Live two-way video versus face-to-face treatment for depression, anxiety, and obsessive-compulsive disorder: A 24-week randomized controlled trial

AIM

Live two-way video, easily accessible from home via smartphones and other devices, is becoming a new way of providing psychiatric treatment. However, lack of evidence for real-world clinical setting effectiveness hampers its approval by medical insurance in some countries. Here, we conducted the first large-scale pragmatic, randomized controlled trial to determine the effectiveness of long-term treatment for multiple psychiatric disorders via two-way video using smartphones and other devices, which are currently the primary means of telecommunication.

METHODS

This randomized controlled trial compared two-way video versus face-to-face treatment for depressive disorder, anxiety disorder, and obsessive-compulsive disorder in the subacute/maintenance phase during a 24-week period. Adult patients with the above-mentioned disorders were allocated to either a two-way video group (≥50% video sessions) or a face-to-face group (100% in-person sessions) and received standard treatment covered by public medical insurance. The primary outcome was the 36-Item Short-Form Health Survey Mental Component Summary (SF-36 MCS) score. Secondary outcomes included all-cause discontinuation, working alliance, adverse events, and the severity rating scales for each disorder.

RESULTS

A total of 199 patients participated in this study. After 24 weeks of treatment, two-way video treatment was found to be noninferior to face-to-face treatment regarding SF-36 MCS score (48.50 vs 46.68, respectively; p < 0.001). There were no significant differences between the groups regarding most secondary end points, including all-cause discontinuation, treatment efficacy, and satisfaction.

CONCLUSION

Two-way video treatment using smartphones and other devices, was noninferior to face-to-face treatment in real-world clinical settings. Modern telemedicine, easily accessible from home, can be used as a form of health care.

Development of medical device software for the screening and assessment of depression severity using data collected from a wristband-type wearable device: SWIFT study protocol

INTRODUCTION

Few biomarkers can be used clinically to diagnose and assess the severity of depression. However, a decrease in activity and sleep efficiency can be observed in depressed patients, and recent technological developments have made it possible to measure these changes. In addition, physiological changes, such as heart rate variability, can be used to distinguish depressed patients from normal persons; these parameters can be used to improve diagnostic accuracy. The proposed research will explore and construct machine learning models capable of detecting depressive episodes and assessing their severity using data collected from wristband-type wearable devices.

METHODS AND ANALYSIS

Patients with depressive symptoms and healthy subjects will wear a wristband-type wearable device for 7 days; data on triaxial acceleration, pulse rate, skin temperature, and ultraviolet light will be collected. On the seventh day of wearing, the severity of depressive episodes will be assessed using Structured Clinical Interview for DSM-5 (SCID-5), Hamilton Depression Rating Scale (HAMD), and other scales. Data for up to five 7-day periods of device wearing will be collected from each subject. Using wearable device data associated with clinical symptoms as supervisory data, we will explore and build a machine learning model capable of identifying the presence or absence of depressive episodes and predicting the HAMD scores for an unknown data set.

DISCUSSION

Our machine learning model could improve the clinical diagnosis and management of depression through the use of a wearable medical device.

CLINICAL TRIAL REGISTRATION

[https://jrct.niph.go.jp/latest-detail/jRCT1031210478], identifier [jRCT1031210478].

Clinical assessment of efficacy of poly-L-lactide sternal pin on sternal stability and post-operative pain: a prospective randomized trial in cardiovascular surgery

Background

Although the incident rate is low, sternal dislocation and dehiscence due to unstable sternal fixation after cardiovascular surgery could cause potentially lethal complications. Thus, to enforce the stability of closed sternum, the sternal pins have been utilized at surgeon’s discretion. However, there is no randomized clinical trial to test whether these pins are effective to stabilize a sternum. Hence, this study aimed to examine the clinical efficacy of bioabsorbable poly-L-lactide (PLLA) sternal pins in reinforcing sternal stability and preventing instability of the sternum after full sternotomy.

Methods

We conducted a single institutional, prospective, randomized, single-blinded clinical study involving 100 patients who underwent an initial cardiovascular surgery via sternotomy. Patients were randomly allocated into two groups: with (group P) and without (group N) PLLA sternal pins, at 1:1 ratio from November 2013 to April 2016. Sternal deviation and stability were assessed with postoperative computed tomography (CT) at two postures to put shear stress on the sternum. Additionally, information on patient demographic indices was obtained prospectively, and patient’s pain intensity was assessed with numerical rating scoring system during rehabilitation. Furthermore, propensity score matching was performed for further comparative sub-analysis.

Results

Ninety-one patients (43 in group P and 48 in group N) were analyzed using the intention-to-treat method. Group N had a significantly higher proportion of males (P=0.015) and ischemic disease as a primary diagnosis (P=0.040) than group P. Postoperative CT showed that the degree of sternal deviation and stability were comparable between the groups. Similarly, the numerical rating score of pain during rehabilitation showed no difference between the groups. Even after adjusting for patient characteristics using propensity score matching method, no significant differences in sternal gaps, stability, and numerical rating score of pain were observed. Of note, no material-related adverse event such as wound infection was found.

Conclusions

We could not identify the efficacy of the sternal pin in enforcing sternal stability based on CT measurements with mild shear stress on sternum after cardiovascular surgery. Nevertheless, our results with no adverse events might encourage further investigations with a more specific cohort who is susceptible to infection but requires an additional sternal fixation.

Trial Registration

This study was registered in University Hospital Medical Information Network Clinical Trial Registry (UMIN000017357).

Japanese project for telepsychiatry evaluation during COVID-19: Treatment comparison trial (J-PROTECT): Rationale, design, and methodology

Introduction

The COVID-19 pandemic has had a profound impact on the mental health of people around the world. Anxiety related to infection, stress and stigma caused by the forced changes in daily life have reportedly increased the incidence and symptoms of depression, anxiety disorder and obsessive-compulsive disorder. Under such circumstances, telepsychiatry is gaining importance and attracting a great deal of attention. However, few large pragmatic clinical trials on the use of telepsychiatry targeting multiple psychiatric disorders have been conducted to date.

Methods

The targeted study cohort will consist of adults (>18 years) who meet the DSM-5 diagnostic criteria for either (1) depressive disorders, (2) anxiety disorders, or (3) obsessive-compulsive and related disorders. Patients will be assigned in a 1:1 ratio to either a “telepsychiatry group” (at least 50% of treatments to be conducted using telemedicine, with at least one face-to-face treatment [FTF] within six months) or an “FTF group” (all treatments to be conducted FTF, with no telemedicine). Both groups will receive the usual treatment covered by public medical insurance. The study will utilize a master protocol design in that there will be primary and secondary outcomes for the entire group regardless of diagnosis, as well as the outcomes for each individual disorder group.

Discussion

This study will be a non-inferiority trial to test that the treatment effect of telepsychiatry is not inferior to that of FTF alone. This study will provide useful insights into the effect of the COVID-19 pandemic on the practice of psychiatry.

Trial Registration

jRCT1030210037, Japan Registry of Clinical Trials (jRCT).

Community transition at younger ages contributes to good cognitive function outcomes in long-term hospitalized patients with schizophrenia spectrum disorder: A 15-year follow-up study with group-based trajectory modeling

AIM

Cognitive dysfunction is a core symptom of schizophrenia spectrum disorder, but the reported long-term cognitive outcomes are heterogeneous. This study aimed to elucidate the long-term trajectories of patients with schizophrenia spectrum disorder who transitioned to community dwelling with integrated care, and to identify predictors of successful community reintegration.

METHODS

After the closure of a psychiatric hospital, 78 patients with schizophrenia spectrum disorder (mean age: 54.6 years) were transferred to the community. We assessed patients' cognitive function over 15 years with the Mini-Mental State Examination (MMSE) and analyzed the scores every 3 years. Forty-four patients completed all assessments.

RESULTS

The mean MMSE score at discharge was 25.8, which changed to 26.8 after 3 years and 25.3 after 6 years. After 12 and 15 years, it had decreased significantly to 23.3 and 23.0, respectively. Group-based trajectory modeling identified two groups of patients: a 'poor-outcome' group (63.4%), showing a decline in scores after maintaining post-discharge levels for several years, and a 'good-outcome' group (36.6%), maintaining post-discharge scores after showing improved scores.

CONCLUSION

Considering the significant difference in age between the aforementioned groups (P = 0.040), we suggest that community transitions at younger ages contribute to better cognitive function and adaptation to community life. Even middle-aged and elderly patients with chronic schizophrenia spectrum disorder showed improved or maintained cognitive function at least 3 years after discharge, and the good-outcome group maintained cognitive function over 15 years. Improvements were dominated primarily by age at discharge, with cognitive function being maintained longer in patients in the good-outcome group.

Maximization of the sealing effect of fibrin glue in aortic surgery

OBJECTIVES

Fibrin glue is used to reinforce anastomosis in aortic surgery. There has not yet been a consensus on how it should be applied optimally. This study aimed to define the optimal condition of applying fibrin glue.

METHODS

In experiment 1, we determined the optimal condition for spraying fibrin glue using an expanded polytetrafluoroethylene graft within a needle hole. The length and area of the fibrin cap within the hole were measured. In experiment 2, methods for applying fibrinogen were assessed by comparing brushing and spraying. In experiment 3, swine aorta segments sutured with a Dacron graft were divided into the following three groups: nothing was applied; fibrinogen was sprayed and rubbed using brush. The aorta was clamped and blood was infused from an occlusion catheter inserted into the graft. The pressure at the first appearance of blood leak was recorded.

RESULTS

In experiment 1, among the four groups divided by the pressure and distance of spraying, the fibrin cap area in the group with 0.075 MPa and 2-cm spray distance was significantly larger than that in the group with 0.15 MPa and 2 cm (P < 0.01). In experiment 2, the fibrin cap area in the brushing group was significantly larger than that in the spraying group (P < 0.05). In experiment 3, the capacity to resist endoluminal pressure was higher in the brushing and combined spraying group compared with that in the sequential combined spraying group (P < 0.01).

CONCLUSIONS

The brush and spray methods showed excellent hemostatic outcomes.

Different desmin peptides are distinctly deposited in cytoplasmic aggregations and cytoplasm of desmin-related cardiomyopathy patients

Desmin-related cardiomyopathy is a heterogeneous group of myofibrillar myopathies characterized by aggregates of desmin and related proteins in myocytes. It has been debated how the expression and protein structure are altered in the aggregates and other parts of myocytes in patients. To address this question, we investigated the proteome quantification as well as localization in formalin-fixed and paraffin-embedded specimens of the heart of patients by imaging mass spectrometry and liquid chromatography-mass spectrometry analyses. Fifteen tryptic peptide signals were enriched in the desmin-related cardiomyopathy myocardium, twelve of which were identified as desmin peptides with 14.3- to 27.3-fold increase compared to normal hearts. High-intensity signals at m/z 1032.5 and 1002.5, which were desmin peptides 59-70 at the head portion and 213-222 at the 1B domain, were with infrequent colocalization distributed not only in desmin-positive intracytoplasmic aggregates but also in histologically normal cytoplasm, indicating that desmin protein is fragmented and different types of naturally-occurring truncated proteins ectopically assemble throughout the heart of patients. Thus, in addition to conventional histological identification of protein aggregates, specific desmin peptides show a marked difference in quantity and localization in a tissue section of desmin-related cardiomyopathy and differentiate from other cardiomyopathies. This article is part of a Special Issue entitled: MALDI Imaging, edited by Dr. Corinna Henkel and Prof. Peter Hoffmann.

Comprehensive data on ionising radiation from Fukushima Daiichi nuclear power plant in the town of Miharu, Fukushima Prefecture: The Misho Project

Data related to radioactivity released from the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident on 15 March 2011 gathered by residents of Miharu, Fukushima Prefecture, and by Tohoku University are presented. These data sets consist of (1) the earliest radiation monitoring by a Geiger counter in the town, (2) ratios of radioactivity between (132)Te and (137)Cs for a wide area between Fukushima and Tokyo, (3) radiation measurement of soil samples collected from 18 school grounds, and (4) external radiation exposure of 1400 students using OSL badges. By combining and analysing these various data sets, a curve for the cumulative total external exposure as a function of time, with 16 : 00 h on 15 March 2011 being time zero, is obtained. The average cumulative external dosage is estimated to be 10 mSv (σ = 4.2 mSv) over 10 years. In addition, the initiative that the residents of Miharu took in response to the FDNPP accident, which became known as The Misho Project (MP), is documented; in particular, the time at which the municipality instructed the immediate ingestion of iodine tablets by those under the age of 40, 13 : 00 h on 15 March 2011, is assessed.

Long-term course of cognitive function in chronically hospitalized patients with schizophrenia transitioning to community-based living

Schizophrenia is associated with impairments in social interactions, and the conditions under which patients live and undergo treatment appear to have an important role in the course of the disease. However, the influences of care settings on the course of cognition remain controversial. The closure of psychiatric hospitals and the transition to community-based living is a golden opportunity to address this issue. The aims of the present study were to examine (1) the longitudinal course of cognition as well as the psychopathology and social functioning of schizophrenia patients who had been chronically hospitalized and then discharged, and (2) the key cognitive predictors of the functional outcome of such patients. Seventy-eight patients were transferred to the community after the closure of a psychiatric hospital. These patients were followed-up for 5 years and underwent annual examinations that included measures of cognition, psychiatric symptoms, and social functioning. Fifty-six patients completed all the assessments. Although consistent improvements were shown in the cognitive domains for attention and memory, the initial improvements in global cognition and processing speed ultimately began to decline. Symptoms and global functioning improved almost consistently over the course of the follow-up period. Stepwise multiple regressions revealed category fluency at baseline predicted social functioning at 5 years. However, this correlation was no longer significant when psychopathological variables were included as predictors. These results suggest that care settings affect the course of cognition, and addressing these conditions may lead to a certain degree of cognitive improvement even among schizophrenia patients who have been chronically institutionalized.

Lower subjective quality of life and the development of social anxiety symptoms after the discharge of elderly patients with remitted schizophrenia: a 5-year longitudinal study

OBJECTIVES

Remitted schizophrenic patients living in the community often encounter difficulties in their daily lives, possibly leading to the development of social anxiety symptoms. Although several studies have reported the significance of social anxiety as a comorbidity in patients with schizophrenia, few longitudinal data are available on the development of social anxiety symptoms in patients with remitted schizophrenia, especially in association with the process of "deinstitutionalization." The aims of this study were to assess the social anxiety symptoms in remitted outpatients with schizophrenia and to examine whether the development of social anxiety symptoms was associated with psychotic symptoms, social functioning, or subjective quality of life.

METHODS

Fifty-six people with schizophrenia who were discharged through a deinstitutionalization project were enrolled in this longitudinal study and prospectively assessed with regard to their symptoms, social functioning, and subjective quality of life. The severity of social anxiety symptoms was measured using the Liebowitz Social Anxiety Scale (LSAS). Global/Social functioning and subjective quality of life were evaluated using the Global Assessment of Functioning Scale, the Social Functioning Scale, and the World Health Organization-Quality of Life 26 (WHO-QOL26).

RESULTS

Thirty-six patients completed the reassessment at the end of the 5-year follow-up period. The mean LSAS total score worsened over time, whereas other symptoms improved from the baseline. The mean WHO-QOL26 score in the worsened LSAS group was significantly lower than that in the stable LSAS group. At baseline, WHO-QOL26 scores were associated with an increase in the severity of social anxiety symptoms.

CONCLUSION

In community-dwelling patients with remitted schizophrenia, a lower subjective quality of life might lead to the development of social anxiety symptoms, both concurrently and prospectively. To achieve a complete functional recovery, additional interventions for social anxiety may be needed.

[Ebstein's anomaly in an adult]

A 56-year-old female who had been diagnosed with Ebstein's anomaly was admitted with cyanosis and congestive heart failure. The echocardiogram showed severe tricuspid valve incompetence, displacement of the tricuspid valve and dilatation of the atrialized portion of the right ventricle. Atrial fibrillation was detected in the electrocardiogram. She underwent tricuspid valve replacement and right atrial maze procedure. She is released from congestive heart failure and remains in sinus rhythm 48 months after the operation.

Successful aging in individuals with schizophrenia dwelling in the community: a study on attitudes toward aging and preparing behavior for old age

AIM

'Successful aging' in individuals with schizophrenia has been attracting attention. We examined two forward-looking factors of successful aging among schizophrenia patients: 'attitude toward aging' and 'preparing behavior for old age'.

METHODS

Fifty-seven middle-aged and elderly schizophrenia patients with successful aging were identified using the Attitude toward Aging Scale, the Preparing Behavior for Old Age Scale, and assessments of their cognitive function, psychiatric symptoms, social functioning and quality of life. A multiple regression analysis was used to detect determinants of attitude toward aging/preparing behavior for old age at that time ('present': community dwelling). We also analyzed predictors of successful aging using demographic/clinical data assessed 3 years previously ('past': residential care).

RESULTS

The multiple regression analysis revealed that quality of life was a significant determinant: a higher quality of life was related to a more positive attitude toward aging and less active preparing behavior. The significant predictors of preparing behavior were quality of life and the length of the hospital stay: a longer hospital stay and a higher quality of life were related to less active preparing behavior.

CONCLUSION

Quality of life and the length of the hospital stay significantly contributed to forward-looking factors of successful aging. Avoiding long hospitalization periods for patients with schizophrenia may lead to more active preparing behavior, but the improvement of quality of life may not be a sufficient condition. As schizophrenia patients have an optimistic attitude and insufficient preparing behavior, support to prepare such individuals for old age is required as part of community-based psychiatric care strategies.

A case of effective cerebrospinal fluid drainage for paraplegia caused by acute aortic dissection

A 65-year-old man with sudden back pain was transferred to our hospital by ambulance, who also complained of sensory and motor disorder of bilateral legs on arrival. The neurological disorder was gradually aggravated and paraplegia below the level of Th10 was manifested. Computed tomography demonstrated DeBakey IIIb acute aortic dissection; therefore, the paraplegia was thought to be due to spinal cord ischemia caused by the acute aortic dissection. Emergent cerebrospinal fluid drainage was performed, and it was very effective for the relief from paraplegia. The hospital course after the drainage was uneventful and he was discharged on the 39th day after the onset of symptoms.

[Promoting "successful aging" in community psychiatric care]

Recently, patients with schizophrenia have been progressively aging in a way similar to that of the general population. In Japan, community mental health care has become more active in the context of the policy of promoting the discharge of patients from psychiatric hospitals. Patients with chronic schizophrenia who have been discharged are already approaching old age. "Successful aging" may be a key concept in their community-based psychiatric care. Successful aging does not emphasize a loss of youth, but focuses on gains and growth achieved with aging. In the Sasagawa Project, 78 patients with schizophrenia were gradually transferred from a psychiatric hospital to a community dwelling. Eight years have passed since the project began. Elder patients (>60 years old) showed stable psychiatric symptoms and were rarely readmitted to the psychiatric ward. They were, however, more often readmitted to hospital due to physical disease (for example, lifestyle-related disease or fracture) than were middle -aged patients (<60 years old). Elder patients cannot simultaneously receive mental health services under the Services and Support for Persons with Disabilities Act, and long-term care under the Long-Term Care Insurance Act. We hope that the government will establish a new system and institutions that address the needs of elder psychiatric patients. Elder patients with schizophrenia have an optimistic view of their own aging, but they are not sufficiently prepared for old age. In the mental health care of aging psychiatric patients, it is necessary to not only control psychiatric symptoms, but also promote and improve their quality of life by maintaining their ability to continue living in the community (for example, by supporting their preparations for old age).

Evaluation of silica gel-immobilized phosphorylcholine columns for size exclusion chromatography and their application in the analysis of the subunit structures of fish-egg lectins

Columns of phosphorylcholine (PC) immobilized on silica gel were shown to be useful for size exclusion chromatography (SEC) of proteins. The columns provided good separation of proteins in 50mM sodium phosphate buffer (pH 6.9) containing 0.25 M NaCl, and there was a linear relationship between the retention times and the logarithmic values of the molecular weights with a correlation coefficient (R(2)) of 0.978-0.992. The columns were used in analyzing the subunit structures of the rhamnose-binding lectins CSL1, CSL2, and CSL3, isolated from chum salmon (Oncorhynchus keta) eggs. Although the lectins, which are a group of carbohydrate-binding and hydrophobic proteins, behaved anomalously in SEC with conventional matrices, they could be eluted from the immobilized PC columns without non-size-related retention, thereby allowing their molecular weights to be reliably estimated.

The adaptive responses in several mediators linked with hypertrophy and atrophy of skeletal muscle after lower limb unloading in humans

AIM

To determine the adaptive changes in several molecules regulating muscle hypertrophy and atrophy after unloading, we examined whether unilateral lower limb suspension changes the mRNA and protein levels of SRF-linked (RhoA, RhoGDI, STARS and SRF), myostatin-linked (myostatin, Smad2, Smad3 and FLRG) and Foxo-linked (P-Akt, Foxo1, Foxo3a and Atrogin-1) mediators.

METHODS

A single lower limb of each of eight healthy men was suspended for 20 days. Biopsy specimens were obtained from the vastus lateralis muscle pre- and post-suspension.

RESULTS

The volume of the vastus lateralis muscle was significantly decreased after unloading. The amount of RhoA, RhoGDI or SRF protein in the muscle was not significantly changed post-suspension. An RT-PCR semiquantitative analysis showed increased levels of myostatin mRNA but not Smad2, Smad3 or FLRG mRNA. Unloading did not elicit significant changes in the amount of p-Smad3 or myostatin protein in the muscle. The amount of p-Akt protein was markedly reduced in the unloaded muscle. Lower limb SUSPENSION DID NOT INFLUENCE THE EXPRESSION PATTERN OF FOXO1, FOXO3A OR ATROGIN-1.

CONCLUSION

Unloading inducing a mild degree of muscle atrophy may decrease p-Akt and increase myostatin but not SRF-linked mediators.

Effects of the CYP2D6*10 alleles and co-medication with CYP2D6-dependent drugs on risperidone metabolism in patients with schizophrenia

OBJECTIVE

Risperidone is converted to 9-hydroxyrisperidone by CYP2D6. Two parameters were used to examine the influences of CYP2D6 polymorphism and of co-medication on risperidone metabolism: the risperidone:9-hydroxyrisperidone concentration ratio (R:9-OHR ratio) and the sum of the risperidone and 9-hydroxyrisperidone concentrations divided by the dose (C:D ratio). We evaluated the effect of the CYP2D6*10 allele, which is a prevalent mutant allele among East Asians.

METHODS

Genotyping using the P450 microarray system was performed for 89 Japanese patients with schizophrenia receiving risperidone. The patients with CYP2D6*1/*1, *1/*2, or *2/*2 were classified as Group 1, those with one CYP2D6*10 allele (CYP2D6*1/*10 or *2/*10) were classified as Group 2, and those with two CYP2D6*10 alleles were classified as Group 3. The R:9-OHR and C:D ratios were analyzed using two-way ANOVAs with the CYP2D6 genotype and co-medication with CYP2D6-dependent drugs as independent variables.

RESULTS

Both the "genotype" and the "co-medication" factors had significant impacts on the R:9-OHR ratio (p = 0.011, p < 0.001). The "genotype" factor also had a significant impact on the C:D ratio (p = 0.032). However, the "co-medication" factor did not have a significant impact on the C:D ratio (p = 0.129).

CONCLUSIONS

The CYP2D6*10 polymorphism and the presence of co-medication exerted significant influences on the pharmacokinetics of risperidone.

Expression of mRNA for specific fibroblast growth factors associates with that of the myogenic markers MyoD and proliferating cell nuclear antigen in regenerating and overloaded rat plantaris muscle

AIM

To examine the relations between specific fibroblast growth factors (FGFs) and satellite cell activation during muscle regeneration and hypertrophy in vivo, we measured mRNA expression of FGFs and myogenic markers in rat plantaris muscle after bupivacaine administration and synergist ablation.

METHODS

mRNA levels for MyoD, myogenin, proliferating cell nuclear antigen (PCNA), p21, M-cadherin, Pax7, FGF-1, FGF-2, FGF-3, FGF-4, FGF-5, FGF-6, FGF-7, FGF-8 and hepatocyte growth factor (HGF) were measured continually for up to 72 h after bupivacaine administration and synergist ablation. FGF-5, FGF-7 and HGF proteins were immunostained at 72 h after bupivacaine administration.

RESULTS

MyoD and PCNA mRNAs started increasing 24 h after bupivacaine administration. Myogenin, p21, M-cadherin and Pax7 mRNAs started to increase after 48 and 72 h. After synergist ablation, MyoD, PCNA, M-cadherin and Pax7 mRNAs had increased at 24 and 48 h, and myogenin and p21 mRNAs at 12 and 24 h. FGF-1, FGF-7 and HGF mRNAs after the treatments started to increase at the same time as MyoD and PCNA mRNAs. FGF-5 was expressed at the same time as MyoD and PCNA mRNAs after bupivacaine administration but did not after the ablation. FGF-2, FGF-3, FGF-4, FGF-6 and FGF-8 mRNAs were not associated with the expression of the myogenic markers. FGF-7 and HGF proteins were expressed in immature muscle fibre nuclei and the extracellular matrix, but FGF-5 protein was preferentially expressed in extracellular matrix.

CONCLUSION

These results indicate that FGF-1, FGF-7 and HGF are associated with specific myogenic marker expression during muscle regeneration and hypertrophy.

Bioabsorbable Gelatin Sheets Latticed With Polyglycolic Acid Can Eliminate Pericardial Adhesion

BACKGROUND

As an extension of our previous studies on bioabsorbable pericardial substitutes, we have created a new form of gelatin sheets latticed with bioabsorbable polyglycolic acid (PGA). This study was undertaken to evaluate the biomechanical property of the sheet and the preventive effect on pericardial adhesions after pericardial replacement in a canine model before its clinical applications.

METHODS

The mechanical property was assessed by measuring tension of suture pull-out at first break test. Fifteen dogs underwent partial pericardial replacement with the bioabsorbable sheets through a left thoracotomy. Macroscopic assessment for severity of adhesions and microscopic evaluation for histologic changes were made at 2, 4, 12, and 24 weeks postoperatively.

RESULTS

The latticed sheets exhibited tenfold higher tension of disruption at the suturing margin compared to our previously developed gelatin sheets (619 +/- 141 versus 62 +/- 7 gf, p < 0.001), and demonstrated equivalent strength to that of clinically available expanded polytetrafluoroethylene membrane. During rethoracotomy, adhesions between the epicardium and the pericardial substitutes were moderate at the 4-week interval and resolved completely after 12 weeks postoperatively. Inflammatory reaction scores graded into 4 scales on histologic assessment were 2 +/- 0.0, 1.6 +/- 0.6, and 0.3 +/- 0.5 at 4, 12, and 24 weeks, respectively. Inflammatory reaction significantly decreased from the 4-week interval to the 24-week interval after the pericardial replacement (p < 0.05).

CONCLUSIONS

The bioabsorbable gelatin sheets latticed with PGA gained improved mechanical properties compared with the previously reported gelatin sheets without impairing its bioabsorbability. The bioabsorbable sheet could eliminate pericardial adhesions after being replaced with regenerated tissue.

Deinstitutionalization of long-stay patients with schizophrenia: the 2-year social and clinical outcome of a comprehensive intervention program in Japan

OBJECTIVES

The Sasagawa Project aimed to investigate the effects of deinstitutionalization and evidence-based strategies for the treatment of mental disorders among long-stay patients after their discharge from a mental hospital using a quasi-experimental longitudinal study design and to assess the patients' social and clinical outcomes over a 2-year post-discharge period.

METHOD

Seventy-eight patients with schizophrenia were transferred to a community facility (Sasagawa Village) following the closure of Sasagawa Hospital in Koriyama in March 2002. The patients had undergone psychosocial training following the protocol outlined by the Optimal Treatment Project. All evaluations were performed prior to the patients' discharge and were repeated 12 and 24 months after discharge using the Positive and Negative Syndrome Scales, the Global Assessment for Functioning, the Schedule for Assessment of Insight, the Rehabilitation Evaluation Hall and Baker Scale, the Social Functioning Scale, the Drug Attitude Inventory, and the Mini-Mental State Examination.

RESULTS

During the 24-month study period, 18 residents had incidents that made their continued stay at Sasagawa Village impossible. Only four (5.1%) of these residents were readmitted to psychiatric wards because of exacerbations of their conditions. Twelve residents were admitted to hospital because of serious physical illnesses. The 60 residents who remained in the community facility for 2 years demonstrated significant improvements in not only their psychiatric symptoms, but also their social functioning, as evidenced by their scores for Social Activity, Speech Skills, Disturbed Speech, Self-Care and General Behaviour on the Rehabilitation Evaluation Hall and Baker Scale and Withdrawal, Independence (Performance), Independence (Competence), and Employment on the Social Functioning Scale.

CONCLUSIONS

Careful planning that minimized social and clinical dislocation may have contributed to the successful transition from mental hospital to community facility assessed in this study. Patients with a long history of illness showed favourable outcomes with little clinical deterioration and various improvements in their psychiatric symptoms and social functioning.

[Aortic root enlargement in elderly patients]

From January 2003 to June 2005, 12 elderly patients with severe aortic stenosis underwent aortic root enlargement (ARE) by Nicks procedure. Their ages ranged from 74 to 87 with a mean of 79.3. Stented bioprosthesis were used in 11 cases. There was no death. Cardiothoracic ratio on chest X-ray decreased from 59.4 to 53.6% and New York Heart Association (NYHA) functional class improved from 3.4 to 1.3. Echocardiography also showed remarkable improvement, in peak pressure gradient (PG) from 98.3 to 20.7 mmHg, in left ventricular mass index (LVMI) 181 to 137 g/m2. LVM and LVMI regression rates were 25.3 and 22.3%, respectively. Comparative study of those with ARE alone and those with combined operation showed much hazardous effect in the latter, but no significant difference in echocardiographic findings postoperatively. ARE by Nicks procedure, if it could be performed without concomitant procedure, is a safe and effective option also in elderly patients with small aortic annulus.

The expression of IGF-I and myostatin mRNAs in skeletal muscle of hypophysectomized and underfed rats during postnatal growth

AIM

To determine the roles of myostatin and insulin-like growth factor-I (IGF-I) during postnatal growth, we examined IGF-I and myostatin mRNA expression in the skeletal muscles of hypophysectomized and underfed rats during postnatal growth.

METHODS

Five-week-old rats were divided into four groups: freely fed control, moderately underfed, severely underfed and hypophysectomized. Four weeks later, blood and muscle samples were gathered to determine serum IGF-I, myosin heavy chain (MHC) isoforms, IGF-I Ea, IGF-I Eb and myostatin mRNA.

RESULTS

The weights of soleus, plantaris and masseter muscles were decreased in underfed and hypophysectomized rats. Hypophysectomy resulted in significant increases of type I MHC at the expense of type IIx in plantaris muscle and of neonatal MHC at the expense of types IIx and IIb in masseter muscle. Serum IGF-I was decreased by underfeeding and hypophysectomy. Plantaris muscle IGF-I Ea mRNA in underfed and hypophysectomized rats was significantly lower than in normal controls. Plantaris muscle IGF-I Eb mRNA in underfed rats was significantly lower than in normal controls. Masseter muscle IGF-I Eb mRNA in severely underfed rats was significantly lower than in normal control and hypophysectomized rats. Soleus muscle myostatin mRNA in hypophysectomized rats was significantly higher than in normal and significantly underfed rats. No significant differences in plantaris and masseter muscle myostatin mRNA were observed between groups.

CONCLUSION

Suppressed muscle growth caused by hypophysectomy and underfeeding may be attributed mainly to reduced circulating IGF-I and partially to reduced IGF-I mRNA, rather than to a change in myostatin.

Several herpesviruses can reactivate in a severe drug-induced multiorgan reaction in the same sequential order as in graft-versus-host disease

BACKGROUND

Drug-induced hypersensitivity syndrome (DIHS) is a severe multiorgan systemic reaction. Numerous studies have linked reactivation of human herpesvirus (HHV)-6 with the development of DIHS. Recent articles have suggested that reactivation of other herpesviruses besides HHV-6 might also be involved in the development of DIHS. On the other hand, recent studies have provided evidence for a role of reactivation of various herpesviruses in the development of graft-versus-host disease (GVHD).

OBJECTIVES

We attempted to determine whether sequential herpesvirus reactivation could be detected in four patients with severe DIHS, as observed in patients with GVHD, and be coincident with various clinical manifestations that developed after discontinuation of the causative drugs.

METHODS

Detection and quantification of viral DNA [cytomegalovirus (CMV), Epstein-Barr virus (EBV), HHV-6 and HHV-7] in sequential blood samples were performed using real-time polymerase chain reaction assays, based on TaqMan technology.

RESULTS

In these patients, the cascade of virus reactivation initiated by HHV-6 or EBV extended to EBV or HHV-7, and eventually to CMV. Clinical manifestations of this syndrome followed by failure of various organs occurring despite discontinuation of the drug were coincident with these herpesvirus reactivations.

CONCLUSIONS

These results suggest that various herpesviruses can reactivate in the setting of severe drug reactions in a similar sequential order to that described in GVHD. The sequential reactivation of these herpesviruses is responsible for the development of multiorgan failure occurring after discontinuation of the causative drug.

Closure of the Pericardium Using Synthetic Bioabsorbable Polymers

BACKGROUND

Pericardial substitutes are known to ensure safer resternotomy at reoperation. A synthetic sheet made from expanded-polytetrafluoroethylene (e-PTFE) has been most commonly used as a pericardial substitute. The e-PTFE sheet, however, can induce severe inflammatory reaction and diffuse fibrosis. This study was designed to investigate the absorption rate and tissue reaction associated with two absorbable pericardial substitutes: a gelatin sheet and L-lactic acid-epsilon-caprolactone copolymer (L-C copolymer). In addition, e-PTFE sheet and autologous pericardium were used as controls.

METHODS

Sixty dogs were divided into four groups of 15. In group A, a 3 x 3 cm segment of pericardium was excised, and the autologous pericardium was resutured. In group B, the pericardial defect was replaced with gelatin sheet. In group C, the defect was replaced with L-C copolymer sheet. In group D, the defect was replaced with e-PTFE sheet. For each group, the implanted membranes were retrieved at 2 weeks (n = 1), 4 weeks (n = 3), 12 weeks (n = 5), and 24 weeks (n = 6) after implantation.

RESULTS

The e-PTFE sheet produced severe adhesions to the heart and pleura and a more prominent inflammatory reaction, as compared with the gelatin sheet. The absorbable pericardial substitutes were completely absorbed by 24 weeks after implantation, and were replaced with fibrous membrane.

CONCLUSIONS

Gelatin sheet may involve less adhesion and a reduced inflammatory reaction compared with e-PTFE.

Axillary Artery Cannulation Improves Operative Results for Acute Type A Aortic Dissection

BACKGROUND

This study was undertaken to identify preoperative and postoperative predictors of hospital death of patients with acute type A aortic dissection.

METHODS

Between May 1,1992, and July 31, 2004, 106 consecutive patients (59 male and 47 female, mean age 62.2 +/- 12.1 years) with acute type A aortic dissection underwent surgery with open technique and cerebral protection by antegrade selective cerebral perfusion. The external iliac artery or femoral artery alone was used for arterial cannulation in 37 patients; however, the right axillary artery was cannulated in 69 patients. Univariate analysis of potential risk factors was performed to identify risk factors for hospital death and was followed by multivariate analysis by a stepwise logistic regression model to identify independent risk factors.

RESULTS

Sixteen patients died postoperatively, and the overall hospital mortality rate was 15.1%. Univariate analysis revealed shock (p = 0.020), visceral ischemia (p = 0.007), root replacement (p = 0.041), and absence of axillary artery perfusion (p = 0.003) as significant risk factors for hospital death. Multivariate analysis revealed visceral ischemia (p = 0.0028, odds ratio 18.4) and absence of axillary artery perfusion (p = 0.0014, odds ratio 8.2) as independent preoperative and intraoperative predictors of hospital death.

CONCLUSIONS

Achievement of greater success in the surgical treatment of acute type A dissection will require axillary artery cannulation and measures to prevent visceral malperfusion.

The HDL2/HDL3 ratio in menopause

OBJECTIVES

The influence of the menopause on the HDL2/HDL3 ratio was assessed in association with hypertriglyceridemia.

METHODS

Fasting blood samples were collected from 607 patients. Commercially available enzymatic methods were used for determination of TG, and total HDL-C. HDL2 and HDL3 were measured by ultracentrifugation.

RESULTS

The HDL2/HDL3 ratio had a strong negative correlation with TG (r=-0.272, P<0.0001 and r=-0.314, P<0.0001) in both pre- and postmenopausal women. No significant differences were observed in HDL2, HDL3, and HDL2/HDL3 ratio between pre- and postmenopausal women without hypertriglyceridemia. Postmenopausal women had a significantly higher HDL2/HDL3 ratio than premenopausal women with hypertriglyceridemia.

CONCLUSIONS

These results indicate that menopausal status not only increases plasma LDL-cholesterol and triglyceride levels, but also increases the HDL2/HDL3 ratio when associated with elevation of plasma triglyceride levels. These changes may increase the risk for CHD due to enlargement of the lipid pool.

The Sasagawa Project: A model for deinstitutionalisation in Japan

Japanese psychiatric services are still typically hospital-based. The Sasagawa Project is the first systematized deinstitutionalization project in Japan that aims to make the transition from hospital to residential living while ensuring both the quality and continuity of care for the patients. Seventy-eight (51 males) patients (mean age 54.6) with chronic schizophrenia, who were considered appropriate for discharge received continuous cognitive behavioural therapies based on the Optimal Treatment Project manualised protocol, both before and after the hospital closure. During the first 12 months after the deinstitutionalisation was initiated on April 1st, 2002, ten people had incidents that interrupted their stay in the residential Sasagawa Village. A common criticism of many treatment outcome trials is that evaluation is focused on changes in clinical severity. In the Sasagawa project the transition appeared to have been smooth and relatively few incidents occurred could be related to the transition to a less intensive residential care. This project might be a useful model for effecting and monitoring transition from hospital to community care in Japan and other countries where such changes have been proposed.

Interleukin-8 expression in the esophageal mucosa of patients with gastroesophageal reflux disease

BACKGROUND

It has been reported that inflammatory cell infiltration can be detected in patients with endoscopically negative gastroesophageal reflux disease (GERD) as well as those with erosive reflux esophagitis. In this study, we examined the expression of mRNA for interleukin (IL)-8, a potent chemokine for neutrophils, in the esophageal mucosa of patients with GERD and compared the results with their endoscopic findings and symptoms.

METHODS

Biopsy samples were obtained from 80 patients. Endoscopic diagnosis was performed according to the Los Angeles classification. Patients with typical symptoms such as heartburn despite normal endoscopic findings were classified as the non-erosive GERD group. Total cellular RNA was extracted from the biopsy samples and IL-8 mRNA was quantified by real-time polymerase chain reaction (PCR). Localization of IL-8 protein in the esophageal mucosa was done by immunostaining.

RESULTS

Expression of IL-8 mRNA was correlated with the endoscopic grade of esophagitis or with inflammatory cell infiltration, but not with the symptoms of the patients. Expression of IL-8 mRNA was also detected in all patients with non-erosive GERD. The level of IL-8 expression in non-erosive GERD was low compared with that in erosive GERD, but was higher than that in normal controls. IL-8 immunostaining was found in the basal layers of the esophageal mucosa. Administration of lansoprazole, a proton-pump inhibitor, decreased both IL-8 mRNA and protein levels in the esophageal mucosa.

CONCLUSION

These results suggest that IL-8 in the esophageal mucosa may be involved in the pathogenesis of esophageal inflammation, including non-erosive GERD.

[A successful management of acute myocardial infarction with severe left main trunk lesion using beating heart coronary artery bypass grafting: report of a case]

A 56-year-old male was admitted for sudden onset of severe chest pain and diagnosed as acute myocardial infarction (AMI). Emergency coronary angiography revealed complete obstruction of the left anterior descending artery (LAD) and 99% stenosis of left circumflex coronary artery (LCX), which was almost same with obstruction of the left main trunk coronary artery. Emergency coronary artery bypass grafting (CABG) to LAD and LCX was performed under a beating-heart. Left ventricular wall motion was improved after bypass grafting. CABG under a beating-heart is a new strategy for critical cases such as acute coronary syndrome. The better patency rate and the more complete revascularization that may be achieved with the new generation of stabilizers and retractors may improve long-term results.

Adequate reduction degree of pituitary gonadotropin levels in the clinical management of short-term hormone replacement therapy of women with menopausal symptoms

The purpose of this study was to clarify the adequate reduction rate of pituitary gonadotropins in ideal clinical management of shortterm hormone replacement therapy (ST-HRT) in postmenopausal women with undefined symptoms. Subjects included a total 324 postmenopausal patients between 48 and 61 years of age who visited the Department of Obstetrics and Gynecology at Osaka Medical College Hospital for the consult of menopausal symptoms. Administration of conjugated equine estrogen (0.625 mg/day) and progestin (2.5 mg/day) in the patients for 8 weeks. HRT was markedly effective in 28.7% of cases, effective in 40.7%, fairly effective in 21.9%, and ineffective in 8.6% of cases. The plasma concentration of FSH and LH after administration decreased significantly (P < 0.001) by 58.1% and 59.9% for markedly effective cases, and by 31.0% and 36.1% for effective cases. On the other hand, decreases in FSH and LH concentration were 14.1% and 1.3% for the fairly effective and 8.5% and -5.1% for ineffective cases, demonstrating a significantly greater decrease in plasma FSH and LH levels in the markedly effective and effective cases than those in ineffective cases (P < 0.001). There were significant differences in the reduction rates of plasma FSH and LH levels between in cases showing (59.9% and 53.2%) and not showing the side effects (24.8% and 25.9%), respectively (P < 0.0001). In conclusion, efficacy of ST-HRT was significantly correlated to the degree of decrease in plasma FSH and LH levels in patients with undefined symptoms. In addition, efficacy appeared to be correlated to the incidence of side effects. The degree of reduction of FSH (24.8-31.0%) and LH (25.9-36.1%) from the baseline may possibly be used as the suitable therapeutic window for hormone levels during HRT. The present results suggest that plasma gonadotropin levels could be a useful indicator for the management of patients undergoing short-term HRT for women with menopausal symptoms.

The effect of physicians' advice and recommendations on the compliance with hormone replacement therapy in the treatment of postmenopausal symptoms in Japanese women--a prospective study

A retrospective study was performed to determine the compliance of hormone replacement therapy (HRT), the reason for discontinuation. This study comprised 477 postmenopausal women who attended the women's psychosomatic and menopause clinic between January 1991 and December 2002. For the purposes of analysis, the women were classified into two groups. In Group A (242 subjects), subjects were allowed to decide whether or not to suspend or discontinue the drug, taking their condition into account, after their symptoms were alleviated. In Group B (235 subjects), all the women were informed as to the drug's excellent effects on osteoporosis and skin tissue before HRT was started and after their symptoms were alleviated. In Group A, the percentage of women who were still on this therapy was 77.7%, 34.3%, 21.1% and 8.7% at 3, 6, 12 and 24 months respectively after the start of therapy. Alternatively, in group B, the 24-month continuation rate was more than 50%. At 36 months (47.2%) and 60 months (38.7%) continuation rates were also significantly higher than those in group A (P < 0.0001). The leading reasons in the women's decision to discontinue HRT were improvement of symptoms (68.0% and 77.8% in group A and B, respectively, p = 0.408). The incidence in the women's decision to discontinue HRT by the reason of fear of cancer was significantly higher in group A (10.8%) than in group B (2.8%) (P = 0.008). In this study, the key factor affecting HRT compliance proved to be physician's advice. This means that when HRT is administered to Japanese women with the objective of alleviating menopausal symptoms and, high compliance can be expected provided individual patients are allowed to decide for themselves when HRT should begin end.

Does daily physical exercise favorably affect the bone mass of postmenopausal women?

To investigate the effects of physical exercise on bone mass during the climacteric and menopausal period. The study group were 1123 postmenopausal Japanese women (mean: 55.4 +/- 3.7 years). Their current bone mineral density of lumbar vertebrae (L2-4) was analyzed taking the presence or absence of regular physical exercise, the type of exercise and its duration into consideration. Of the 1123 postmenopausal women, 643 (57.3%) were currently involved is some form of physical exercise on a regular basis. Bone mineral density did not differ significantly between the women exercising at present (1.035 +/- 0.08 g/cm2) and the women who had never been involved in regular physical exercise at any time in their life (1.089 +/- 0.08 g/cm2). The bone mineral density did not differ significantly in relation to the duration of physical activity (less than 6 months: 1.054 +/- 0.169 g/cm2; 6 months to 3 years: 1.049 +/- 0.128 g/cm2; over 5 years: 1.024 +/- 0.168 g/cm2). Although a majority of the postmenopausal women surveyed were involved in some form of physical activity, the practice of mild exercise at and around the time of perimenopause did not significantly increase bone mineral density.

Elevated plasma leptin levels associated with high blood pressure and TG rich lipoproteins but not associated with plasma gonadotropins, estradiol and cortisol levels in peri- and postmenopausal lean women with undefined symptoms

We evaluated associations of leptin with blood pressure, plasma lipid metabolism, and endocrine status in 140 perimenopausal Japanese women. In this study, the mean plasma leptin level is 8.6 +/- 4.8 ng/ml and the range is 1.7 to 29.6 ng/ml. There were significant correlations between plasma leptin concentration and systolic blood pressure (r +/- 0.647, p < 0.0001) and diastolic blood pressure (r = 0.242, p = 0.0043). We observed significant correlation of plasma leptin concentration and LDL-cholesterol, triglyceride concentrations. However, no significant differences were observed in the correlation of plasma leptin and LH, FSH, estradiol and cortisol concentrations. In conclusion, leptin showed a significant association with blood pressure and lipid metabolism. It is suggested that leptin may play an important role in physiological regulation of sympathetic nervous system and lipid metabolism in peri-and postmenopausal women.

A successful management of concomitant renovascular hypertension and symptomatic subclavian steal syndrome due to Takayasu's arteritis using balloon angioplasty and axillo-axillary bypass grafting

We present a case of Takayasu's arteritis with severe renovascular hypertension and symptomatic subclavian steal syndrome. A 60-year-old woman underwent successful percutaneous balloon renal angioplasty and axillo-axillary bypass grafting. The role of hybrid therapy, angioplasty and extra-anatomical bypass grafting for revascularization of symptomatic ischemia in this disease is reviewed. (Ann Thorac Cardiovasc Surg 2003: 9; 334-6)

[Coronary vasospasm during off-pump coronary artery bypass grafting; report of two cases]

Coronary vasospasm is one of the most dangerous and fatal complications of coronary artery bypass grafting (CABG) operation. Our experiences in recent 2 cases happened during off-pump CABG (OPCAB) are presented. Case 1: A 63-year-old male who had 3 vessels disease underwent OPCAB using left internal thoracic artery (LITA) and the radial artery. When the sternotomy was going to be closed, ST elevation of electrocardiogram (ECG) occurred and was followed by ventricular fibrillation. Intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were applied immediately and an additional grafting to first diagonal artery (D 1) was carried out using a saphenous vein. Case 2: A 67-year-old male underwent OPCAB using LITA and the radial artery. ST elevation of ECG suddenly occurred and was followed by complete atrio-ventricular (AV) block when the sternum was closed. IABP and the ventricular pacing were applied immediately. While OPCAB may be less invasive operating method than conventional CABG, we should pay more attention to the coronary vasospasm.

Does decreased T1 signal intensity in the retrodiscal tissue of the temporomandibular joint reflect increased density of collagen fibres?

OBJECTIVE

To evaluate whether decreased signal intensity on T(1) weighted MR images of the retrodiscal tissue of the temporomandibular joint (TMJ) reflects increased density of collagen fibres.

METHODS

Corrected sagittal T(1) weighted MR images of six TMJs from six fresh cadavers (three males and three females; age range 76-87 years, mean 80.8 years) were obtained. Following MRI, slices of tissue samples were taken from the cadavers that exactly matched the planes of the MR image. These samples were fixed, decalcified and stained (haematoxylin-eosin stain, Elastica van Gieson's stain) for light microscopy. The samples were evaluated for density of collagen fibres according to Hall et al (1984) and for vascularity, arterial wall thickness, fat content and elastin. In these sagittal samples, the retrodiscal tissue was divided anteroposteriorly and vertically into six areas and each area was classified by histological parameters. The MR images were similarly divided into six areas. Areas with reduced signal intensity were classified as the low signal group and those with no reduced signals were classified as the control group.

RESULTS

Collagen density assessed histologically differed between the low signal intensity group and the control group, and loose collage density on the histological samples was observed significantly more often in the low signal group (Fisher's exact test, P=0.03). There were no statistically significant differences in the other categories between the two groups.

CONCLUSION

The results suggest that reduced T1 signals of retrodiscal tissue do not necessarily reflect a dense distribution of collagen fibres.

Acute mitral regurgitation due to total rupture in the anterior papillary muscle after acute myocardial infarction successfully treated by emergency surgery

A 68-year-old female was admitted for sudden onset of chest pain. She received a successful percutaneus coronary intervension for total occlusion in the diagonal artery, but continued to develop progressive heart failure. A chest X-ray showed right pulmonary edema without cardiomegaly, and an echocardiogram revealed massive mitral regurgitation with prolapse in the anterior mitral leaflet due to a rupture in the papillary muscle. An emergency operation was conducted using routine cardiopulmonary bypass. There was complete rupture in the anterior papillary muscle. Mitral valve replacement with posterior mitral leaflet preservation was performed using a size 25 mm Carbomedics prosthetic valve. The postoperative course was uneventful, and she was discharged on postoperative day 29 in New York Heart Association class I. Postoperative pathological findings showed necrosis in the papillary muscle with inflammatory changes. Early diagnosis, prompt medical stabilization, and aggressive surgical intervention are essential to save such a group of patient.

Method of producing tissue sections from endometrial scrapings

Endometrial cytology is important not only for observing cytological findings, but also for assessing histological architecture. Therefore, we attempted to produce a histological preparation from the sample using an automatic fixation apparatus (ACF 1000) which employs a membrane filter method. After observation of the cytological features, the cover slip was removed and a paraffin-embedded section was prepared. Producing a histological section from a cytological specimen prepared with the ACF 1000 apparatus was more useful and easier than with the techniques described to date. Peelability of the cell was avoided by using a silane-coated membrane filter. Observation of the same cell cluster as that observed in the cytological sample was also facilitated in the histological section by this technique.

Cryopreserved aortic homograft replacement in 3 patients with noninfectious inflammatory vascular disease

OBJECTIVE

Although mechanical prosthetic heart valves are most commonly used for aortic valve replacement in patients with aortic regurgitation due to noninfectious inflammatory vascular disease, postoperative perivalvular leakage and/or detachment of the prosthetic valve occurs due to the fragility of the aortic annulus. Aortic root replacement with cryopreserved homografts is reported to be useful in such patients.

METHODS

Three patients having aortic regurgitation associated with severe long standing noninfectious inflammatory vascular disease-2 patients with Takayasu's arteritis and 1 patient with Behçet disease--had the aortic root replacement by a cryopreserved aortic homograft valve and conduit.

RESULTS

All surgery was successful and the postoperative course uneventful. Echocardiography showed neither aortic regurgitation nor graft detachment at 6-39 months after operation.

CONCLUSIONS

Homograft valve and conduit replacement is appropriate in patients with aortic regurgitation associated with noninfectious inflammatory vascular disease, with mid-term results favorable.

Chronic docosahexaenoic acid intake enhances expression of the gene for uncoupling protein 3 and affects pleiotropic mRNA levels in skeletal muscle of aged C57BL/6NJcl mice

Docosahexaenoic acid [DHA, 22:6(n-3)] prevents cardiovascular disease by decreasing obesity. It also prevents cancer and other geriatric diseases. We studied the chronic pleiotropic effects of DHA on transcription including that of mRNAs for uncoupling proteins (UCP). Male and female mice (9 mo old) were fed high (n-6) or high (n-3) fatty acid diets for 4 mo. Compared with controls fed high (n-6) fatty acid diets [high (n-6) group], the livers of male and female mice fed DHA [high (n-3) group] contained six- (P < 0.001) and fivefold (P < 0.001) more DHA, respectively. The high (n-3) group had less white adipose tissue [35.3% in males (P < 0.001) and 27.3% in females (P < 0.001)]. The high (n-3) group expressed more uncoupling protein 3 (UCP3) in the gastrocnemius, 108% higher (P < 0.001) and 104% higher (P < 0.001) in males and females, respectively, than those in the high (n-6) group. However, the prevention of many diseases by DHA is not explained by UCP3. Thus, the gene expression profiles of both high (n-3) and high (n-6) groups were analyzed in skeletal muscle using cDNA expression array. Of 588 genes surveyed in the array, the high (n-3) group showed 12 genes (2%) including those for glucose regulators (e.g., CD38) and tumor suppressors (e.g., CTCF) that were expressed 100-340% more than those of the high (n-6) group. Furthermore, 28 genes (4.8%), including growth factors (e.g., ErbB-2 receptor) and immune regulators (e.g., interleukin-1 beta precursor) were expressed 50-90% less in the high (n-3) group than in the high (n-6) group. These results explain in part the important pleiotropic effects of DHA, which are independent of obesity control by UCP3 suppression.