exercise (28 +/- 8 mm Hg) in 11 patients with HCM (group I). In the remaining nine patients with HCM (group II), changes in LVEDP during exercise were biphasic, with an initial progressive increase and a subsequent gradual decline up to peak exercise (14 +/- 4 mm Hg at baseline, 27 +/- 5 mm Hg at the critical heart rate, 16 +/- 3 mm Hg at peak exercise). Exercise-induced changes in LV dimensions and LV peak systolic pressures were similar in both groups. However, the maximum first derivative of LV pressure was greater and the LV pressure half-time was shorter in group II than in group I at a similar peak exercise heart rate. The biphasic changes in LVEDP disappeared by pretreatment with propranolol. The LV hypertrophy scores were higher in group I than in group II. Exercise thallium-201 images showed more severe perfusion defects in group I than in group II patients.

CONCLUSIONS

The biphasic changes in LVEDP seen during exercise may be related to improved coronary microcirculation in response to beta-adrenergic stimulation in patients with mild to moderate HCM.

Cardiac functional and structural alterations induced by endotoxin in rats: Importance of platelet-activating factor

OBJECTIVE

In this study, we evaluated the time course of the alterations in left ventricular (LV) dimensions, LV wall thickness, and LV systolic function in rats with endotoxemia by using echocardiography as well as myocardial histopathologic assessments. Our second goal was to examine whether pretreatment with a platelet-activating factor (PAF) antagonist would ameliorate the lipopolysaccharide (LPS)-induced cardiovascular collapse during the early phase.

DESIGN

A prospective, controlled, in vivo animal laboratory study.

SETTING

Research laboratory at a university.

SUBJECTS

Male, Wistar rats (8-9 wks old; n = 83).

INTERVENTIONS

In pentobarbital-anesthetized rats, the right carotid artery was cannulated to measure the arterial blood pressure and to sample blood. The right jugular vein also was catheterized for the administration of drugs. LPS (2 mg/kg) derived from Klebsiella pneumoniae or physiologic saline was administered in the presence or absence of pretreatment with TCV-309, a specific potent PAF antagonist. Echocardiographic studies were performed with an 8- to 13-MHz transducer.

MEASUREMENTS AND MAIN RESULTS

LPS administration immediately induced progressive hypotension. The maximal hypotensive response was observed at 10 mins after LPS infusion with mean arterial pressure decreasing from 119 +/- 2 to 56 +/- 3 mm Hg (p < .001). LV end-diastolic internal dimensions decreased from 6.4 +/- 0.1 to 3.1 +/- 0.1 mm (p < .001) at 30 mins after LPS and remained significantly reduced compared with control rats. LV end-systolic dimensions also decreased dramatically from 3.5 +/- 0.2 to 0.5 +/- 0.1 mm (p < .001) at 30 mins after LPS and remained significantly reduced throughout the experiment. LV fractional shortening increased from 45 +/- 1% to 84 +/- 2% (p < .001) at 30 mins after LPS and remained elevated compared with control rats. LV wall thickness increased strikingly from 15 mins until 2 hrs after LPS infusion. Pathologic studies demonstrated marked congestion of capillaries and mild edema in the LV myocardium. The hematocrit increased after the administration of LPS. LPS markedly increased sympathetic tone as demonstrated by the elevation of plasma concentrations of epinephrine and norepinephrine. There was no elevation of concentrations of nitrite and nitrate. Pretreatment with TCV-309, a specific potent PAF antagonist, reduced LPS-induced hypotension and attenuated LV functional and structural changes. TCV-309 administration reduced the LPS-induced adrenergic activation and hemoconcentration.

CONCLUSIONS

The hypotension that occurred during the initial phase of LPS-induced shock was accompanied by LV functional and structural alterations. The marked increase in LV wall thickness can be ascribed to the congestion of capillaries and edema in the LV myocardium. Pretreatment with a PAF antagonist reduced LPS-induced alterations. PAF may play a pivotal role during the initial phase of LPS-induced cardiovascular responses.

Different beta-adrenergic regulation of myocardial contraction and relaxation between apical and nonobstructive hypertrophic cardiomyopathy

BACKGROUND

The impaired adrenergic control of both inotropic and lusitropic reserves has been evaluated in patients with hypertrophic cardiomyopathy (HCM) but not in those with apical HCM (APH).

OBJECTIVES

We examined the influence of increases in heart rate and adrenergic stimulation on inotropic and lusitropic reserves in HCM and APH with normal resting left ventricular (LV) systolic function.

METHODS

We evaluated LV isovolumic contraction and relaxation during atrial pacing and during supine leg exercise in 7 patients with APH and in 8 patients with HCM.

RESULTS

Heart rate was significantly correlated with LV isovolumic contraction and relaxation during pacing and exercise in all patients. In all patients with APH, the increase in LV isovolumic contraction was greater during exercise (101%) than pacing alone (27%) for similar increase in heart rate. In 5 patients with HCM, the increase in LV isovolumic contraction was greater during exercise (83%) than pacing alone (24%), whereas in 3 patients with HCM the increase in LV isovolumic contraction was similar between during exercise (25%) and during pacing alone (22%). In all patients with APH, relaxation was shorter during exercise (39%) than pacing alone (16%). Conversely, in patients with HCM relaxation was similarly shortened between during pacing alone (20%) and during exercise (19%).

CONCLUSIONS

The force-frequency and the relaxation-frequency relations were well-preserved in all patients. In patients with HCM, the adrenergic enhancement of force-frequency relation and/or relaxation-frequency relation was impaired. In patients with APH, however, adrenergic control of both force-frequency and relaxation-frequency relations was well-preserved, which may indicate a preserved beta-adrenergic signaling pathway.

Solid-phase synthesis of substituted guanidines using a novel acid labile linker

A novel acid labile linker for solid-phase synthesis of substituted guanidines has been developed. Its synthetic utility is exemplified by high-yielding pyrazole displacement with structurally and electronically diverse sets of aliphatic and aromatic amines. The final cleavage is achieved by treatment with 95:5 trifluoroacetic acid/water for 1 h. The corresponding guanidines were obtained in high purity (80-95%) and good isolated yields (50-95%). The scope and limitations of this linker were further demonstrated by the solid-phase synthesis of an 880-member library of individual trisubstituted arylguanidines employing pyrazole displacement with a set of 11 anilines and two subsequent Mitsunobu N-alkylations with sets of 10 and 8 alcohols, respectively.

Acute effects of a single low oral dose of pimobendan on left ventricular systolic and diastolic function in patients with congestive heart failure

A recent long-term multicenter trial has shown that pimobendan is more effective when administered in low doses. However, no data are available concerning the effect of a low dose of pimobendan on the systolic and diastolic pressure-volume relations in patients with heart failure. Therefore we examined the effects of a single low dose of oral pimobendan, a calcium sensitizer, on systolic and diastolic hemodynamics in patients with cardiomyopathy and congestive heart failure. We measured the left ventricular (LV) pressure-volume relations using a conductance catheter with a micromanometer tip in 10 patients with chronic congestive heart failure resulting from idiopathic cardiomyopathy before and 45 and 90 min after administration of a single oral dose of 2.5 mg of pimobendan. End-systolic elastance was used as an index of LV contractility and was measured during transient occlusion of the inferior vena cava. End-systolic elastance increased significantly by 25% at 45 min (p < 0.05) and by 55% at 90 min (p < 0.01) without an increase in myocardial oxygen consumption. The inotropic effect was accompanied by improved ventriculoarterial coupling. This effect was attenuated in patients with severely impaired myocardial contractility. LV relaxation, assessed by the time constant of isovolumic pressure decay (T(1/2)), was significantly shortened at 90 min (from 47.7 +/- 1.9 to 41.2 +/- 1.7 ms; p < 0.01), although it remained unchanged at 45 min. The diastolic pressure-volume relation showed a leftward and downward shift in all patients. These results indicate that low-dose oral pimobendan had favorable short-term inotropic and lusitropic effects in patients with congestive heart failure caused by idiopathic dilated cardiomyopathy, and may thus be a useful alternative to traditional agents. Further study in a large-scale trial is merited.

Histopathological analysis of apoptosis, and expression of p53, bcl-2, bax, and Ki-67 in laryngeal squamous cell carcinomas and dysplasia

The growth of neoplasia is determined by the proliferation and loss of cells. The purpose of this study is to determine the frequency of apoptosis in laryngeal carcinomas and to examine its relationship to the pathological parameters, including ki-67 expression, and to expression of p53, bcl-2, and bax protein. The materials are 67 cases of laryngeal squamous cell carcinomas (SCCs) and 22 cases of squamous dysplasia using biopsy and surgery specimens. Apoptotic cells were determined by the modified TUNEL method. Expressions of p53, bcl-2, and bax, i.e. apoptosis-related genes, and ki-67, a proliferation marker, were immunohistochemically examined. The relationships between apoptosis and the clinicopathological findings were studied. The stage of the carcinoma was not related to the apoptotic index. The expression of p53 was frequently detectable in the advanced carcinomas with T3, T4 and N-positive. The apoptotic index was not significantly related to recurrence, metastasis or histological differentiation. Apoptosis occurred frequently in the cornified areas of well differentiated SCCs. The expressions of ki-67 observed in the poorly differentiated SCCs was significantly higher than that observed in the well differentiated SCCs (P< 0.01). The apoptotic index increased after irradiation in the carcinoma. No relationship was found between apoptotic index, ki-67 index, and expression of p53, bcl-2 and bax. The apoptotic index obtained form the SCCs was significantly higher than that obtained form squamous dysplasias (P < 0.05). Various apoptosis-related findings including p53 expression were observed in the advanced type of laryngeal SCCs, and apoptosis of the carcinoma was suggested to be controlled by complicated factors including bcl-2.

Impaired force-frequency relations in patients with hypertensive left ventricular hypertrophy. A possible physiological marker of the transition from physiological to pathological hypertrophy

BACKGROUND

The extent to which force-frequency and relaxation-frequency relations (FFR and RFR, respectively) and exercise-induced adrenergic stimulation affect myocardial inotropic and lusitropic reserves has not been established in patients with left ventricular (LV) hypertrophy (LVH).

METHODS AND RESULTS

We calculated the maximum first derivative of LV pressure (LV dP/dtmax) and the LV pressure half-time (T1/2) during pacing, exercise, and isoproterenol infusion in 17 patients with hypertensive LVH and 9 control subjects to investigate the influence of increases in heart rate (HR) and adrenergic stimulation on inotropic and lusitropic reserves. Group A consisted of 10 LVH patients who showed a progressive increase in the HR-LV dP/dtmax relation. Group B consisted of 7 LVH patients in whom the HR-dP/dtmax relation at physiological pacing rates was biphasic. The LV mass index was larger and the LV ejection fraction was smaller in group B than in group A (244+/-72 g/m2 versus 172+/-22 g/m2 and 55+/-18% versus 72+/-6%, respectively; both P<0.05). The increase in LV dP/dtmax was greater during exercise than pacing alone for similar increases in HR in all groups (P<0.05) (group A, 111+/-22% versus 25+/-14%; group B, 105+/-35% versus 14+/-10%; control, 111+/-24% versus 25+/-12%). T1/2 was shorter (P<0.05) during exercise than with pacing alone in all groups (group A, 41+/-6% versus 11+/-3%; group B, 38+/-9% versus 14+/-4%; control, 44+/-6% versus 12+/-5%). Isoproterenol infusion caused similar increases in LV dP/dtmax and similar decreases in T1/2 in all groups.

CONCLUSIONS

The FFR was biphasic in patients with severe LVH irrespective of LV function but was preserved in patients with less severe LVH and control subjects. Importantly, the RFR and adrenergic control of both inotropic and lusitropic reserves were well preserved in all LVH patients. A biphasic FFR at physiological pacing rates may be one of the earliest markers of the transition from physiological adaptation to the pathological process in LVH patients.

A new surgical procedure for the very severe inverted nipple

Severe cases of inverted nipple usually cannot be corrected by a simple procedure, especially if the nipple cannot be pulled out above the areolar level by manipulation. We describe a new method for these cases and we classify the inverted nipple into 3 grades following the choice of their required operative procedure. Our classification for inverted nipple is as follows. Grade I: The inversion is corrected simply by manipulation; the nipple protrusion is long-lasting. Grade II: The inversion can be corrected by manipulation, but recurrence of the inversion is frequent. Grade III: The inversion cannot be corrected without a surgical procedure. Cases of Grades I and II can be corrected by conventional simple surgical procedures. But some cases of Grade II and almost all of Grade III cannot be corrected by conventional methods, in spite of the high frequency of relapse. Cutting of the lactiferous duct, such as the Pitanguy and Broadbent methods, can correct the very severely inverted nipple. But if we want to maintain the lactiferous function after correction, we had better not cut the lactiferous ducts. Our new procedure for correcting very severe cases can keep the lactiferous function after correction without any relapse. In order to avoid the recurrence of nipple retraction and to maintain the lactiferous function, the new surgical procedure that we performed makes an incision deeply and vertically on the nipple to free the lactiferous ducts from the contracted tissues surrounding them. After extension or resection of the restricting tissues, the nipple is raised easily. This procedure will preserve the feeding function and prevent the recurrence of nipple inversion. For very severe cases, using a dermal flap inserted into the base of the nipple may be necessary due to its role of interposing tissue to prevent reverting to inversion.

Cdk2/cdc2 expression in colon carcinogenesis and effects of cdk2/cdc2 inhibitor in colon cancer cells

Cyclin dependent kinases propel the cell cycle in collaboration with cyclins. We have examined the expression of cdk2/cdc2 in adenoma and focal carcinoma in adenomatous tissue to explore their role in tumorigenesis of colorectum. Immunohistochemical study revealed that cdk2/cdc2 was overexpressed in a subsets of adenoma (14/50; 28.0%) but this overexpression was much more obvious in focal carcinoma (13/15; 86.7%). These results suggest that cdk2/cdc2 is remarkably upregulated together with a malignant change. In an effort to demonstrate a significant role for cdk2/cdc2 in colon cancer, we investigated growth and apoptosis with butyrolactone I, a specific inhibitor for cdk2/cdc2, using 4 colon carcinoma cell lines (HCT116, LoVo, HT29, Colo 320DM). Butyrolactone I inhibited proliferation of all colon carcinoma cell lines at 100 microM and it induced apoptosis in LoVo cell line with induction of p53. Our findings suggest that inhibition of cdk2/cdc2 may be a useful strategy against colon cancer.

[PyNPase expression and cancer progression in the colorectum]

We analyzed PyNPase expression discriminating between cancer and tumor stroma of the colorectum by Western blotting using a newly developed extraction method from microdissected tissue sections fixed with buffered formalin. Analysis of 98 colorectal cancers revealed that PyNPase was as high as 70.2 +/- 18.5 unit/mg protein in the stroma fraction (SF), whereas it was 45.1 +/- 10.5 in the cancer fraction (CF) (p < 0.0001). Vessel density was correlated with PyNPase in the SF but not in the CF. In stage IIIb, 11 cases expressing a high level of PyNPase in the CF showed poorer prognosis than 10 cases with low-level PyNPase expression (p < 0.05), although the level of PyNPase expression in the SF did not affected the patients prognosis. Immunohistochemical examination indicated that PyNPase in the SF was mainly produced by macrophages (M phi), and therefore we investigated the profile of PyNPase production by M phi. In in vitro experiments PyNPase production by M phi was greatly enhanced by stimulation with OK-432, and the culture supernatant had the ability to convert 5'DFUR to 5-FU.

Changes in size of intracellular pools of coenzyme A and its thioesters in Escherichia coli K-12 cells to various carbon sources and stresses

Intracellular pools of three CoA molecular species of coenzyme A, CoASH, acetyl-CoA, and malonyl-CoA, in Escherichia coli K-12 cells were studied by acyl-CoA cycling method in replacement culture. The sizes and compositions of CoA pools starved for a carbon source changed within minutes after the addition of one of various carbon sources. A large acetyl-CoA pool formed after the addition of D-glucose, D-fructose, D-mannose, glycerol, or sorbitol, but there was little change when L-glucose, sucrose, maltose, succinate, or acetate was added. The beta-anomer of D-glucose was assimilated 10 times faster than the alpha-anomer. Intracellular CoA pools also changed with stress: in the pH, incubation temperature, or with osmotic stress. The sizes and compositions of CoA pools were not affected by pH changing between 4 and 8, but the breakdown of acetyl-CoA and CoASH was greater at pH 9 than at pH 4 to 8. Production of acetyl-CoA was greatest at 40 degrees C, and at 50 degrees C, an acetyl-CoA pool did not form at all and the size of the CoASH pool declined. When the organism was stressed by the addition of NaCl at concentrations of more than 0.6 M, little acetyl-CoA was produced. The total CoA pool (the sum of the concentrations of CoASH, acetyl-CoA, and malonyl-CoA) remained within the limits of 0.83-1.40 nmol/mg of dry cell weight (0.30-0.52 mM). Whenever acetyl-CoA increased, CoASH decreased. Therefore, the acetyl-CoA/CoASH ratio is an important index of facultative anaerobes that reflects the state of carbon and energy metabolism in vivo.

Extraction and analysis of diagnostically useful proteins from formalin-fixed, paraffin-embedded tissue sections

We describe and discuss a method of protein extraction for Western blot analysis from formalin-fixed, paraffin-embedded tissue sections. From 5-mm2 50-micron-thick tissue sections, an abundance of proteins could be extracted by incubating the sections in lysis buffer containing 2% sodium dodecyl sulfate (SDS) at 100C for 20 min followed by incubation at 60C for 2 hr. Extracts yielded discernible protein bands ranging from 10 kD to 120 kD as identified by SDS-polyacrylamide gel electrophoresis (PAGE). Western blot analysis successfully detected membrane-bound protein such as E-cadherin, cytosolic protein such as beta-catenin, and nuclear proteins including proliferating cell nuclear antigen (PCNA), mutant-type p53, cyclin D1, cyclin E, and cyclin-dependent kinases (CDKs). With this technique, we could examine cyclin D1 and CDK2 expression in small adenomas compared with cancer tissues and normal mucosa. The simple method of protein extraction described here should make it possible to use large-scale archives of formalin-fixed, paraffin-embedded samples for Western blot analysis, and its application could lead to detailed analysis of protein expression. This new technique should yield valuable information for molecular biology.