Hemodialysis Initiation in Oldest-Old Patients: A Case Series

With an increase in the number of older adults worldwide, the oldest-old population, defined as individuals over the age of 90, is also growing. Japan is now facing the problem of a “super-aged society” in which over 21% of the population is aged over 65. The oldest-old constituted 1.8% (2.31 million) of the Japanese population in 2019. Such individuals have special health-care needs. In cases of acute or chronic (or both) renal failure in the oldest-old, it becomes difficult to decide whether dialysis should be initiated. The issue is controversial, and there is some debate on whether dialysis should be avoided in elderly people because of their frailty or if it should be initiated to enable them to spend their remaining years with their families by improving their quality of life. Herein, we describe our experience in 4 cases of hemodialysis initiated in patients over the age of 90. In our experience, dialysis enabled them to spend the rest of their lives with their families, which could not have been possible without it. Although further studies are needed, we concluded that oldest-old individuals in good general health could be eligible for and benefit from hemodialysis.

Biodistribution of colloidal gold nanoparticles after intravenous injection: Effects of PEGylation at the same particle size

BACKGROUND

Recently, polyethylene glycol (PEG) modified gold nanoparticles have been studied to maintaining long-term stability in biological fluids. Its biodistribution was also reported, however, comparison of bare gold nanoparticles and PEGylated gold nanoparticles with equal particle size is not sufficient.

OBJECTIVE

We prepared bare gold nanoparticles and PEGylated gold nanoparticles with diameters of 20-30-nm or 50-nm to avoid the influence of particle diameter, and studied their biodistribution in the mouse.

METHODS

Gold concentrations in brain, heart, lungs, liver, stomach, pancreas, spleen, kidneys, blood, urine, and feces were measured at 0.5, 1, 2, 3, 6, 12, 18, 24, and 48 h after administration of gold nanoparticles using inductively coupled plasma atomic emission spectrometry.

RESULTS

At 48 h after intravenous administration, accumulation in the liver and spleen was significantly reduced by PEGylation, and the gold amounts of PEGylated gold nanoparticles with diameters of 20-30 nm and 50-nm in the brain were 3.6 times and 2.7 times higher than those of bare gold nanoparticles, respectively.

CONCLUSIONS

These results indicated that the usefulness of PEGylated gold nanoparticles with small particle size for a drug carrier.

Goadsporin, a chemical substance which promotes secondary metabolism and morphogenesis in streptomycetes. I. Purification and characterization

Streptomycetes, which belong to the Gram-positive bacteria, produce secondary metabolites and sporulate. The timing of starting the secondary metabolite production and the sporulation depends on environmental conditions such as nitrogen and carbon sources. In order to obtain a tool for understanding the regulation mechanism, we carried out screening for chemical substances that induce secondary metabolism and sporulation in streptomycetes and found an active substance from the culture broth of Streptomyces sp. TP-A0584. This substance designated goadsporin promoted the formation of red pigment and sporulation at a concentration of 1 microM in Streptomyces lividans TK23 which does not produce the pigment under normal growth conditions. Goadsporin is an oligopeptide consisting of 19 amino acids with the molecular formula C72H97N19020S2. Sporulation and/or secondary metabolite production was induced in 36 streptomycetes strains among 42 strains tested. These results suggest that goadsporin acts on a common regulation pathway for sporulation and secondary metabolism in streptomycetes and can be a powerful tool to analyze the regulation mechanism.

Goadsporin, a chemical substance which promotes secondary metabolism and Morphogenesis in streptomycetes. II. Structure determination

The structure of goadsporin was determined by using spectroscopic techniques. NMR analysis revealed that goadsporin consists of 19 amino acids, two of which are dehydroalanines (Deala), and six of which are cyclized to oxazoles (Oxz) and thiazoles (Thz) by dehydrative cyclization and dehydrogenation from serine, threonine and cysteine. NMR analysis established seven partial structures, and their sequence was determined by CID-MS/MS. Negative mode FAB-MS/MS gave product ions arising from charge-remote fragmentation that allowed determination of the sequence of the amino acid components as AcNH-Ala-MeOxz-Val-Deala-MeOxz-Ile-Leu-Thz-Ser-Gly-Gly-MeOxz-Leu-Deala-Oxz-Ala-Gly-Thz-Val-OH. The chiral amino acids were determined by the advanced Marfey's method to have L-configurations.

Association of induced disease resistance of rhododendron seedlings with inoculation of Streptomyces sp. R-5 and treatment with actinomycin D and amphotericin B to the tissue-culture medium

Seedlings of rhododendron were treated by adding Streptomyces sp. strain R-5, actinomycin D and/or amphotericin B to the tissue-culture medium. HPLC analysis showed that all of the treated seedlings contained these antibiotics at concentrations higher than the suppressive levels to mycelial growth of Pestalotiopsis sydowiana, a major pathogen of rhododendron. Occurrence of disease caused by this fungus in the seedlings was suppressed by treatment of the medium surface with strain R-5, but not by treatment with these antibiotics, suggesting that growth of strain R-5, an antibiotic producer, could be essential for induction of disease resistance in tissue-cultured seedlings of rhododendron.

Fistupyrone, a novel inhibitor of the infection of Chinese cabbage by Alternaria brassicicola, from Streptomyces sp. TP-A0569

A new microbial metabolite, designated fistupyrone, was isolated from the culture broth of a plant-associated Streptomyces sp. TP-A0569. Fistupyrone inhibited the in vivo infection of the seedlings of Chinese cabbage by Alternaria brassicicola TP-F0423, the cause of Alternaria leaf spot, without any in vitro fungicidal activity.

The A-factor regulatory cascade leading to streptomycin biosynthesis in Streptomyces griseus : identification of a target gene of the A-factor receptor

In Streptomyces griseus, A-factor (2-isocapryloyl-3R-hydroxymethyl-gamma-butyrolactone) at an extremely low concentration triggers streptomycin biosynthesis and cell differentiation by binding a repressor-type receptor protein (ArpA) and dissociating it from DNA. An A-factor-responsive transcriptional activator (AdpA) able to bind the promoter of strR, a pathway-specific regulatory gene responsible for transcription of other streptomycin biosynthetic genes, was purified to homogeneity and adpA was cloned by PCR on the basis of amino acid sequences of purified AdpA. adpA encoding a 405-amino-acid protein containing a helix-turn-helix DNA-binding motif at the central region showed sequence similarity to transcriptional regulators in the AraC/XylS family. The -35 and -10 regions of the adpA promoter were found to be a target of ArpA; ArpA bound the promoter region in the absence of A-factor and exogenous addition of A-factor to the DNA-ArpA complex immediately released ArpA from the DNA. Consistent with this, S1 nuclease mapping showed that adpA was transcribed only in the presence of A-factor and strR was transcribed only in the presence of intact adpA. Furthermore, adpA disruptants produced no streptomycin and overexpression of adpA caused the wild-type S. griseus strain to produce streptomycin at an earlier growth stage in a larger amount. On the basis of these findings, we propose here a model to demonstrate how A-factor triggers streptomycin biosynthesis at a late exponential growth stage.

Prognostic significance of the pattern of multivessel spasm in patients with variant angina

Multivessel spasm in variant angina is believed to be a major prognostic factor. Three patterns of multivessel spasm have been detected: (1) spasm at different sites on different occasions (migratory spasm); (2) spasm sequentially affecting 2 different sites (sequential spasm); and (3) simultaneous spasm at more than 1 site (simultaneous spasm). The present study investigated the prognosis based on this factor for variant angina without fixed coronary stenosis and examined the influence of multivessel spasm on cardiac events. Twenty-six patients were diagnosed as having variant angina without fixed coronary stenosis using 12-lead 24-h ECG recording system and coronary cineangiography. These patients were followed up prospectively for 57.1+/-7.6 months. Of the 26 patients 13 had single-vessel spasm, 6 had migratory multivessel spasm angina, and 7 showed sequential and/or simultaneous multivessel spasm angina. The survival free of serious cardiac events and of all cardiac events was significantly lower for patients with sequential and/or simultaneous multivessel spasm than for those with migratory multivessel spasm (p<0.05, p<0.05), whereas for patients with migratory multivessel spasm the difference comparison with single-vessel spasm did not attain statistical significance (p = ns, p = ns). The results of this study suggest that there seems to be a high-risk subgroup (i.e., sequential and/or simultaneous multivessel spasm) among patients with variant angina.

Site-directed mutagenesis of the A-factor receptor protein: Val-41 important for DNA-binding and Trp-119 important for ligand-binding

The A-factor receptor protein (ArpA) plays a key role in the regulation of secondary metabolism and cellular differentiation in Streptomyces griseus. ArpA binds the target DNA site forming a 22 bp palindrome in the absence of A-factor, and exogenous addition of A-factor to the ArpA-DNA complex immediately releases ArpA from the DNA. An amino acid (aa) replacement at Val-41 to Ala in an alpha-helix-turn-alpha-helix (HTH) motif at the N-terminal portion of ArpA abolished DNA-binding activity but not A-factor-binding activity, suggesting the involvement of this HTH in DNA-binding. On the other hand, an aa replacement at Trp-119 to Ala generated a mutant ArpA that was unable to bind A-factor, thus resulting in an A-factor-insensitive mutant that bound normally to its target DNA in both the presence and absence of A-factor. These data suggest that ArpA consisting of two functional domains, one for HTH-type DNA-binding at the N-terminal portion and one for A-factor-binding at the C-terminal portion, is a member of the LacI family. Consistent with this, two ArpA homologues, CprA and CprB, from Streptomyces coelicolor A3(2), each of which contains a very similar aa sequence of the HTH to that of ArpA, also recognized and bound the same DNA target. However, neither CprA nor CprB recognized A-factor, probably due to much less similarity in the C-terminal domains.

Detection of myocardial ischemia with a computer-assisted 12-lead 24-hour ECG monitoring system (EAGLE) in patients with suspected unstable angina

This study was undertaken to evaluate the diagnostic value of a new device, the 'EAGLE' computer-assisted multiple-lead long-term electrocardiography (ECG) monitoring and analyzing system, in patients with suspected unstable angina, and to compare the results with the Holter monitor. A total of 101 patients with a history of suspected unstable angina underwent a simultaneous 24-h examination with the EAGLE and 2-channel Holter monitors. The diagnosis of unstable angina was established in 70 patients: 41 had significant organic stenosis, and 29 had coronary spasm. Ischemic ST deviations were detected 229 times in 44 patients (62.9%) with the EAGLE system and 101 times in 20 patients (28.6%) with the Holter monitor. The sensitivity of myocardial ischemia in unstable angina with the EAGLE system was significantly higher than that with Holter monitor (62.9 vs 28.6%, p<0.05). The difference of sensitivity was due mainly to the low detection rate of the Holter monitor for asymptomatic myocardial ischemia (EAGLE vs Holter; 187 times vs 72 times) and myocardial ischemia in the infero-posterior area in patients with organic stenosis (30 times vs none). It is concluded that the EAGLE system is a sensitive tool for the diagnosis of unstable angina in patients without significant ECG changes, and an excellent tool for evaluating silent myocardial ischemia or myocardial ischemia of the infero-posterior area.

Involvement of two A-factor receptor homologues in Streptomyces coelicolor A3(2) in the regulation of secondary metabolism and morphogenesis

Nucleotide sequences homologous to arpA encoding the A-factor receptor protein (ArpA) of Streptomyces griseus are distributed in a wide variety of streptomycetes. Two genes, cprA and cprB, each encoding an ArpA-like protein were found and cloned from Streptomyces coelicolor A3(2). CprA and CprB shared 90.7% identity in amino acid sequence and both showed about 35% identity to ArpA. Disruption of cprA by use of an M13 phage-derived single-stranded vector resulted in severe reduction of actinorhodin and undecylprodigiosin production. In addition, the timing of sporulation in the cprA disruptants was delayed by 1 day. The cprA gene thus appeared to act as a positive regulator or an accelerator for secondary metabolite formation and sporulation. Consistent with this idea, introduction of cprA on a low-copy-number plasmid into the parental strain led to overproduction of these secondary metabolites and accelerated the timing of sporulation. On the other hand, cprB disruption resulted in precocious and overproduction of actinorhodin. However, almost no effect on undecylprodigiosin was detected in the cprB disruptants. Sporulation of the cprB disruptant began 1 day earlier than the parental strain. The cprB gene thus behaved as a negative regulator on actinorhodin production and sporulation. Consistent with this, extra copies of cprB in the parental strain caused reduced production of actinorhodin and delay in sporulation. It is thus concluded that both cprA and cprB play regulatory roles in both secondary metabolism and morphogenesis in S. coelicolor A3(2), just as the arpA/A-factor system in Streptomyces griseus.

Circadian variation of myocardial ischemia in patients with unstable angina pectoris secondary to fixed and/or spastic coronary narrowing

We investigated the circadian variation of myocardial ischemia in patients with unstable angina using a 24-hour 12-lead electrocardiographic monitoring system with computer analysis. The circadian variation of ischemic attacks in patients who had ST elevation showed a similarity to that of the onset of acute myocardial infarction and most of these patients had vasospasm without organic stenosis; no similarity was seen in patients with organic stenosis.

DNA-binding activity of the A-factor receptor protein and its recognition DNA sequences

The A-factor receptor protein (ArpA) containing an alpha-helix-turn-alpha-helix DNA-binding consensus sequence at its N-terminal portion plays a key role in the regulation of secondary metabolism and cell differentiation in Streptomyces griseus. A binding site forming a palindrome 24bp in length was initially recovered from a pool of random-sequence oligonucleotides by rounds of a binding/immunoprecipitation/amplification procedure with histidine-tagged ArpA and anti-ArpA antibody. By means of further binding/gel retardation/amplification experiments on the basis of the recovered sequence, a 22 bp palindromic binding site with the sequence 5'-GG(T/C)CGGT(A/T)(T/C)G(T/G)-3' as one half of the palindrome was deduced as a consensus sequence recognized and bound by ArpA. ArpA did not bind to the binding site in the presence of its ligand, A-factor. In addition, exogenous addition of A-factor to the ArpA-DNA complex induced immediate release of ArpA from the DNA. All of these data are consistent with the idea, obtained from previous genetic studies, that ArpA acts as a repressor-type regulator for secondary metabolism and cellular differentiation by preventing the expression of a certain key gene(s) during the early growth phase. A-factor, produced in a growth-dependent manner, releases ArpA from the DNA, thus switching on the expression of the key gene(s), leading to the onset of secondary metabolism and aerial mycelium formation.

A mutation at proline-115 in the A-factor receptor protein of Streptomyces griseus abolishes DNA-binding ability but not ligand-binding ability

A-factor (2-isocapryloyl-3R-hydroxymethyl-gamma-butyrolactone) and its specific receptor protein (ArpA) are required for streptomycin production and aerial mycelium formation in Streptomyces griseus. A mutant strain HO1 that produced streptomycin and formed aerial mycelium and spores was derived from an A-factor-deficient mutant, S. griseus HH1. The phenotypes of mutant HO1 were found to result from a single amino acid replacement of ArpA; the proline residue at position 115 in the wild-type ArpA was replaced by serine, yielding mutant ArpA (P115S). The mutant ArpA (P115S) was still able to form a homodimer and possessed A-factor-binding ability but lost the ability to bind DNA. The properties of P115S suggest that ArpA consists of two independently functional domains, one for A-factor binding and one for DNA binding, and that proline-115 plays an important role in DNA binding. This is in agreement with the idea that A-factor binding to the COOH-terminal domain of ArpA causes a subtle conformational change of the distal NH2-terminal DNA-binding domain, resulting in dissociation of ArpA from DNA.

Comparison of immediate and long-term outcome of percutaneous transvenous mitral commissurotomy in patients who have and have not undergone previous surgical commissurotomy

This study compared the immediate and long-term outcome of percutaneous transvenous mitral commissurotomy (PTMC) in patients who had (restenosis group, n = 9) or had not (de novo group, n = 27) previously undergone surgical mitral commissurotomy. The baseline echocardiographic score, which is an index of deformity of the mitral valve apparatus, was significantly higher in the restenosis group than in the de novo group (11 +/- 3 vs 7 +/- 2, p < 0.01), although age, left atrial diameter, and the prevalence of atrial fibrillation were similar. PTMC was performed by the Inoue technique, and was abandoned in 1 patient from the restenosis group because of failed trans-septal puncture. Including this patient, 3 patients (33%) in the restenosis group had a thickened atrial septum compared with only 1 (4%) in the de novo group. One patient in the de novo group developed cardiac tamponade during this procedure. In both groups, the mitral valve area increased significantly, but the success rate of PTMC was lower in the restenosis group (4/9 patients, 44%) than in the de novo group (22/27 patients, 81%) (p < 0.05). Twenty-six patients who had successful PTMC were followed up over 51 +/- 14 months. After 4 years of follow-up. 3 out of 4 patients (75%) in the restenosis group and 3 out of 22 patients (14%) in the de novo group demonstrated echocardiographic restenosis (p < 0.01). Stepwise multivariate analysis revealed that the echocardiographic score was the only significant predictor of both the immediate and long-term outcome. In conclusion, the immediate and long-term outcome of PTMC were worse in patients who had undergone previous surgical mitral commissurotomy than in those who had not. This was mainly attributable to the difference in the severity of the valvular lesions. In addition, our data suggested that a thickened atrial septum, possibly related to surgery as well as chronic rheumatic disease, may affect the performance of PTMC.

Aortic counterpulsation may improve late patency of the occluded coronary artery in patients with early failure of thrombolytic therapy

OBJECTIVES

Using a prospective, randomized design, we tested our hypothesis that the augmentation of diastolic pressure by intraaortic balloon counterpulsation (IABP) would improve the late patency of the occluded coronary artery in patients with early failure of thrombolytic therapy.

BACKGROUND

Rescue angioplasty is often performed in patients in whom thrombolysis has failed, although 30% to 60% of the infarct-related arteries that are closed early after thrombolytic therapy will open later with conservative therapy.

METHODS

The study included 45 patients in whom thrombolysis had failed, despite treatment with intravenous tissue-type plasminogen activator (alteplase 0.75 mg/kg body weight) delivered over 60 min within 12 h of the onset of symptoms. All patients underwent coronary angiography 60 min after initiation of thrombolytic therapy (baseline), and Thrombolysis in Myocardial Infarction (TIMI) grade 0, 1 or 2 flow was defined as failed thrombolysis. The patients were randomized to groups receiving IABP for 48 h (n = 23) or conservative therapy (n = 22, control subjects) at the end of cardiac catheterization. The late patency of the infarct-related artery, the primary end point of the study, was evaluated 3 weeks after myocardial infarction. Stenosis of the infarct-related artery was measured using a computer-assisted quantitative angiographic system in blinded manner. Data are expressed as mean value +/- SEM.

RESULTS

There was no difference with regard to the baseline value for TIMI flow grade between the groups. However, 3 weeks after myocardial infarction, the patients treated with IABP had a significantly higher frequency of TIMI flow grade 3, lower residual percent stenosis and larger minimal lumen diameter of the infarct-related artery than did the control subjects (74% vs. 32%, p < 0.05; 42 +/- 5% vs. 68 +/- 6%, p < 0.01; and 1.6 +/- 0.1 vs. 0.9 +/- 0.2 mm, p < 0.01, respectively).

CONCLUSIONS

These findings suggest that in patients with early failure of thrombolytic therapy, IABP may improve late patency of the occluded coronary artery, probably due to augmented perfusion pressure.

Natural history and left ventricular response in chronic aortic regurgitation

This study was aimed at clarifying the natural history and left ventricular response in aortic regurgitation using M-mode echocardiography. We analyzed the history and echocardiographic data on 94 patients, who were divided into 4 stages according to symptoms. The duration of the asymptomatic period, which represents pure volume overload, is long, and the period of minimal symptoms, combined volume and pressure overload, is relatively short. Patients with overt heart failure due to impaired contractility can survive longer than is usually believed, and the factor that predicted the onset of heart failure was a decrease in fractional shortening > 3.8 percentage points.

Clinical observation of spontaneous anginal attacks and multivessel spasm in variant angina pectoris with normal coronary arteries: evaluation by 24-hour 12-lead electrocardiography with computer analysis

OBJECTIVES

Using a new, computerized 24-h 12-lead electrocardiographic (ECG) recording and analysis system (the EAGLE system), we sought to evaluate the clinical manifestations of ischemic episodes in patients with variant angina and normal coronary arteries.

BACKGROUND

Although the prognosis of variant angina without significant organic stenosis is generally good, the incidence of multivessel spasm, a major prognostic factor, is surprisingly high in provocation tests.

METHODS

A total of 122 patients with suspected variant or unstable angina underwent 24-h examination with the EAGLE system and two-channel Holter monitoring. Thirty patients in this group were diagnosed as having variant angina with normal or nearly normal coronary arteries. Twenty-two (73%) of these 30 patients developed anginal attacks with ST segment elevation during monitoring and were enrolled in the study.

RESULTS

The 22 patients had a total of 138 episodes of transient ST segment elevation and 13 episodes of ST segment depression. No arrhythmias were observed during ST segment depression, but 26 episodes of ST segment elevation (19%) were associated with arrhythmias: 7 with premature ventricular contractions, 3 with ventricular bigeminy, 3 with complete atrioventricular (AV) block, 1 with complete AV block and couplets of premature ventricular contractions and 12 with marked sinus bradycardia (< 45 beats/min). Ten (45%) of the 22 patients had multivessel spasm. We observed three different patterns of multivessel spasm: 1) spasm at a different site on different occasions (migratory spasm); 2) spasm that sequentially affected two different sites; 3) simultaneous spasm at more than one site. The duration of ST segment elevation was much longer in patients with sequential and simultaneous spasm than in those with single-vessel spasm, and arrhythmias were more frequent during these two types of multivessel spasm.

CONCLUSIONS

Although the prognosis of multivessel spasm is believed to be poor, this may not necessarily be so. Anginal attacks due to sequential and simultaneous multivessel spasm seem to be more dangerous than those involving single-vessel spasm or migratory multivessel spasm.

Cloning and characterization of the A-factor receptor gene from Streptomyces griseus

A-factor (2-isocapryloyl-3R-hydroxymethyl-gamma-butyrolactone) and its specific receptor protein control streptomycin production, streptomycin resistance, and aerial mycelium formation in Streptomyces griseus. The A-factor receptor protein (ArpA) was purified from a cell lysate of S. griseus IFO 13350. The NH2-terminal amino acid sequences of ArpA and lysyl endopeptidase-generated fragments were determined for the purpose of preparing oligonucleotide primers for cloning arpA by the PCR method. The arpA gene cloned in this way directed the synthesis of a protein having A-factor-specific binding activity when expressed in Escherichia coli under the control of the T7 promoter. The arpA gene was thus concluded to encode a 276-amino-acid protein with a calculated molecular mass of 29.1 kDa, as determined by nucleotide sequencing. The A-factor-binding activity was observed with a homodimer of ArpA. The NH2-terminal portion of ArpA contained an alpha-helix-turn-alpha-helix DNA-binding motif that showed great similarity to those of many DNA-binding proteins, which suggests that it exerts its regulatory function for the various phenotypes by directly binding to a certain key gene(s). Although a mutant strain deficient in both the ArpA protein and A-factor production overproduces streptomycin and forms aerial mycelium and spores earlier than the wild-type strain because of repressor-like behavior of ArpA, introduction of arpA into this mutant abolished simultaneously its streptomycin production and aerial mycelium formation. All of these data are consistent with the idea that ArpA acts as a repressor-type regulator for secondary metabolite formation and morphogenesis during the early growth phase and A-factor at a certain critical intracellular concentration releases the derepression, thus leading to the onset of secondary metabolism and aerial mycelium formation. The presence of ArpA-like proteins among Streptomyces spp., as revealed by PCR, together with the presence of A-factor-like compounds, suggests that a hormonal control similar to the A-factor system exists in many species of this genus.

Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium

OBJECTIVES

The purpose of this study was to determine whether a relation exists between electrocardiographic (ECG) abnormalities and left ventricular wall motion in patients with subarachnoid hemorrhage.

BACKGROUND

Although ECG changes simulating acute myocardial infarction are frequently seen in patients with subarachnoid hemorrhage, their relation to left ventricular wall motion has not been established.

METHODS

Twelve patients with subarachnoid hemorrhage were classified according to the presence of ST segment elevation in at least two consecutive leads on admission: seven patients with ST segment elevation (group I) and five patients without ST segment elevation (group II). No patients had a previous history of heart disease. Left ventricular regional wall motion was evaluated by the centerline method. The mean (+/- SEM) duration from onset of subarachnoid hemorrhage to left ventriculography was 9 +/- 3 h in group I and 10 +/- 1 h in group II. Coronary angiography was performed to rule out wall motion abnormalities due to coronary artery disease while the ST segment was still elevated. Two-dimensional echocardiography was used to evaluate wall motion thereafter.

RESULTS

All patients in group I showed ST segment elevation in ECG leads V4 to V6. Wall motion of the left ventricular apex was significantly reduced in group I compared with group II (-2.48 +/- 0.41 vs. -0.45 +/- 0.72, p < 0.02). No patients showed organic stenosis or vasospasm, or both, of epicardial coronary arteries. Wall motion abnormalities decreased echocardiographically in all patients, but one patient in group I died in hospital at 2 or 3 weeks after the onset of subarachnoid hemorrhage, when the T wave was inverted in leads V4 to V6.

CONCLUSIONS

These findings suggest that patients with subarachnoid hemorrhage and ST segment elevation may demonstrate transient corresponding regional wall motion abnormalities. The mechanism of neurogenic stunned myocardium was not clearly elucidated in the present study.

The effect of pravastatin on prevention of restenosis after successful percutaneous transluminal coronary angioplasty

Numerous attempts have been made to prevent late restenosis after successful percutaneous transluminal coronary angioplasty (PTCA), but there is still no effective treatment. This report describes the effect of an oral lipid-lowering agent, pravastatin, on restenosis after successful PTCA. Sixty-six patients who underwent successful elective PTCA were assigned to a pravastatin-treated group (Group 1, n = 29) or an untreated group (Group 2, n = 37) in a prospective and randomized fashion. Pravastatin (5 mg or 10 mg twice a day) was given to Group 1 patients from day 3 after the procedure. Selective coronary angiography was repeated 3 to 5 months later, or sooner if the patient developed angina pectoris. The serum cholesterol level was decreased significantly in Group 1 (from 215.7 +/- 44.3 mg/dl to 181.2 +/- 30.3 mg/dl, p < 0.001), but not in Group 2 (from 191.9 +/- 30.8 mg/dl to 191.8 +/- 33.3 mg/dl, p = ns), at the time of repeat coronary angiography. However, there were no differences between the groups with regard to the recurrence of angina, the need for repeat PTCA, or restenosis, as assessed by quantitative analysis of coronary cineangiograms. These results suggest that oral pravastatin therapy does not effectively prevent late restenosis after successful PTCA by this mode of administration.

Organization and nucleotide sequence of the secE-nusG region of Streptomyces griseus

The nusG genes of Streptomyces griseus and Streptomyces coelicolor A3(2) were cloned by the DNA-probing method with synthetic oligonucleotides designed on the basis of the nucleotide sequence of the nusG gene of Streptomyces virginiae. The amino acid sequences of the NusG proteins deduced from the nucleotide sequences showed significant homologies to those from a variety of microorganisms. Nucleotide sequence analysis of the region upstream of the nusG gene of S. griseus revealed the presence of the secE gene, suggesting that secE and nusG are organized as an operon as is found in other microorganisms.

Usefulness of serum CA125 measurement for monitoring pericardial effusion

To investigate the clinical significance of carbohydrate antigen 125 (CA125), an antigen related to ovarian cancer, in patients with pericardial effusion, we examined the relationship between serum levels of CA125 and the presence or severity of pericardial effusion. Fifty-seven patients (25 with heart failure, 22 with pericardial metastasis, 4 with hypothyroidism, 4 with renal failure, and 2 with other diseases) in whom pericardial effusion was confirmed by echocardiography or autopsy, were used as subjects. Thirty-seven of these patients (65%) tested positive for CA125 in the serum. Of these, no significant differences in serum levels of CA125 were found between patients with benign and those with malignant underlying diseases or between those with, or without, pericarditis. However, CA125 values were higher in the patients with larger pericardial effusions and the serum level decreased when the pericardial effusion reduced. In some cases, the serum level normalized before the effusion resolved. Pericardial drainage was performed on 6 patients with cardiac tamponade. Four of these 6 patients had high serum CA125 levels and recurrent pericardial effusion. The other 2 patients had normal serum CA125 levels and no recurrence of effusion. An immunohistological study showed that a positive stain of pericardial tissues reacting to CA125 antibodies correlated to higher serum and pericardial fluid levels of CA125 than the levels of groups staining negative to the antibody. These results suggest that CA125 can be useful in assessing the status and clinical course of this disease.

Significance of endothelial deposition of von Willebrand factor in thrombotic thrombocytopenic purpura: autopsy findings of a case complicated with systemic lupus erythematosus

We report the renal immunohistochemical findings of a patient with thrombotic thrombocytopenic purpura complicated with systemic lupus erythematosus. Aggregated platelets were observed adhering to the arteriole walls. Intense deposition of von Willebrand factor (vWF) was noted in the endothelium, even in areas where thrombi were not seen. This difference in the distribution of platelets and vWF suggested that the endothelium was damaged prior to platelet aggregation.

[Two cases of hypothyroidism with echocardiographic features similar to cardiomyopathy: one simulates hypertrophic and the other dilated cardiomyopathy]

Two cases of hypothyroidism with echocardiographic features similar to cardiomyopathy were presented. In case 1 (a 68 year-old woman), moderate pericardial effusion and myocardial hypertrophy were observed on admission. In case 2 (a 69 year-old woman), dilation of the left ventricle, hypokinesis of the interventricular septum and the left ventricular free wall, and reduced left ventricular systolic function were observed on admission. These echocardiographic findings were similar to hypertrophic or dilated cardiomyopathy. In the two cases, after recovery to euthyroid state, these echocardiographic abnormalities returned to normal. We concluded that hypothyroidism led to a reversible hypertrophic or dilated cardiomyopathy, and that echocardiographic study was useful for diagnosis and for following up cardiac manifestations of hypothyroidism.

[The effect of acebutolol and metoprolol on noninvasive ambulatory blood pressure monitoring system in essential hypertension]

We compared the antihypertensive effects of acebutolol and metoprolol during 2-4 weeks of treatment in patients with mild to moderate essential hypertension. Acebutolol (n = 12) significantly decreased conventionally measured blood pressure from 173/100 mmHg to 148/86 mmHg (p less than 0.005), and metoprolol (n = 11) decreased it from 164/106 mmHg to 138/87 mmHg (p less than 0.01). Based on data derived from automated 24-hour ambulatory blood pressure monitoring, both drugs significantly decreased the blood pressure in the early morning (5:00-10:00). Moreover, in the metoprolol group, there were significant falls in day-time blood pressure (7:30-19:30) and night-time blood pressure (23:00-7:00). In contrast, acebutolol showed significant antihypertensive effect on day-time blood pressure, but not effect on night-time blood pressure. The study confirmed the efficacy and character of metoprolol and acebutolol. We must choose an effective beta-blocker when using an automated 24-hour ambulatory blood pressure monitoring system to get adequate blood pressure reduction for the whole 24 hours.

[Recurrent hyperkalemia in the course of rheumatoid arthritis--a case report]

A 69-year-old woman with advanced rheumatoid arthritis (RA) suffered two episodes of hyperkalemic hyperchloremic metabolic acidosis (HCMA). Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were markedly suppressed in the first episode occurring in paralell with the administration of metoprolol during piroxicam and lobenzarit (CCA) therapy. Rechallenge with diclofenac sodium and CCA lead to the second hyperkalemia, but no significant suppression of the renin-aldosterone axis was seen at that time. This suggests that the different mechanisms contribute to the development of these episodes, including the tubulo-interstitial injury which is not uncommon in RA. The combined use of nonsteroidal anti-inflammatory drugs (NSAIDs) and beta-adrenergic blockers may increase the risk of life-threatening hyperkalemia through their suppressive effect on the renin-aldosterone system, whereas the concomitant administration of CCA with NSAIDs through the impairment in the renal tubular function. These drugs should be most carefully given to patients with a latent defect in renal potassium excretion.