The complete chloroplast genome of Ziziphus jujuba cv. Bokjo (Rhamnaceae)

We have sequenced the Ziziphus jujuba cv. Bokjo chloroplast genome by de novo assembly using next-generation sequencing. The complete circular chloroplast genome consisted of 161,714 bp and contained four parts: a large single-copy (LSC) region of 89,323 bp, a small single-copy (SSC) region of 19,361 bp, and two inverted repeat regions (IRa and IRb) of 26,515 bp each. The genome annotation predicted a total of 110 genes, including 76 protein-coding genes, 30 tRNA genes, and four rRNA genes. Phylogenetic analysis demonstrated the close taxonomic relationship between Z. jujuba cv. Bokjo and two other members of the Ziziphus genus, Z. spina-christi and Z. mauritiana. We found 135 polymorphic loci, 63 single nucleotide polymorphism (SNP) and 72 insertion-deletion (InDel), from the comparison of Z. jujuba cultivar Bokjo and Z. jujuba reference (NC_030299). The polymorphic loci could be used for the differentiation of Z. jujuba genetic resources and for breeding in the future.

Laparoscopic uncontained power morcellation-induced dissemination of ovarian endodermal sinus tumors: A case report

BACKGROUND

Endodermal sinus tumors (ESTs), which arise primarily in children and adolescents, account for 20% of malignant ovarian germ cell tumors, but constitute only 1% of all ovarian malignancies. Treatment of ESTs consists of surgical staging with fertility-sparing surgery and chemotherapy.

CASE SUMMARY

A 15-year-old nulliparous patient was diagnosed with disseminated ovarian ESTs after laparoscopic unilateral salpingo-oophorectomy using uncontained power morcellation for treatment of a ruptured solid adnexal mass in another hospital. Exploratory laparotomy; total abdominal hysterectomy, right salpingo-oophorectomy, and lymphadenectomy were performed with optimal debulking, and surgical stage 3C was assigned to the patient.

CONCLUSION

In 2014, the Food and Drug Administration noted that power morcellation was probably associated with a risk of disseminating suspected cancerous tissue. Furthermore, the use of power morcellation to remove solid adnexal mass is considered a contraindication because of the potential for a malignant tumor. This case report aims to warn of the dangers of using uncontained power morcellation to treat solid adnexal masses.

Abstract P6-05-05: The expression of lysyl oxidase and fibrotic focus is related to inflammation in breast cancer

Background: Lysyl oxidase (LOX) is an extracellular matrix enzyme that catalyzes the

cross-linking of collagens or elastin. Our hypothesis is that LOX contributes to the formation

of a fibrotic focus (FF), which is related to inflammation in breast carcinogenesis.

In this study, we analyzed the association between the expression LOXs and FF, and

investigated prognostic significance in breast cancer.

Methods: Tissue microarrarys were constructed from the specimens of 444 patients

with primary invasive breast cancer. Immunohistochemical staining for LOX, LOXlike

(LOXL)-, LOXL-2 and LOXL-3 was performed. The status of FF within the tumor

was assessed. The number of CD4+ T cells, CD8+ T cells, CD68+ macrophages was

counted, and intratumoral and peritumoral lymphocyte infiltration were evaluated.

The clinicopathologic characteristics of the patients were analyzed.

Result: The percentage of positive FF was 39.2% and positive rate of LOX expression

was 50% in primary breast cancer tissues. FF was found to be significantly associated

with intratumoral and peritumoral inflammation, lymph node metastasis, high histologic

grade, larger tumor size. LOX was associated with intratumoral and peritumoral

inflammation, CD8+ T cells and menopausal status. LOXL-3 was significantly associated

with positive expression of ER and PR, and molecular subtype.

Conclusions: FF and the expression of LOX were associated with inflammation in

breast cancer in this study. Our results suggest that LOXs may contribute to the formation

of a FF indirectly in relation with inflammation in breast cancer. Further studies

are needed to clarify the role of LOXs, FF and inflammation in tumorigenesis and

prognostic value of them in breast cancer.

Citation Format: Park SH, Jeong YJ, Bong JG, Oh HK. The expression of lysyl oxidase and fibrotic focus is related to inflammation in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-05-05.

The submuscular sliding plate technique for acetabular posterior wall fractures extending to the acetabular roof

There is extension of the Kocher-Langenbeck approach using trochanteric osteotomy for posterior wall fracture extending to acetabular roof, but it exposes to complications such as nonunion, breakage, and heterotopic ossification. The current study introduces a submuscular sliding plate technique. We retrospectively analyzed 13 patients treated with this technique. It is based on conventional method for posterior wall fracture. After reduction of roof fragment with direct visualization, a pre-contoured plate was passed through a submuscular tunnel under the gluteus medius and minimus. A small split incision was performed on the muscles, and screws were inserted with a triple trocar complex safely under fluoroscopic imaging. All patients had fracture union without complications. X-rays results showed anatomical reduction in 10 cases and imperfect reduction in 3 cases. Our results were satisfactory, particularly without heterotopic ossifications despite no prophylactic regimen of NSAID was applied and no neurological complications, so we believe that this technique is a good option for posterior wall fractures extending to the acetabular roof.

Abstract P2-06-05: Association of promoter methylation status of the FHIT gene and Fhit expression with HER2/neu status in breast cancer

Purpose: Aberrant DNA methylation has been recognized to contribute to breast carcinogenesis, and promoter hypermethylation of many tumor suppressor genes has been correlated with decreased gene expression. The fragile histidine triad (FHIT) gene is a putative tumor suppressor gene in breast and other cancers, and loss of Fhit expression has been observed in breast cancers. The aim of this study was to evaluate the association between methylation of the FHIT gene and its expression in breast cancer, and to investigate whether methylation and expression of the FHIT gene would correlate with clinicopathological characteristics in relation to human epidermal growth factor receptor 2 (HER2) status.

Methods: Pyrosequencing of bisulfite treated DNA was performed to study the methylation status of the FHIT gene in 60 breast cancer samples from Korean women obtained at Daegu Catholic University Hospital. We examined the expression of FHIT using tissue microarrays by immunohistochemical staining. Association between the methylation status of the FHIT gene and its expression was analyzed, and the relationship between the FHIT expression and the clinicopathological characteristics of the patients was evaluated.

Results: FHIT methylation was detected in 96.7% and positive expression rate of Fhit was 87.3% of the patients. The mean methylation level of the FHIT gene was associated with intratumoral inflammation. Methylation level of the FHIT gene had no significant differences according to molecular subtypes. Loss of Fhit expression was associated with large tumor size, basal-like subtype and positive expression of EGFR. In HER2-negative breast cancers, loss of Fhit expression was significantly associated with tumor size, estrogen receptor status and Ki-67 proliferation index. There was no significant correlation between methylation of the FHIT gene and its expression in this study.

Conslusion: Our study revealed that loss of Fhit expression in breast cancer is associated with poor prognostic features, although there is no significance association between the FHIT gene methylation and Fhit expression. We found that in HER2-negatvie breast cancers, loss of Fhit expression was associated with poor prognostic features. These results support the possibility of potential complementation between HER2 and the Fhit pathway. The clinical significance of our findings needs to be further evaluated in larger cohorts with longer follow-up.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-06-05.

Effects of alendronate on a disintegrin and metalloproteinase with thrombospondin motifs expression in the developing epiphyseal cartilage in rats

A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) have been reported to play a role in the degradation of aggrecan, a major component of cartilage. This study was performed to examine the effects of alendronate on the expression of ADAMTS in developing femoral epiphyseal cartilage. Primary cultured chondrocytes from this cartilage were treated with alendronate in vitro and postnatal day 1 rats were injected subcutaneously with alendronate (1 mg/kg) every second day in vivo. The number of cultured chondrocytes and their aggrecan mRNA levels were unaffected by the alendronate treatment at 10(-6) to 10(-4) M concentrations. The mRNA levels of ADAMTS-1, -2 and -9 in chondrocytes were also unaffected. However, the levels of ADAMTS-5 and -4 were reduced significantly by the same treatment. The thickness of the proliferating chondrocyte layers and the aggrecan mRNA levels in the epiphysis were unaffected by the alendronate treatment in vivo. However, the hypertrophied chondrocyte layers became significantly thicker, and the size of the secondary ossification centre was reduced significantly by the same treatment (P < 0.05). Both ADAMTS-4 and -5 mRNA expressions were also reduced significantly in vivo. The immunoreactivity against ADAMTS-4 was seen in hypertrophied chondrocytes and reduced significantly by the alendronate treatment. These results suggested that alendronate can inhibit the degradation of aggrecan in the articular cartilage by downregulating the expression of matrix enzymes such as ADAMTS-4 and -5.

Systemic Herpes Simplex Virus Infection Following Cadaveric Renal Transplantation: A Case Report

Herpes simplex virus (HSV) infection usually occurs in immunocompromised or severely debilitated patients. It is not so common in patients with renal transplants. The diagnosis can only be made histologically. It usually occurs during or shortly after treatment of graft rejection with high-dose steroids. We have recently experienced a case of HSV esophagitis and nephropathy in the renal allograft biopsy, which was identified by histology, immunostaining, and electron microscopy. A 43-year-old woman underwent cadaveric renal transplantation with cyclosporine and prednisolone treatment. Twelve months later, she developed renal insufficiency and proteinuria. Allograft renal biopsy showed some evidence of acute rejection. She was treated with 3 successive days of methylprednisolone (1.0 g/d) intravenously and continued tapering of steroids. Three weeks after steroid pulse therapy, she had throat pain, oral cavity ulcer, dysphagia, and febrile sensation. Esophagoscopy revealed multiple confluent ulcers in the whole esophagus, and biopsy showed enlarged epithelial cells with prominent nuclei. Immunohistochemically, the epithelial cells were positive with a monoclonal antibody to HSV type 1. She was started on acyclovir intravenously, which was continued for a week. After a week, her symptoms began to improve and repeat endoscopy showed no residual esophagitis. A renal allograft infection with HSV can persist in heavily immunosuppressed patients with recurrent rejection episodes. HSV mainly affects tubular cells causing necrosis, a major reason for functional deterioration. A biopsy is required for diagnosis.

KNT-artificial neural network model for flux prediction of ultrafiltration membrane producing drinking water

This paper describes the prediction of flux behavior in an ultrafiltration (UF) membrane system using a Kalman neuro training (KNT) network model. The experimental data was obtained from operating a pilot plant of hollow fiber UF membrane with groundwater for 7 months. The network was trained using operating conditions such as inlet pressure, filtration duration, and feed water quality parameters including turbidity, temperature and UV254. Pre-processing of raw data allowed the normalized input data to be used in sigmoid activation functions. A neural network architecture was structured by modifying the number of hidden layers, neurons and learning iterations. The structure of KNT-neural network with 3 layers and 5 neurons allowed a good prediction of permeate flux by 0.997 of correlation coefficient during the learning phase. Also the validity of the designed model was evaluated with other experimental data not used during the training phase and nonlinear flux behavior was accurately estimated with 0.999 of correlation coefficient and a lower error of prediction in the testing phase. This good flux prediction can provide preliminary criteria in membrane design and set up the proper cleaning cycle in membrane operation. The KNT-artificial neural network is also expected to predict the variation of transmembrane pressure during filtration cycles and can be applied to automation and control of full scale treatment plants.

Purification of recombinant human B-domain-deleted factor VIII using anti-factor VIII monoclonal antibody selected by the surface plasmon resonance biosensor

The surface plasmon resonance (SPR) biosensor measures the real-time kinetics of noncovalent interaction between a receptor and its ligand. Monoclonal antibodies (mAbs) against recombinant factor VIII (rFVIII) were screened from 127 mAb candidates using the SPR biosensor for the purpose of affinity purification of rFVIII. Each mAb showed a different association and dissociation capacity for rFVIII at each buffer condition. One mAb, F8-38, was selected for immunopurification of rFVIII. To characterize the selected mAb F8-38, the immunopurification results on the anti-FVIII mAb F8-38 affinity gel and the anti-von Willebrand factor (vWF) mAb affinity gel were studied. Immunopurification by the anti-vWF affinity gel showed a lower binding capacity of rFVIII and resulted in low purification efficiency. On the other hand, immunopurification by the anti-FVIII affinity gel exhibited a 3.5-fold binding capacity and a 2-fold purification efficiency compared to those of the anti-vWF affinity gel. The amounts of proteins and DNAs derived from host cells and mouse IgGs derived from the affinity matrix in the affinity eluate were similar to those of the anti-vWF affinity gel. In conclusion, the SPR method of immunopurification is a useful technology in the screening of mAbs aimed at the development of an affinity purification procedure, and the mAb F8-38 was selected using this technology on the basis of the purification procedure of rFVIII.

The modified human DNA repair enzyme O(6)-methylguanine-DNA methyltransferase is a negative regulator of estrogen receptor-mediated transcription upon alkylation DNA damage

Cell proliferation requires precise control to prevent mutations from replication of (unrepaired) damaged DNA in cells exposed spontaneously to mutagens. Here we show that the modified human DNA repair enzyme O(6)-methylguanine-DNA methyltransferase (R-MGMT), formed from the suicidal repair of the mutagenic O(6)-alkylguanine (6RG) lesions by MGMT in the cells exposed to alkylating carcinogens, functions in such control by preventing the estrogen receptor (ER) from transcription activation that mediates cell proliferation. This function is in contrast to the phosphotriester repair domain of bacterial ADA protein, which acts merely as a transcription activator for its own synthesis upon repair of phosphotriester lesions. First, MGMT, which is constitutively present at active transcription sites, coprecipitates with the transcription integrator CREB-binding protein CBP/p300 but not R-MGMT. Second, R-MGMT, which adopts an altered conformation, utilizes its exposed VLWKLLKVV peptide domain (codons 98 to 106) to bind ER. This binding blocks ER from association with the LXXLL motif of its coactivator, steroid receptor coactivator-1, and thus represses ER effectively from carrying out transcription that regulates cell growth. Thus, through a change in conformation upon repair of the 6RG lesion, MGMT switches from a DNA repair factor to a transcription regulator (R-MGMT), enabling the cell to sense as well as respond to mutagens. These results have implications in chemotherapy and provide insights into the mechanisms for linking transcription suppression with transcription-coupled DNA repair.

Management of advanced mandibular osteoradionecrosis with free flap reconstruction

BACKGROUND

The purpose of this study was to assess the effectiveness of free tissue transfer for treatment of advanced mandibular osteoradionecrosis (ORN) in head and neck cancer patients.

METHODS

We reviewed 29 patients who were treated for advanced mandibular ORN by radical resection and reconstruction with free flaps at our institution. All patients had either failed to respond to conservative treatment, including hyperbaric oxygen therapy and debridement or had pathological fracture due to ORN.

RESULTS

Twenty-four vascularized bone (17 fibula, five iliac, and two scapula), four rectus abdominis myocutaneous, and one radial forearm fasciocutaneous free flaps were used. The complications occurred in 6 of 29 patients (21%). A total of four flaps (14%) were lost. The mean follow-up was 2 years 9 months. All patients had complete resolution of ORN symptoms. No evidence of ORN recurrence was observed in any patient.

CONCLUSION

For advanced osteoradionecrosis of the mandible, radical resection followed by reconstruction using free flap provides a reliable means of obtaining good wound healing with acceptable aesthetic and functional results.

Insulin allergy resolution following pancreas transplantation alone

Clinically significant immunological reactions to exogenous insulin are classified as local or generalized. Most of the insulin allergies are local reactions which usually improve or resolve spontaneously. Generalized allergic reactions to insulin range in severity from simple urticaria to life-threatening anaphylaxis. Most of the allergic reactions to exogenous insulin are antibody-mediated reactions to antigens such as zinc, protamine, non-insulin proteins, and aggregates of insulin molecules as well as animal antigens. Immunologic reactions to endogenous insulin usually result in insulin resistance. Herein, we report a case in which systemic insulin allergy was intractable, thus requiring a pancreas transplantation which is the first of its case according to the International Pancreas Transplant Registry/United Network for Organ Sharing (IPTR/UNOS) Registry.

Fibrillary glomerulonephritis in a renal allograft

Fibrillary glomerulonephritis is an uncommon disease seen in approximately 1% of all native kidney biopsy specimens. We present here a case of a 40-year-old white woman with the rapid loss of graft function secondary to fibrillary glomerulonephritis within 7 days of receiving a living-related renal allograft. This case emphasizes the values of combining urinalysis with prompt allograft kidney biopsy in recipients with an elevated serum creatinine posttransplantation. When one encounters rapidly progressing glomerulonephritis or a pulmonary-renal syndrome in the immediate posttransplantation period, fibrillary glomerulonephritis must be considered in the differential diagnosis. Because of a high recurrence rate and no available treatment to modify a potentially malignant course of this disease, we recommend caution when considering these patients for transplantation.

Two low-dose OKT3 induction regimens following renal transplantation--clinical experience at a single center

Experience with quadruple-drug induction therapy with two regimens of low-dose OKT3 in renal transplant patients was evaluated. Group I received 5.0 mg OKT3 in the operating room and on day 1, followed by 2.5 mg/d for a total dose and duration of 40 mg and 14 d, respectively, and group II received 14 d of OKT3 2.5 mg/d (a total dose of 35 mg). Rejection episodes developed in 21% of patients: 29% of group I vs. 17% of group II. In groups I and II, the mean number of days until first rejection was 134 and 119 d, respectively, and delayed graft function was observed in 24 vs. 13% of patients, respectively. Cytokine release syndrome was noted in 95% of group I patients and in 78% of group II patients. The overall incidence of infections did not differ significantly between the two groups; however, the incidence of oral candidiasis was higher in group II (30 vs. 11% in group I, p = 0.021) and the incidence of herpes simplex virus infection was higher in group I (13 vs. 1% in group II, p = 0.015). The average length of hospital stay was 6.7 d in group I and 6.2 d in group II. The current pharmacy charge for a 2.5-mg vial of OKT3 is 28% lower for a 5.0-mg vial. Our study suggests that by using either low-dose OKT3 regimen renal transplant patients can be safely treated with shortened hospital stays, lower pharmacy costs, and without increased incidence of graft loss or patient morbidity.

Implication of localization of human DNA repair enzyme O6-methylguanine-DNA methyltransferase at active transcription sites in transcription-repair coupling of the mutagenic O6-methylguanine lesion

DNA lesions that halt RNA polymerase during transcription are preferentially repaired by the nucleotide excision repair pathway. This transcription-coupled repair is initiated by the arrested RNA polymerase at the DNA lesion. However, the mutagenic O6-methylguanine (6MG) lesion which is bypassed by RNA polymerase is also preferentially repaired at the transcriptionally active DNA. We report here a plausible explanation for this observation: the human 6MG repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) is present as speckles concentrated at active transcription sites (as revealed by polyclonal antibodies specific for its N and C termini). Upon treatment of cells with low dosages of N-methylnitrosourea, which produces 6MG lesions in the DNA, these speckles rapidly disappear, accompanied by the formation of active-site methylated MGMT (the repair product of 6MG by MGMT). The ability of MGMT to target itself to active transcription sites, thus providing an effective means of repairing 6MG lesions, possibly at transcriptionally active DNA, indicates its crucial role in human cancer and chemotherapy by alkylating agents.

Conformational change in human DNA repair enzyme O6-methylguanine-DNA methyltransferase upon alkylation of its active site by SN1 (indirect-acting) and SN2 (direct-acting) alkylating agents: breaking a "salt-link"

Human O6-methylguanine-DNA methyltransferase (MGMT) repairs DNA by transferring alkyl (R-) adducts from O6-alkylguanine (6RG) in DNA to its own cysteine residue at codon 145 (formation of R-MGMT). We show here that R-MGMT in cell extracts, which is sensitive to protease V8 cleavage at the glutamic acid residues at codons 30 (E30) and 172 (E172), can be specifically immunoprecipitated with an MGMT monoclonal antibody, Mab.3C7. This Mab recognizes an epitope of human MGMT including the lysine 107 (K107) which is within the most basic region that is highly conserved among mammalian MGMTs. Surprisingly, the K107L mutant protein is repair-deficient and readily cleaved by protease V8 similar to R-MGMT. We propose that R-MGMT adopted an altered conformation which exposed the Mab.3C7 epitope and rendered that protein sensitive to protease V8 attack. This proposal could be explained by the disruption of a structural "salt-link" within the molecule based on the available structural and biochemical data. The specific binding of Mab.3C7 to R-MGMT has been compared with the protease V8 method in the detection of R-MGMT in extracts of cells treated with low dosages of methyliodide (SN2) and O6-benzylguanine. Their identical behaviors in producing protease V8 sensitive R-MGMT and Mab.3C7 immunoprecipitates suggest that probably methyl iodide (an ineffective agent in producing 6RG in DNA) can directly alkylate the active site of cellular MGMT similar to O6-benzylguanine. The effectiveness of MeI in producing R-MGMT, i.e., inactivation of cellular MGMT, indicates that this agent can increase the effectiveness of environmental and endogenously produced alkylating carcinogens in producing the mutagenic O6-alkylguanine residues in DNA in vivo.

Inhibition of PDGF-induced phospholipase D but not phospholipase C activation by herbimycin A

It is known that PDGF-induced phospholipase D (PLD) activation occurs downstream of phospholipase C gamma 1 (PLC-gamma 1) activation. Herbimycin A, a specific inhibitor of Src family tyrosine kinase, dose-dependently inhibited PDGF-induced PLD activation (IC50 of 8 micrograms/ml) without affecting PLC-gamma 1 activation and significantly reduced PDGF-induced tyrosine phosphorylations of 40-46 kD and 60 kD proteins in PLC-gamma 1-overexpressing NIH 3T3 gamma 1 cells. These results suggest that PLC activation is necessary but not sufficient for PDGF-induced PLD activation. Tyrosine phosphorylation of p40-p46 and p60 is thought to be involved in PDGF-induced activation of PLD but not of PLC.

Plasma type IV collagen and fibronectin concentrations in diabetic patients with microangiopathy

In diabetes mellitus, thickening of basement membrane in capillaries and small vessels is a well-known finding and important in the progression of diabetic microangiopathy. We evaluated whether the plasma levels of type IV collagen and fibronectin, which are important factors of basement membrane, are related with the presence of diabetic microangiopathy. Plasma type IV collagen and fibronectin levels were measured in 40 healthy controls (Mean +/- SD, age; 50.3 +/- 5.5 yr) and 94 diabetic patients (age; 52.4 +/- 13.5 yr) with and without microvascular complications. The mean plasma levels of type IV collagen (5.3 +/- 2.9 ng/ml) and fibronectin (474.4 +/- 119.4 ug/ml) in diabetic patients were significantly higher (p < 0.01) than in healthy controls (3.7 +/- 1.3 ng/ml and 319 +/- 50.9 ug/ml). The mean plasma level of type IV collagen in diabetic patients with complications (6.6 +/- 3.7 ng/ml) was significantly higher (p < 0.01) than in those without complications (4.3 +/- 1.7 ng/ml) and became higher in more complicated patients. Furthermore, the severity of retinopathy and several indicators of nephropathy such as serum BUN, creatinine and proteinuria were closely associated with plasma type IV collagen level and a significant correlation was found between plasma type IV collagen and creatinine clearance (r = -0.31, p < 0.001). There was no significant difference in plasma fibronectin concentrations, however, between the diabetic patients with complications and those without complications.(ABSTRACT TRUNCATED AT 250 WORDS)

A method for simultaneous identification of human active and active-site alkylated O6-methylguanine-DNA methyltransferase and its possible application for monitoring human exposure to alkylating carcinogens

Cells resist the major mutagenic effects of alkylating agents by the action of O6-methylguanine-DNA methyltransferase (MGMT), which transfers the alkyl (R) group of O6-alkylguanine, produced in DNA by these chemicals, to a cysteine residue in its active site (formation of R-MGMT). We demonstrate that cellular R-MGMT (which represents a record or memory within the cells exposed to these chemicals) can be assayed by its sensitivity toward proteolysis by protease V8. The possible use of this assay for monitoring exposure to alkylating carcinogens was investigated by using cultured cells and a preliminary study with the use of human blood from normal subjects and patients undergoing chemotherapy. Cultured cell experiments show that R-MGMT is sufficiently stable for the monitoring purpose and its level bears a dose-response relationship to the concentrations of the alkylating agent used. Interestingly, experiments with blood from patients undergoing chemotherapy show a gradual formation of R-MGMT in 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea and an induced MGMT deficiency in cyclophosphamide-treated patients. The use of this methodology, which allows for the possible quantification of active MGMT (cellular DNA repair capacity) and R-MGMT (recent exposure) simultaneously, in monitoring human exposure to alkylating carcinogens is discussed.

Epidural morphine on ventilatory function in chest trauma and thoracotomy patients

Epidural morphine injection was done in nineteen patients who had been admitted from March to August 1990 to the Intensive Care Unit, Severance Hospital, Yonsei Medical Center for respiratory care including ventilator care. Morphine suplphate, 2.67 +/- 0.27 mg was injected one to three times to four patients after chest trauma, and to fifteen patients after thoracotomy. Tidal volume and vital capacity were increased from 4.45 +/- 0.48 and 8.31 +/- 0.50 to 6.91 +/- 0.41 and 12.81 +/- 0.73 mg/kg. However, respiratory rates decreased from 26.07 +/- 1.41 to 20.07 +/- 1.16/min. Inspiratory force increased from -13.40 +/- 1.31 to -26.53 +/- 1.82 cmH2O. Pain score decreased from 9.22 +/- 0.57 to 3.56 +/- 0.83 during this period. PaCO2 did not differ significantly (39.33 +/- 1.13 and 39.48 +/- 1.42 mmHg). Side effects such as pruritus and urinary retention were treated with naloxone 7 approximately 10 ng/kg/min. Mean arterial pressure and pulse rates stayed stable during the study periods. Ventilator hours and ICU stays differed from the control group. However, the duration was not statistically significant. The control group consisted of patients who were admitted during the six months from September 1989 to February 1990 to the ICU for respiratory care, without epidural morphine injection.

Clinical experiences of fiberoptic bronchoscopy in patients with respiratory failure in the intensive care unit

Seventy-nine fiberoptic bronchoscopies were performed in 46 Patients during 2 years in the Intensive Care Unit of Severance Hospital, Yonsei Medical Center. Bronchoscopies were done more than twice in 13 patients. Forty-three bronchoscopies were done through the orotracheal tube in 27 patients, and narcotics and sedatives such as morphine sulfate, diazepam and lorazepam were added with pancuronium bromide during 52 bronchoscopy procedures in 21 patients. Ventilatory support was accomplished by control mode ventilation for 63 bronchoscopies in 37 patients. Twenty-four patients were from the surgical department, and 37 bronchoscopies were performed in 18 patients in a post-thoracotomy state. Twenty-two patients were nonsurgical patients. We performed 48 bronchoscopies in 26 patients to treat lung haziness, 14 bronchoscopies in 3 patients to confirm the operative anastomosis after pneumonectomy or tracheoplasty, and 11 bronchoscopies to confirm the airway patency and vocal cord movement. We obtained good results from 41 bronchoscopies performed for therapeutic purposes and 28 bronchoscopies done for diagnostic purposes. But in 4 patients with pleural effusion and pneumonia, we could not get any improvement in chest X-ray taken after bronchoscopy. We suggested other procedures in 6 patients for diagnosis or treatment, such as suspension laryngoscopy, thoracentesis, ultrasonogram and laser surgery.

A prospective controlled trial of cold-storage versus machine-perfusion preservation in cadaveric renal transplantation

A prospective controlled study was carried out in 60 consecutive cadaver renal donors comparing cold storage to pulsatile machine-perfusion preservation. Each donor served as its own control, by allocating one of the kidneys to each of the two preservation methods. There were 51 evaluable pairs of kidneys. Recipient age, panel-reactive antibody level, history of prior renal transplant, and immunosuppressive regimen were similar in the two preservation groups. Almost all recipients were treated with cyclosporine, and over 50% received antilymphoblast globulin. Total cold ischemic time was 1262 +/- 387 min in the machine-perfused group and 1309 +/- 426 min in the cold-storage group (P = NS). Prolonged ischemia (greater than 24 hr) occurred in 31% of machine-perfused and 22% of cold-stored kidneys (P = NS). Post-operative serum creatinine levels at 1, 7, and 30 days posttransplant were similar in both groups. Dialysis requirements were also similar, with 21 recipients of machine-perfused kidneys (41%) requiring at least one dialysis treatment compared to 16 patients (31%) in the cold-stored group (P = NS); the mean number of dialysis treatments required was 3.14 +/- 1.46 and 3.06 +/- 1.29, respectively (P = NS). Long ischemic time (greater than 24 hr) was associated with a higher rate of dialysis requirement in both groups, but in neither case did this achieve statistical significance. The distribution of graft losses within the first 30 days was similar in both groups, and the incidence of preservation-related graft failure was not significantly different. These results demonstrate that, in the cyclosporine era, machine perfusion offers no significant advantages over cold storage for cadaver renal preservation. Because machine perfusion is considerably more expensive and cold storage is simpler and facilitates the logistics of organ sharing, we recommend simple hypothermic storage of renal allografts as the preservation method of choice.

Pulse oximetry during shunt surgery in pediatric patients with tetralogy of fallot

Pulse oximetry is a noninvasive technique for measuring O2 saturation (SpO2) continuously. We applied pulse oximetry to 9 pediatric patients with tetralogy of Fallot during shunt surgery. Arterial oxygen tensions (PaO2) and saturations (SaO2) were also measured at the time of postinduction, just before the shunt, after the shunt and at the end of the operation. The SpO2 and SaO2 levels were identically changed in all 4 periods. The PaO2 was increased a little without statistical significance after the shunt procedure and at the end of the operation compared with the values before the shunt. However, SaO2 values increased with statistical significance after the shunt procedure and SpO2 values also showed similar increases with significance. In conclusion, continuous monitoring of SpO2 by pulse oximetry, instead of PaO2, is a very useful and reliable method to assess the improvement of perfusion after shunt, particularly in cyanotic cases.

Kidney retrieval from cadaver donors with disseminated intravascular coagulopathy

Cadaver kidneys from donors with DIC appear to have an increased incidence of delayed function and primary nonfunction. These kidneys may be safely transplanted if cortical necrosis is ruled out. Heparin, antiplatelet therapy, and withholding of cyclosporin A therapy in the early post-transplantation period may improve renal function if there is evidence of glomerular capillary thrombosis.

Complete replacement of methylprednisolone by azathioprine in cyclosporine-treated primary cadaveric renal transplant recipients

In cyclosporine (CsA)-treated renal transplant recipients complete corticosteroid withdrawal followed by CsA monotherapy has been associated with severe rejection episodes in a significant proportion of patients. We report the results of replacement of steroids by azathioprine (AZA) in 25 primary cadaveric renal transplant recipients initially treated with CsA and methylprednisolone (MP). MP taper was started 8.8 +/- 5.6 months posttransplant when the MP dose was either 10 mg/day or 20 mg every other day. MP was tapered off over a 5-month period. At the initiation of MP taper, AZA was added at 1 mg/kg/day and increased to 1.5 mg/kg/day after two months. The CsA dose was adjusted to maintain trough serum levels as measured by radioimmunoassay (RIA) of 50-75 ng/ml, during and after MP withdrawal. Seventeen patients have remained continuously off MP for 14.6 +/- 5.0 months with stable renal function. Reinstitution of MP at 10 mg/day was required in 8 patients, 6 for rejection (1.8 +/- 0.7 months after MP withdrawal), 1 for AZA-induced leukopenia, and 1 for de novo glomerulopathy. Renal function returned to baseline in all 6 patients with rejection after reinstitution of MP. Two of these patients have again been successfully retapered off MP. In the patients withdrawn from MP, body weight and mean arterial blood pressure had decreased by 2.1 +/- 1.3 kg (P less than .05) and 11 +/- 7 mmHg (P less than .05), respectively, at the time of the most recent follow-up compared with values at the initiation of steroid withdrawal. The number of blood pressure medications per patient decreased by 38% (P less than .05) and 6 patients were able to discontinue all antihypertensive drugs after cessation of steroids. Discontinuation of MP also resulted in a decrease in serum cholesterol concentration from 248 +/- 50 to 217 +/- 55 mg/dl (P less than .05). We conclude that steroids can be replaced by AZA in the majority of CsA-treated primary cadaveric renal transplant recipients by the end of the first posttransplant year without an adverse effect on graft survival. This protocol resulted in significant reductions in serum cholesterol, mean arterial blood pressure, and body weight, and may avoid the long-term side effects of steroid therapy.

Effective long-term immunosuppression maintained by low cyclosporine levels in primary cadaveric renal transplant recipients

Nephrotoxicity and cost are the major problems in the use of cyclosporine (CsA) in renal transplantation. Thus, maintenance of CsA levels at the lower limits of the therapeutic range is desirable. The lowest CsA level effective in preventing rejection while avoiding nephrotoxicity has not been defined. We report on 44 primary cadaveric renal transplant recipients treated with a protocol that involved a progressive reduction in the trough CsA levels. CsA was initiated at an oral dose of 15 mg/kg, and this dose was adjusted to achieve serum trough levels, as measured by radioimmunoassay, of 150-200 ng/ml during the first month, 100-150 ng/ml during the second month, 75-100 ng/ml during the third month, and 50-75 ng/ml thereafter. Patient and graft survival at 18 months were 94% and 83.6%, respectively. The mean daily CsA doses were 6.7 +/- 3.1 mg/kg at 6 months, 5.5 +/- 3.2 mg/kg at 12 months, and 4.7 +/- 2.4 mg/kg at 18 months. Corresponding trough serum CsA levels were 94 +/- 59 ng/ml, 64 +/- 22 ng/ml, and 44 +/- 21 ng/ml at 6, 12, and 18 months, respectively. Mean serum creatinine concentrations were 1.8 +/- 0.6 mg/dl at 6 months, 1.7 +/- 0.5 mg/dl at 12 months, and 1.6 +/- 0.5 mg/dl at 18 months. The mean serum creatinine concentration at 18 months was not significantly different from that of 18 conventionally treated primary cadaveric renal transplant recipients (1.6 +/- 0.5 vs. 1.4 +/- 0.4 mg/dl, P = .31). A total of 67% of patients did not have any rejection episodes under this protocol, while 71% of patients never developed CsA nephrotoxicity. No patient was taken off CsA for progressive nephrotoxicity. We conclude that trough serum CsA levels of 50-75 ng/ml, as measured by radioimmunoassay, are sufficient to maintain effective immunosuppression in the long-term management of primary cadaveric renal transplant recipients. These values are much lower than previously recommended, and this approach ameliorates chronic CsA nephrotoxicity.

Malignant lymphoma in transplanted renal pelvis

A middle-aged man with chronic renal failure received a renal transplant from his healthy daughter. Two years later, malignant lymphoma developed in the transplanted renal pelvis. The lymphoma was found to be B-cell immunoblastic lymphoma bearing monoclonal IgG and kappa immunoglobulin, and it was of recipient origin.

Suprarenal mycotic aortic aneurysm: surgical management and follow-up

A case is reported of a rare 7 cm saccular mycotic aneurysm that developed in the suprarenal abdominal aorta of a severely atherosclerotic 63-year-old man from presumed hematogenous inoculation of an atherosclerotic plaque. At operation a right axillobifemoral artery bypass graft was performed along with autotransplantation of the left kidney to the left common iliac vessels and the suprarenal aorta was ligated, excised, and widely debrided. The patient recovered and was in good health for 6 months when sudden occlusion of his axillofemoral graft required thrombectomy for limb salvage and to preserve renal function. Elective thoracoaortic to bilateral iliac artery bypass was successfully undertaken 8 months after the initial operation. However, the patient suffered a fatal myocardial infarction 2 weeks after operation. At autopsy a well-perfused nephrosclerotic kidney, healed aortic ligation, and no graft infections were found.

Sequential use of Minnesota antilymphoblast globulin and cyclosporine in cadaveric renal transplantation

The use of Cyclosporine (CsA) immediately after renal transplantation may be associated with an increased incidence and duration of acute tubular necrosis (ATN) and permanent primary graft nonfunction. To avoid this potential interaction we treated recipients of primary cadaveric grafts initially with azathioprine (AZA), methylprednisolone (MP), and 5 daily doses of Minnesota antilymphoblast globulin (MAG) (postoperative days 3-7). AZA was discontinued and CsA started on day 6 if the graft was functioning by then. If ATN persisted beyond day 6, AZA and MAG (maximum 12 doses) were continued and CsA withheld until graft function was established (group 1-33 patients). This protocol is compared to our previous regimen of MAG (14 doses over the first 3 weeks), AZA and MP (group 2-68 primary cadaveric graft recipients). Improved one-year graft survival (81% vs. 60%, P less than 0.05) and patient survival (93% vs. 81%, P less than 0.05) were seen in group 1. The incidence and duration of ATN did not differ in the two groups. During the first year after transplantation more patients in group 1 were completely free of rejection episodes (40% vs. 20%, P less than 0.05) and the number of rejection episodes per patient was also lower in this group (1.0 +/- 15 vs. 1.6 +/- 49, P less than 0.05). The incidence of infections was not different in the two groups. No tumors have developed in either group. We conclude that in primary cadaveric renal transplantation the initial administration of a short course of MAG followed by CsA therapy results in excellent graft and patient survival while avoiding the potential adverse effect of CsA on an allograft already subjected to preservation injury.

Perirenal fluid collection after renal transplant

During the two year from January 1977 to December 1978, 59 renal allograft transplant patients were studied for perirenal collections. During the second or third postoperative day and then at weekly intervals during the initial postoperative period, serial echograms were obtained. Twenty-five perirenal fluid collections were identified in 24 patients. Twelve lymphoceles, three hematomas, three urinomas, one abscess, and six undetermined collections were found. Small and asymptomatic collections were observed. Twelve lymphoceles were managed by aspiration under ultrasound guidance in five patients, closed external drainage in six patients, and nephrectomy for acute rejection 1 patient. Three patients with hematomas had evacuation and drainage with no recurrence. Among three patients with urinomas, two had Foley catheter drainage and one had uretero-ureterostomy. The patient with an abscess required a nephrectomy. Six small collections were managed consecutively, with spontaneous resolution in four patients. Large or symptomatic collections are managed accordingly. Aspiration or closed external drainage was adequate in most cases of lymphoceles. Exploration, with evacuation and drainage of hematomas, has good results. Minor urine leaks were treated with indwelling Foley catheters; major leaks necessitated surgical repair. An abscess would require drainage or nephrectomy. Small or asymptomatic collections should be treated conservatively. We have also found the routine use of ultrasound scanning postoperatively in renal transplant patients to be of value in early diagnosis and follow-up or perirenal fluid collections.

Islet cell autotransplantation after pancreatectomy for chronic pancreatitis. Its limitations

Of 12 patients operated on for intractable pain from chronic pancreatitis, only the three with adequate preoperative insulin reserve were selected to undergo islet-cell replantation after subtotal pancreatectomy. Fourteen, nine, and four months postoperatively, they require no therapy with insulin. Since most techniques for obtaining islet cells have been performed with normal pancreata, chronic pancreatitis was produced in ten dogs by ligating the main and accessory pancreatic ducts. These dogs 162.6 +/- 15.8 days later underwent total pancreatectomy. The scarred pancreatic fragments were dissociated with collagenase for 20 minutes in five dogs or subjected to two intermittent digestions of ten minutes in the other five dogs and were autotransplanted to the liver. One dog from each group became normoglycemic within one week of replantation, and their percent per minute decreases of serum glucose level were 2.72 and 3.46, respectively. Our experimental and clinical data suggest that (1) present techniques for dissociating fibrotic tissue are unsatisfactory and lead to a very low yield of islet cells; (2) postoperative assessment of islet-cell function involves complicated invasive procedures (portal and hepatic vein cannulation) to determine accurately the source of insulin; and (3) careful preoperative evaluation of beta-cell function is needed.

Are there any important predicting factors of renal function during hypothermic pulsatile perfusion for transplantation?

Fifty perfused cadaver kidneys transplanted in this institution were statistically analyzed with an IBM computer to determine the most important prognostic factors in long-term actual function, namely, the kidney donor warm ischemia, length of preservation, the perfusion characteristics (flow, pressure, perfusate gases, and occasionally electrolytes and osmolarity), and the recipient's response and clinical history (age, sex, race, original renal disease, HLA-antigen matching, number of transplants, number of rejection episodes, kidney function, final outcome, etc.). Although we found no significant (P greater than 0.05) correlation between graft survival and the parameters studied, high perfusate flow appeared to have an important beneficial effect on long-term graft function. Other prognostic indicators of posttransplantation renal function were not clearly seen in our study. It is important to mention that although no significant (P greater than 0.05) differences were seen, patients without diabetes mellitus, first cadaver kidney transplants, and more than two HLA-antigen matches did better than the group without these characteristics.

Role of posttransplant kidney biopsy after hypothermic pulsatile perfusion

Biopsies were obtained from 24 perfused cadaver kidneys. The histologic findings were correlated with short- and long-term kidney function after transplantation. There was no correlation between structural findings present immediately after perfusion and transplantation and short- or long-term kidney function. Thus, we believe that one-hour posttransplant kidney biopsy does not have a role in assessing recently perfused and transplanted kidneys.

Comparison of rumen microbial inhibition resulting from various essential oils isolated from relatively unpalatable plant species

Essential oils were isolated from eight plant species which were relatively unpalatable to sheep and deer. The inhibitory potency of these essential oils upon sheep and deer rumen microorganisms was compared, in terms of total gas and volatile fatty acid (VFA) production, by use of an anaerobic manometric technique. Inhibitory effects of oils from the eight plant species may be placed in four groups: (i) essential oils from vinegar weed (Trichostema lanceoletum) and California bay (Umbellularia californica) inhibited rumen microbial activity most; (ii) lesser inhibition was exhibited by rosemary (Rosmarinus officinalis) and California mugwort (Artemisia douglasiana) oils, followed by (iii) blue-gum eucalyptus (Eucalyptus globulus) and sagebrush (Artemisia tridentata) oils; and (iv) oils from Douglas fir (Psuedotsuga menziesii) and Jerusalem oak (chenopodium botrys) resulted in the least inhibition, when 0.3 ml of each oil was used. A highly significant correlation coefficient (r = 0.98(**)) between total gas and VFA production indicated the validity of either method to measure the activity of rumen microorganisms. Our results are discussed in relation to the hypothesis that the selectivity and voluntary consumption of ruminants are related to the characteristic odor and antibacterial action of essential oils isolated from relatively unpalatable plant species.

Effect of various essential oils isolated from Douglas fir needles upon sheep and deer rumen microbial activity

The effects of essential oils isolated from Douglas fir needles on sheep and deer rumen microbial activity were tested by use of an anaerobic manometric technique. Rumen microorganisms were obtained from a sheep which had been fed mainly on alfalfa hay and dried range grass. One deer used in this study had access to Douglas fir trees the year around, whereas the other deer had no access to Douglas fir. All of the monoterpene hydrocarbons isolated from Douglas fir needles-alpha-pinene, beta-pinene, limonene, myrcene, camphene, Delta(3)-carene, and terpinolene-promoted only slightly or had no effect on deer rumen microbial activity, whereas all of them promoted activity in sheep rumen microbes, except Delta(3)-carene and terpinolene, which inhibited activity. Of the oxygenated monoterpenes, all monoterpene alcohols-alpha-terpineol, terpinen-4-ol, linalool, citronellol, and fenchyl alcohol-strongly inhibited the rumen microbial activity of both sheep and deer. Monoterpene esters (bornyl acetate) produced mild inhibition for both sheep and deer microbes, and citronellyl acetate inhibited rumen microbial activity in sheep, whereas it promoted activity in both deer. Monoterpene aldehyde (citronellal) inhibited the activity of rumen microbes from both sheep and deer having no access to Douglas fir from the Hopland Field Station, whereas they produced no effect upon the deer having access to Douglas fir from the Masonite forest. Rumen microbial activity for sheep and deer was promoted slightly with aliphatic ester (ethyl-n-caproate). There was a marked difference between sheep and deer rumen microbes as affected by addition of the various essential oils. The monoterpene hydrocarbons promoted activity more on sheep rumen microbes than on deer, and the monoterpene alcohols inhibited sheep rumen microbial activity more than that of deer. Furthermore, the deer rumen microbes from Hopland Field Station were affected more than the deer from Masonite forest.