Development of a partnership between academia, community, and government in response to the 2022 mpox outbreak in Japan

Objectives　In response to the steady rise in the number of cases of mpox in nonendemic countries, starting with an outbreak in the United Kingdom in May 2022, the World Health Organization declared a public health emergency of international concern on July 23, 2022. As of November 13, 2022, seven cases of mpox have been reported in Japan.Methods　A community engagement approach was applied to prevent the spread of mpox in Japan.Results　A tripartite partnership between academia, community, and government (ACG) was established to promote multisectoral communication between vulnerable communities, medical personnel involved in diagnosis and treatment, public health specialists at public health centers, epidemiologists at the National Institute of Infectious Diseases (NIID), and government and public administration. Through information sharing, this ACG partnership can translate accurate information into effective infection control measures.Conclusion　By developing and maintaining the ACG partnership, an environment will be created that allows an immediate response to future public health crises affecting vulnerable communities. This Practice Report describes the process of establishing an ACG partnership.

Elimination of HIV transmission in Japanese MSM with combination interventions

Background

Japan has a concentrated HIV epidemic, with the majority of transmission among men who have sex with men (MSM). This study aimed to explore the effect of behavioral and biomedical interventions on the HIV epidemic and forecast the time required to eliminate HIV transmission among Japanese MSM.

Methods

A deterministic compartmental model was built to estimate and forecast the HIV epidemic among Japanese MSM from 2010 to 2050. Elimination of HIV transmission among MSM was defined as incidence less than 1/1000 person-years. The time required for eliminating HIV transmission under different scenarios was calculated.

Findings

Under the current policies, HIV transmission cannot be eliminated by 2050. Both behavioral and biomedical interventions can achieve elimination of HIV among MSM by 2050 with annual number of sexual partners among high-risk MSM less than 9, or with condom use rate above 65%, or with testing and treatment rate above 80%, or with more than 10% PrEP coverage rate. Under comprehensive interventions, HIV elimination will be achieved in 2032, 2025 and 2024 using weak, moderate and strong intervention combinations, respectively.

Interpretation

Both behavioural and biomedical interventions can achieve elimination of HIV among MSM by 2050, but comprehensive interventions can accelerate the realization of this goal with higher feasibility.

Funding

This study was funded by a Health and Labor Sciences Research Grant (Research on HIV/AIDS) from The Ministry of Health Labour and Welfare (21HB0701) and National Natural Science Foundation of China (No. 81773543 and 81973150), and the KC Wong Education Foundation.

Association between N-methyl-D-aspartate Receptor Subunit 2B Gene Polymorphisms and Personality Traits in a Young Japanese Population

OBJECTIVE

The N-methyl-D-aspartate receptor subunit 2B (GluN2B) is involved in regulation of anxiety and depression and nervous activity in the brain. Single nucleotide polymorphisms of the GluN2B gene (GRIN2B) are associated with human mental function and behaviour. We investigated whether four GRIN2B polymorphisms (rs7301328, rs1806201, rs1805247, and rs1805502) affect characterisation of personality traits.

METHODS

In 248 young people, GRIN2B polymorphisms were analysed, and personality traits were assessed using the Neuroticism Extraversion Openness-Five Factor Inventory (NEO-FFI) and State-Trait Anxiety Inventory (STAI).

RESULTS

There was no main effect of the GRIN2B polymorphisms on the NEO-FFI and STAI dimension scores. Interaction between polymorphism and sex was found in rs1805247 (p = 0.034) and rs1805502 (p = 0.040) in terms of the conscientiousness score of the NEO-FFI. However, post hoc simple main effect analysis showed no significant effect. The preliminary haplotype analysis indicated that haplotype CTT (rs1806201-rs1805247-rs1805502) in the haplotype block was associated with the extraversion score of the NEO-FFI in female participants (p = 0.044), but the significance was lost on correction for multiple testing.

CONCLUSION

There was no significant association between selected GRIN2B polymorphisms and personality traits, but this may be due to low statistical power. Further studies involving a larger study population are needed to clarify this.

Splenectomy and antiviral treatment for thrombocytopenic patients with chronic hepatitis C virus infection

Thrombocytopenic patients with chronic hepatitis C virus (HCV) infection are poor candidates for antiviral treatment with interferon (IFN), but no standard treatment for thrombocytopenia has yet been established. We evaluated the safety of splenectomy and its efficacy for the initiation and continuation of antiviral therapy. From March 2003 to April 2006, 10 patients (mean age 62.5 years) with HCV-related cirrhosis, low platelet count (<==106 000/mm(3)) and splenomegaly (spleen size >==10 cm) underwent splenectomy. Platelet counts significantly increased at 4-8 weeks after splenectomy [pre: 64 200 +/- 6900/mm(3)vs post 209 000 +/- 40 600/mm(3) (P = 0.004)]. No severe operative complications were observed. All patients subsequently received antiviral therapy. Of the eight patients who were infected with HCV genotype 1 and had a high viral load (>==100 KIU/mL), four received combination therapy with pegylated IFNalpha-2b plus ribavirin, and the other four received standard IFNalpha-2b plus ribavirin. One patient infected with HCV genotype 2 and another with HCV genotype 1 and a low viral load (<100 KIU/mL) were treated with pegylated IFNalpha-2a. Six patients achieved sustained virologic response (SVR). Among four patients who failed to achieve SVR, one was given retreatment with pegylated IFN plus ribavirin, and the other three received low-dose long-term IFN therapy. Although this study was small, the treatment results were similar to those for patients without thrombocytopenia and suggested that splenectomy would not reduce the antiviral efficacy of IFNalpha-based treatment.

[Aortic arch aneurysm with aortopulmonary fistula; report of a case]

A 77-year-old female was admitted to our hospital due to congestive heart failure. Computed tomography and angiography showed a saccular aneurysm with aortopulmonary fistula in the aortic arch. The patient underwent total arch replacement and patch closure of the pulmonary artery in an urgent operation. She was discharged after uneventful postoperative course, although staged sternal closure and 5 days of respiratory management were needed. A few cases of aortic arch aneurysm with perforation to the pulmonary artery are operated with success, which depends on severity of congestive heart failure and urgency. Therefore, it should be diagnosed exactly and rapidly. In the operation, special care should be taken to avoid right heart failure and postoperative respiratory distress.

Linkage disequilibrium and association with methamphetamine dependence/psychosis of mu-opioid receptor gene polymorphisms

Several studies indicate that the mu-opioid receptor plays a role in addiction not only to opiate drugs but also to alcohol and non-opiate addictive drugs. Our studies aim to reveal the associations between gene polymorphisms and methamphetamine (MAP) dependence/psychosis. We newly identified several polymorphisms and four substantial linkage disequilibrium (LD) blocks in the mu-opioid receptor (OPRM1) gene. We found significant differences in both genotype and allele frequencies of the single-nucleotide polymorphism (SNP) IVS2+G691C between control (n=232) and MAP-dependent/psychotic patients (n=128). There was also a significant association between IVS2+G691C and patients with transient psychosis. These results suggest that the OPRM1 gene variations may be a factor in development and prognosis of MAP psychosis.

[Pulmonary dirofilariasis resected by video-assisted thoracoscopy; report of a case]

A 35-year-old female was admitted for biopsy of abnormal shadow on chest X-ray. She was operated on for partial wedge resection of the right lower lobe by video-assisted thoracoscopy without complication. Pathological findings in operation showed inflammatory benign tissues and suggested pulmonary dirofilariasis. Serologic examination was negative after operation, however histological diagnosis supported pulmonary dirofilariasis because a pulmonary artery embolism of calcified tissues consisted of non-human cells. There may be many cases due to old infections like this one, so it is important to consider it for diagnosis and perform more positive surgical procedures. We review a case of pulmonary dirofilariasis safely resected by video-assisted thoracoscopy for diagnosis by exclusion.

Expression of the exocytotic protein syntaxin in mouse oocytes

Syntaxin is an integral membrane protein that is involved in membrane fusion. The exocytosis of the contents of cortical granules, secretory vesicles located in the cortex of an egg, modify the extracellular environment to block additional spermatozoa from penetrating the newly fertilized egg. The aim of this study was to characterize syntaxin expression in mouse oocytes, and to determine the specific isoform that is expressed. Syntaxin was demonstrated in the mouse ovary and in mouse oocytes by both western blot and reverse transcription-polymerase chain reaction analyses. Syntaxin 4 was specifically expressed in metaphase II oocytes. Syntaxin was also immunolocalized within metaphase II oocytes and one-cell embryos with pronuclei using laser scanning confocal microscopy. In metaphase II oocytes, syntaxin was located on the plasma membrane and in the cortex, where cortical granules are present, but was not seen at sites free of cortical granules. In one-cell embryos, no cytoplasmic region was free of syntaxin immunoreactivity. Immunoelectron microscopy detected syntaxin on both the plasma membrane and the vesicle membranes in mouse metaphase II oocytes. In conclusion the results indicate that syntaxin 4 co-localizes with cortical granules and participates in membrane fusion and exocytosis during the cortical reaction.

Effects of whole deletion of CYP2A6 on nicotine metabolism in humans

We investigated the effects of CYP2A6 genotypes on nicotine metabolism, focused from nicotine to cotinine and its additional 3'-hydroxylating resulted in trans-3'-hydroxycotinine formation. In the subjects genotyped by PCR-RFLP method, one cigarette smoking experiment was performed and urine samples were collected for 24 h. In all subjects who smoked, we detected nicotine, cotinine and trans-3'-hydroxycotinine in urine by GC-MS analysis. In whole deletion of CYP2A6, urinary excretion amounts of cotinine and trans-3'-hydroxycotinine were significantly smaller than those in the wild-type of CYP2A6*1. A lack of CYP2A6 reduces the formation of cotinine and trans-3'-hydroxycotinine, but not entirely reduces the trans-3'-hydroxycotinine formation. Unknown cotinine 3'-hydroxylating activity except CYP2A6 are suspected in humans.

Analysis of the metabolism of haloperidol and its neurotoxic pyridinium metabolite in patients with drug-induced parkinsonism

The blood levels of the neurotrophic drug haloperidol (HP) and its pyridinium metabolite, HPP(+), have been analyzed by liquid chromatography/electrospray ionization-mass spectrometry in 10 schizophrenic patients treated with HP, without carbamazepine (HP, oral daily dose of 0.3-0.5 mg/kg body weight for more than 1 year, females, aged 41 +/- 8.5 years). There was a significant difference (t-test, d.f. = 8, p (t(0) = 7.2) <0.005) in the blood HPP(+) level between the 5 patients with (18.5 +/- 6.4 ng/ml) and the 5 without (6.3 +/- 2.4 ng/ml) severe side effects such as drug-induced parkinsonism (Extrapyramidal Symptom Rating Scale (ESRS) parkinsonism severity scores 2.8 +/- 1.5 and 1.8 +/- 1.1, respectively). Moreover, it is suggested that vitamin E may be effective for drug-induced parkinsonism through a change in the blood HPP(+) level. It is necessary to investigate the HPP(+) metabolism in psychiatric patients to avoid severe side effects such as drug-induced parkinsonism and cardiac functional disorders.

Lack of association between smoking and CYP2A6 gene polymorphisms in A Japanese population

This study determined the genotypes of the CYP2A6 gene in 96 smokers and 141 non-smokers in a Japanese population. The frequencies of wild-type of the CYP2A6* 1 and those with a whole deletion of the CYP2A6 gene were 93 (96.9%) and 3 (3.1%) in 96 smokers, and 134 (95.0%) and 7 (5.0%) in non-smokers, respectively. In addition, neither the CYP2A6* 2 nor CYP2A6* 3 alleles were observed in the population studied. There were no significant differences in the CYP2A6 genotype frequencies between smokers and non-smokers, as well as in the number of cigarettes smoked and the nicotine amounts inhaled per day between the CYP2A6* 1 and the deletion of CYP2A6. These results suggest that either the deletion or non-deletion of the CYP2A6 gene shows no significant effect on smoking behavior for the Japanese population examined.

[A case of pseudomyxoma peritonei treated successfully with intraperitoneal administration of CBDCA and etoposide, followed by local delivery of dextran with CDDP during surgery]

A 77-year-old woman was diagnosed as having pseudomyxoma peritonei originating in the ovary or appendix. Low-molecular dextran and CDDP 70 mg was administered directly into the peritoneal cavity, followed by initial exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, and omentectomy. During surgery, an implantable port system was positioned to facilitate repeated intraperitoneal administration. Dextran was used with mucolytic therapy and augmentable efficacy of drug administered simultaneously. Within three weeks after surgery, four courses of intraperitoneal CBDCA 300 mg and etoposide 100 mg were administered at four-week intervals. The patient has remained in good general condition with no sign of recurrence for one year. This chemotherapy regimen has minimum side effects and seems effective in maintaining quality of life.

Mitral valve replacement through right thoracotomy after coronary arterial bypass grafting with functioning conduits

A 67-year-old man who had undergone coronary artery bypass grafting 3 years previously suffered from severe mitral regurgitation associated with Streptococcal infective endocarditis. He was placed in New York Heart Association functional class III. Preoperative angiography demonstrated good opacification of all 3 conduits implanted in the previous operation. We replaced the mitral valve through an anterolateral right thoracotomy, approaching the mitral valve as an alternative to redoing sternotomy to minimize potential injury to patent grafts. His postoperative course was uneventful. After a 1-month course of antibiotics, the patient was discharged as New York Heart Association class II and at present, 3 months after discharge, is doing well. This approach is an effective alternative to redoing sternotomy for mitral valve operation, especially in patients undergoing a previous coronary arterial bypass grafting via median sternotomy.

Early results of coronary grafting using ultrasonically skeletonized internal thoracic arteries

BACKGROUND

We have developed an ultrasonic complete skeletonization technique for obtaining internal thoracic artery (ITA) grafts and have used this method clinically since January 1998. In this report, we discuss the early results of bilateral ITA grafts obtained with our method.

METHODS

We studied 200 consecutive patients who underwent coronary artery bypass grafting using ITAs obtained by this technique. Angiography of the grafts was performed in 188 patients (94%) within 1 month after coronary artery bypass grafting.

RESULTS

The ITA grafts were about 4 cm longer than pedicled ITA grafts. The free flow through the grafts was at least 30% higher than through pedicled ITAs. The early patency rate determined by postoperative angiography of the grafts was 99.7% for left ITAs and 100% for right ITAs. No patient required postoperative intervention or repeated surgery.

CONCLUSIONS

Ultrasonic complete skeletonization increases the effective length of ITA bypasses, improves free flow through the bypasses, and it is less invasive than conventional pedicled harvesting. These excellent early results indicate that this technique is a straightforward, safe, less invasive, and optimal method for obtaining ITA bypass grafts.

Positive and negative syndromes, and Borna disease virus infection in schizophrenia

The relationship between Borna disease virus (BDV) infection and positive and negative syndromes in schizophrenia was investigated. By nested RT-PCR and Western blotting, BDV-specific RNA and anti-BDV antibodies were examined in blood from 67 schizophrenic patients (DSM-III-R) in Japan, and the psychometric properties of the Positive and Negative Syndrome Scale (PANSS) were analyzed. There were significant (p < 0.05) differences in the composite index denoting the positive minus negative difference indicating a dominant contribution by negative items, and the proportion of negative type (positive minus negative value below zero) patients, between patients positive and negative for anti-BDV p24 antibodies. It is possible that BDV infection with induction of BDV p24 antibodies may be associated with negative syndromes in schizophrenic patients.

Role of beta 1 integrins in human endometrium and decidua during implantation

The present study was undertaken to investigate the expression and function of beta 1 integrins in human endometrium and decidua. Fluorescence-activated flow cytometry demonstrated the greater expression of the beta 1, alpha 1, alpha 2, and alpha 5 subunits of the beta 1 integrin family in cultured stromal cells from the midsecretory phase than in those of the early proliferative phase. The addition of estradiol (E2) and progesterone (P) to cultured stromal cells in the early proliferative phase increased the expression of beta 1 integrins in vitro. The immunohistochemical distribution of beta 1 integrins demonstrated predominantly glandular epithelial staining in the proliferative phase, and stromal and glandular staining in the midsecretory phase. Flow cytometry also demonstrated the expression of beta 1, alpha 1, alpha 2, alpha 3, alpha 5, and alpha 6 subunits of beta 1 integrin family in cultured decidual cells. Immunohistochemistry confirmed the beta 1 integrin cell surface phenotypes in cultured decidual cells observed by flow cytometry. In the subsequent experiment, the effects of antibodies against specific beta 1 integrin heterodimers on mouse embryo attachment and spreading were tested to identify the role of beta 1 integrins in early implantation. We developed assays for the attachment of mouse embryos and for trophoblastic spreading on cultured human decidual cells. The addition of antibodies directed against beta 1 and alpha integrin subunits to cultured decidual cells did not affect the rates of hatching or attachment of the blastocysts, whereas the outgrowth of embryos on the decidual cells was inhibited by their antibodies in a dose-dependent manner. Thus, beta 1 integrin in human endometrium and decidua may be important in mediating the organization of extracelllar matrix proteins derived from embryos during the early stage of implantation.

CYP2D6 HhaI genotype and the neuroleptic malignant syndrome

To investigate the relationship between CYP2D6 genotypes (reported to be associated with the susceptibilities to Parkinson's disease and multisystem atrophy) and the possible susceptibility to neuroleptic malignant syndrome (NMS) and subacute myelo-optico-neuropathy (SMON), we analyzed the CYP2D6 gene by polymerase chain reaction and restriction fragment length polymorphism in Japanese schizophrenia patients with a history of NMS. There was no significant difference in the frequency of the poor metabolizer genotype of CYP2D6 between the cases with a history of NMS and controls (p > 0.05). The frequency of the mutation located at the HhaI site in exon 6 of CYP2D6 in the cases was higher, but not significantly (p > 0.05; the mutated allele frequency was 0.25), than that in the controls, schizophrenia patients without NMS (0.11) and healthy controls (0.09). The frequency (0.10) of the HhaI mutation type in patients with a diagnosis of SMON was also not significantly higher than in healthy controls. These results suggest that the poor metabolizer and HhaI polymorphism of CYP2D6 may not be a useful molecular marker for predicting the onset of NMS and SMON.

The human serotonin receptor gene (HTR2) MspI polymorphism in Japanese schizophrenic and alcoholic patients

Epidemiological and genetic studies of alcoholism and schizophrenia have been performed, and in this study, the human serotonin receptor (HTR2) polymorphism was examined in 75 alcoholics and 31 schizophrenic patients. We found that there might not be a significant difference between these psychiatric disease patients and controls in the frequency of the C1/C2 HTR2 gene (MspI polymorphism). The results suggest that the human HTR2 MspI polymorphism might not be associated with a risk factor for developing alcohol dependence or susceptibility to schizophrenia. It is possible that there may be a racial difference in the frequency of the C1/C2 gene between Japanese and Caucasians. Further studies are required to determine whether or not the novel serotonin receptor polymorphism reflects the pathogenesis of alcoholism or schizophrenia.

Characteristics of Japanese alcoholics with inactive aldehyde dehydrogenase: clinical features of alcoholics with ALDH2*2

Abstract In a person with inactive ALDH2 (ALDH2*2) the blood aldehyde concentration tends to rise faster and higher and there are flushing responses which are considered to be a restraint against excessive alcohol drinking. The subjects in this study comprised 71 Japanese alcoholics. Psychiatrists interviewed the patients concerning the clinical features. Alcoholics homozygous (n = 59) for ALDH2*1/ALDH2*1 (Group I) and those heterozygous (n = 12) for ALDH2*1/ALDH2*2 (Group II) were compared. Group II alcoholics included significantly more cases of guilt or personality disorder. These findings indicate that alcoholics with the ALDH2*2 genotype showed generally typical clinical features.

[Management of coronary artery disease combined with aortic stenosis: how to do with mild aortic stenosis]

A total of fourteen patients with combined operation of coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) for coronary artery disease (CAD) and aortic stenosis (AS) were reviewed to evaluate the indication of the combined operation. Preoperative pressure gradient across the valve and effective orifice area were 21-89 mmHg (mean 64 mmHg), 0.5-1.9 cm2 (mean 0.92 cm2), respectively. The extent of CAD was 1-3 (mean 2.0). Fractional shortening (%FS) ranged from 13% to 43% with mean value of 28%. All patients underwent CABG and AVR. The number of grafts was 1-4 (mean 2.3) with internal thoracic artery used in 7 cases. Mechanical valves were employed for all patients except 1 case with cerebral aneurysm. There was no operative death, although low output syndrome developed in 2 cases. One had poor left ventricular function preoperatively, and the other was emergency case. Fractional shortening improved postoperatively even in two cases with preoperative %FS less than 20%, and all grafts were patent on postoperative coronary angiography. The event-free survival was 100% during 32 months of mean follow-up. Combined AVR with CABG is recommended to avoid risky secondary operation in patients of CAD and AS, even if one of which is relatively mild, because of the fact that operative and late results of the combined surgery are satisfactory.

Nontransplant cardiac surgery for end-stage cardiomyopathy

OBJECTIVE

To treat end-stage cardiomyopathy, we evaluated endoventricular circular patch plasty, partial left ventriculectomy, and valvular reconstruction alone in our 2-year experience.

METHODS

Among 86 patients with heart failure evaluated between December 1996 and February 1999, 33 patients with ischemic cardiomyopathy (25 men and 8 women; mean age 61 +/- 7.8 years; New York Heart Association class 3.5 +/- 0.5) were treated with endoventricular circular patch plasty combined with coronary bypass grafting (84%) and mitral reconstruction (36%). The other 53 patients with nonischemic cardiomyopathy (45 men and 8 women; mean age 48 +/- 14.3 years, New York Heart Association class 3.7 +/- 0.5), were treated by left ventricular reduction by partial left ventriculectomy (n = 37) or patch plasty (n = 3) and valve reconstruction alone (n = 13). The first 24 patients (group I) underwent ventriculectomy with or without valve reconstruction; the more recent 29 patients (group II) underwent left ventricular reduction (n = 16) or valve reconstruction alone (n = 13) on the basis of the intraoperative echocardiographic evaluation to observe changes of wall motion and thickness during cardiopulmonary bypass.

RESULTS

Ischemic Group: Hospital mortality in elective (n = 26) and emergency (n = 7) operations was 4% and 43%, and 3 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.5 +/- 0.5 to 1.5 +/- 0.7 and from 23% +/- 7.7% to 36% +/- 8.6%, respectively. Left ventricular end-diastolic and end-systolic volume indexes decreased from 162 +/- 46 mL/m(2) to 110 +/- 39 mL/m(2) and from 130 +/- 47 mL/m(2) to 70 +/- 32 mL/m(2), respectively. Nonischemic Group: In 40 patients with left ventricular reduction, hospital mortality in elective (n = 33) and emergency (n = 7) operations was 6% and 86%, and 5 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.7 +/- 0.5 to 1.7 +/- 0.6 and from 18% +/- 6.4% to 31% +/- 5.9%. Left ventricular end-diastolic and end-systolic volume indexes decreased from 203 +/- 45 mL/m(2) to 110 +/- 37 mL/m(2) and from 164 +/- 40 mL/m(2) to 79 +/- 33 mL/m(2), respectively. In 13 patients undergoing valve reconstruction alone (12 mitral with or without tricuspid and 1 tricuspid plus left ventricular assist device), hospital mortality in elective (n = 9) and emergency (n = 4) operations was 0% and 50% with no late deaths. Mean New York Heart Association class and ejection fraction improved from 3.6 +/- 0.5 to 2.0 +/- 0.5 and from 22% +/- 6.0% to 30% +/- 14.5%, respectively. Mean left ventricular end-diastolic and end-systolic volume indexes decreased from 170 +/- 34 mL/m(2) to 150 +/- 50 mL/m(2) and from 140 +/- 38 mL/m(2) to 104 +/- 40 mL/m(2), respectively. Overall mortality decreased from 50% in group I to 10% in group II. The survival estimates at 2 years were 77% (confidence limits 57%-88%) in the ischemic group and 63% (confidence limits 47%-75%) in the nonischemic group (no significant difference). The analysis of our data showed that the factors influencing the surgical results for dilated cardiomyopathy were presence of severe mitral regurgitation, preoperative New York Heart Association functional class IV with emergency operation, and operative procedures with randomly performed partial left ventriculectomy without an intraoperative echo test.

CONCLUSION

Endoventricular circular patch plasty, partial left ventriculectomy, and solo valve reconstruction can be performed with an acceptably low risk as elective operations. The selection of operative procedures in idiopathic dilated cardiomyopathy and avoidance of emergency surgery improved operative mortality and morbidity. Among patients who survived at least 1 year, there were no late deaths up to 30 months' follow-up.

Coronary artery bypass grafting using the "Super Pulse" dynamic pulsatile cardiopulmonary bypass device in patients with cerebrovascular occlusive disease

Patients with coronary disease complicated by severe carotid or intracranial arterial stenosis underwent coronary artery bypass graft surgery (CABG) using a novel method of dynamic pulsatile cardiopulmonary bypass (Super Pulse CPB). The Super Pulse technique can maintain the systolic pressure and systolic-diastolic amplitude in such a way that they mimic the physiologic circulation. Forty-five patients (33 males and 12 females, mean age 65.1 years) with coronary disease who had a greater than 75% stenosis of the carotid or intracranial arteries were evaluated. Evaluation was performed for the following 3 groups: 8 patients with conventional pulsatile CPB (Group I), 8 patients with conventional pulsatile CPB plus intraaortic balloon pumping (Group II), and 29 patients with Super Pulse CPB. Maximum, minimum, and mean perfusion pressures during CPB were 112.7, 53.6, and 76.9 mmHg (integrated mean), respectively, in Group III. The systolic-diastolic amplitude was significantly better than for Group I and similar to baseline pressures. No patients in Group II or Group III developed perioperative cerebral disorders or myocardial infarction, while in Group I perioperative cerebral disorders developed in 3 patients, myocardial infarction occurred in 2 patients, and 2 patients died during hospitalization. The initial performance of the Super Pulse CPB indicates excellent safety, and is useful for patients with co-morbid cerebral arterial disease.

Isolation of Borna disease virus from human brain tissue

Serological and molecular epidemiological studies indicate that Borna disease virus (BDV) can infect humans and is possibly associated with certain neuropsychiatric disorders. We examined brain tissue collected at autopsy from four schizophrenic patients and two healthy controls for the presence of BDV markers in 12 different brain regions. BDV RNA and antigen was detected in four brain regions of a BDV-seropositive schizophrenic patient (P2) with a very recent (2 years) onset of disease. BDV markers exhibited a regionally localized distribution. BDV RNA was found in newborn Mongolian gerbils intracranially inoculated with homogenates from BDV-positive brain regions of P2. Human oligodendroglia (OL) cells inoculated with brain homogenates from BDV-positive gerbils allowed propagation and isolation of BDVHuP2br, a human brain-derived BDV. Virus isolation was also possible by transfection of Vero cells with ribonucleoprotein complexes prepared from BDV-positive human and gerbil brain tissues. BDVHuP2br was genetically closely related to but distinct from previously reported human- and animal-derived BDV sequences.

The effects of the ALDH2*1/2, CYP2E1 C1/C2 and C/D genotypes on blood ethanol elimination

The effects of CYP2E1 genotypes on the blood ethanol and acetaldehyde levels were investigated in a pair of Japanese volunteers whose ADH2, ADH3 and ALDH2 genotypes were identical but whose CYP2E1 genotypes were different. In the same way, the effects of ALDH2 and ADH2 on the ethanol elimination kinetics were also studied. The predicting 95% confidence bounds determined on regression analysis of the data suggested that after venous injection of ethanol, the blood ethanol and acetaldehyde concentrations in a volunteer normal homozygous for ALDH2 (ALDH2*1/1) were lower than in a heterozygous one (ALDH2*1/2). Also, the blood ethanol and acetaldehyde concentrations in a volunteer with the c2 and C alleles of CYP2E1 (c1/c2 and C/D) were lower than in one without the c2 and C alleles (c1/c1 and D/D). However, there were no significant differences in the blood ethanol and acetaldehyde concentrations between volunteers with ADH2*1 (ADH2*1/1) and without ADH2*1 (ADH2*1/2).

Immunohistochemical study on acetaldehyde adducts in alcohol-fed mice

BACKGROUND

Acetaldehyde binds to some proteins, which results in Schiff base formation. It is assumed that acetaldehyde binds to the proteins after the consumption of ethanol, to form an adduct. Such acetaldehyde adducts are related to organ disease.

METHODS

We examined 8-week-old male BALB/c mice, which were given a liquid diet for 7 days. The diet consisted of vitamins, minerals, amino acids, and a 5% (v/v) ethanol solution. After the 7 days, we took tissue samples from the brain, liver, and adrenal cortex to investigate the distribution of acetaldehyde adducts. We performed immunohistochemical staining of the cerebral cortex, liver, and adrenal cortex from the mice by using antibodies against acetaldehyde adducts.

RESULTS

Our study showed that acetaldehyde adducts formed in the cerebral cortex in the early phase in alcohol-fed mice.

CONCLUSIONS

Because acetaldehyde in the liver has been shown to cause liver damage, our study suggests a relationship between acetaldehyde adducts in the brain and brain damage.

[Acetaldehyde adducts in the cerebral cortex of long-term ethanol-fed mice]

It is assumed that the acetaldehyde binds to the proteins after the consumption of ethanol to form an adduct. Such acetaldehyde adducts are related to organ diseases. We examined 8-week-old female BALB/cAJcl mice which had been on a liquid diet for six months. The alcohol-fed mice's liquid diet comprised vitamins, minerals, amino acid and a ethanol solution. The five groups of mice examined were 1.5% ethanol-fed, 2% ethanol-fed, 2.5% ethanol-fed, 3% ethanol-fed, and 3.5% ethanol-fed mice respectively. All mice fed by 2.5% or more ethanol died within a month. Tissue samples were taken from the 1.5% and 2% ethanol-fed mice to investigate the distribution of acetaldehyde adducts in various organs. We demonstrated the immunohistochemical staining of the cerebral cortex and liver from the ethanol-fed mice with antibodies against acetaldehyde adducts. In the 2% ethanol-fed mice, the protein epitope related to acetaldehyde was found in the cerebral cortex and the liver. There was a significant difference in the amount of cell degeneration between the 1.5% and 2% ethanol-fed mice. The results suggest that the neurotoxicity of ethanol starts to cause serious cell degeneration in concentrations of more than 1.5%. The neurotoxicity of ethanol in the cerebral cortex was found to be more prominent than in the liver, resulting in more cell degeneration.

Spontaneous accumulation of eosinophils and macrophages throughout the stroma of the epididymis and vas deferens in alymphoplasia (aly) mutant mice: I. A histological study

PROBLEM

The alymphoplasia (aly) mutation of mice causes the systemic absence of lymph nodes and Peyer's patches. Histopathological analysis has revealed that lymphocytes accumulate in some organs such as the salivary glands, lungs, kidneys, liver, and pancreas of homozygotes (aly/aly) but not heterozygotes (aly/ + ). However, the presence of lymphocytic accumulation in male reproductive tissues of aly/aly mice has not been reported.

METHOD OF STUDY

The male reproductive organs of homozygous aly/aly, heterozygous aly/ +, and other immunodeficient mice bred in a specific pathogen-free state were histologically investigated.

RESULTS

Testes, ductuli efferentes, prostates, coagulating glands, and seminal vesicles of homozygous aly/aly mice were free from any pathological accumulation of leukocytes. However, their epididymides and vasa deferentia exhibited massive infiltration by leukocytes, which were composed of eosinophils and macrophages. In all homozygotes examined, both eosinophils and macrophages were extensively observed throughout the stroma of the epididymis and vas deferens, but never within the epithelium or lumen of the ducts, with no parenchymal tissue damage. The accumulation of eosinophils was never found in nonreproductive organs. In aly/ + heterozygous mice and other immunodeficient mice, no pathological accumulation of leukocytes were noted.

CONCLUSIONS

The accumulation of eosinophils and macrophages is specific to the epididymides and vasa deferentia of immunodeficient aly/aly homozygotes, although the pathogenesis remains unknown.

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.

[Relationship between alcoholism and HTR2 MspI polymorphism]

We investigated the human serotonin receptor, HTR2 genotype among 73 alcoholics. We found that there might not be a significant difference between alcoholics and controls in the frequency of HTR2 C1/C2 gene (MspI polymorphism). This result suggested that the HTR2 C1/C2 gene might not be associated with the risk factor for developing alcohol dependence. Further studies are required to determine whether or not a novel serotonin receptor polymorphism reflects pathogenesis of alcoholism.

Successful pregnancy in a woman with a human seminal plasma allergy. A case report

BACKGROUND

Human seminal plasma allergy is an anaphylaxis caused by immediate hypersensitivity to human seminal plasma. The utilization of a condom is usually recommended as the primary means of preventing an allergic reaction. Infertility resulting from condom use, however, is an undesirable complication in many cases. Here we report on a successfully established pregnancy in a woman with seminal plasma allergy.

CASE

A 29-year-old, married nulligravida with a human seminal plasma allergy consulted us to conceive. She showed a positive reaction to a skin-prick test with whole semen. In order to remove the seminal plasma, the sperm were washed three times using a continuous-step density gradient centrifugation method. Artificial insemination with the washed sperm was performed without anaphylactic symptoms. After six inseminations, pregnancy was achieved, and a healthy infant was delivered.

CONCLUSION

Artificial insemination with sperm devoid of seminal plasma was very useful for establishing pregnancy in a woman with a human seminal plasma allergy.

Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction

BACKGROUND

Time limits for neuroprotection by retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) in aortic arch aneurysm repair or dissection are undergoing definition.

METHODS

Using near-infrared optical spectroscopy, changes in regional cerebrovascular oxygen saturation (rSO2) were compared between the two perfusion methods.

RESULTS

Immediately before cardiopulmonary bypass, baseline rSO2 was 63.9%+/-6.9% for the RCP and 66.1%+/-5.3% for the SCP group (no significant difference). As patients were core-cooled to 20 degrees C, rSO2 increased to 73.1%+/-8.8% and 74.1%+/-7.9% in the RCP and SCP groups, respectively. With circulatory arrest, rSO2 suddenly decreased. After starting cerebral perfusion, rSO2 returned to prearrest values in the SCP group but continued decreasing steadily in the RCP group, to levels below baseline after about 25 minutes. At the end of perfusion, rSO2 was 57.4%+/-12.2% for the RCP group and 71.7%+/-6.9% for the SCP group, and the ratio of rSO2 to baseline value was 0.89 for RCP and 1.08 for SCP despite a shorter brain perfusion time for RCP (38.8+/-18.0 versus 103.3+/-43.3 minutes). Three of 5 patients whose ratios of rSO2 to baseline at the end of brain protection were 0.7 or less had neurologic deficits.

CONCLUSIONS

Although SCP showed no clinically important time limitation, rSO2 continued to decrease with time during RCP. An rSO2 ratio less than 0.7 could represent a critical lower limit.

The Batista operation in patients with dilated cardiomyopathy

Between December 1996 and October 1998, 34 patients with nonischemic dilated cardiomyopathy (DCM) received cardiac volume reduction surgery. The patients' ages ranged from 14 to 67 years (mean = 48 years) and included 28 males and 6 females. Associated mitral regurgitation was present in 31 patients, tricuspid regurgitation in 19 patients, and aortic regurgitation in 4 patients. We performed a partial left ventriculectomy (PLV) using antegrade intermittent warm blood cardioplegia in 15 patients (group A), and in 19 patients (group B) PLV was performed using the on-pump beating heart technique. In group A, the mean aortic clamping time was 79+/-33 minutes and the total cardiopulmonary bypass time was 155+/-58 minutes. In group B the mean cardiopulmonary bypass time was 121+/-43 minutes. There were eight hospital deaths (five in group A and three in group B). Five of 10 survivors of group A required inotropic support for 13.8+/-25.3 days after the operation, while 5 of 12 survivors in group B required inotropes for 4.2+/-3.1 days. Hospital mortality was 86% in 7 emergent cases and 7% in 27 elective cases. Echocardiographic study showed that the left ventricular ejection fraction improved from a mean of 18.7% to 30.3% and the left ventricular diameter decreased from a mean of 80.2 mm to 62.3 mm after the operation. All 26 hospital survivors were followed for 1 to 20 months. Three patients died at early follow-up because of congestive heart failure, thrombosed valve, and hepatic failure, respectively. Nineteen patients were in New York Heart Association (NYHA) Class I or II and four were in NYHA Class III. In conclusion, cardiac volume reduction surgery is effective when the operative technique and proper judgment of patient selection are established, and emergent operation is avoided.

Relationship between alcoholism and CYP2E1 C/D polymorphism

The genotypes of the CYP2E1 loci of 35 alcoholic and 130 nonalcoholic (healthy controls) Japanese were investigated to determine the relationship between CYP2E1 (C/D) polymorphism and susceptibility to alcohol dependence. There was a significant (d.f. = 1, chi2 = 11.0, p < 0.001) difference in the CYP2E1 C gene frequency between alcohol dependents (0.41) and controls (0.28), suggesting that the C gene of CYP2E1 may be related to the risk of developing alcoholism in Japanese, whereas the frequency of the D gene was higher among controls than alcoholics. Healthy Japanese controls showed a significantly (d.f. = 1, chi2 = 30.1, p < 0.001) higher frequency of the C allele than Swedish healthy controls (0. 10) did.

Two-year experience of the Batista operation for non-ischemic cardiomyopathy

The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation.

Emergency percutaneous cardiopulmonary bypass support for acute myocardial infarction

We assessed the efficacy of emergency percutaneous cardiopulmonary bypass support (PCPS) in the treatment of patients with acute myocardial infarction complicated by cardiogenic shock. Emergency PCPS was instituted in 21 consecutive patients beginning in 1991. After the stabilization of the hemodynamics, coronary reperfusion was performed by means of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Of the seven patients with acute myocardial infarction involving either the left main or two-vessel territories, five survived more than 1 month, but only one patient remained alive and well after 20 months. The main cause of death for this group was low output syndrome. Four of 12 patients with acute left main trunkal occlusion in the catheter laboratory survived and showed a preserved cardiac function (mean followup 28.5 months). The main cause of death for this group was brain damage. Two patients with single-vessel territory acute myocardial infarction underwent PCPS to treat refractory ventricular fibrillation. Both patients were still alive and well at a 12-month followup. Percutaneous cardiopulmonary bypass support successfully stabilized the hemodynamics, allowing time to perform revascularization for all three groups of patients with life-threatening acute myocardial infarction. Recanalization was nevertheless unable to salvage the damaged myocardium in cases of prolonged ischemic time.

The relationship between phenytoin pharmacokinetics and the CYP2C19 genotype in Japanese epileptic patients

The relationship between the phenytoin pharmacokinetics, expressed by the mean of the Michaelis-Menten equation and the CYP2C19 genotype was investigated in 16 Japanese epileptic patients treated with phenytoin. Between genetically (S)-mephenytoin poor and extensive metabolizers, there were no differences in the Michaelis-Menten parameters. But divided into genotype groups, Vmax values were 3.9 +/- 0.4, 5.3 +/- 0.7, and 5.7 +/- 1.4 mg/kg/day for the patients with the m2 allele, with the m1 allele, and with neither the m1 or m2 allele, respectively. In the patients with the m2 allele of CYP2C19, the Vmax value was significantly lower than in those without the m2 allele. It is possible that the m2 allele of CYP2C19 may be one of the factors of slow phenytoin metabolism, and its frequency may underlie the ethnic difference in phenytoin metabolism between Japanese and white individuals.

Essential pathogenic role for endogenous interferon-gamma (IFN-gamma) during disease onset phase of murine experimental autoimmune orchitis. I. In vivo studies

We previously found that immunization of CH3/He male mice with syngeneic testicular germ cells (TGC) without the aid of any adjuvants was sufficient to induce DTH to TGC and experimental autoimmune orchitis (EAO). To evaluate the role of endogenous IFN-gamma in this model, C3H/He mice immunized subcutaneously with TGC on days 0 and 14 received a single injection of anti-murine IFN-gamma MoAb on day 15, 20 or 25. On day 45, DTH to TGC was tested, testis specimens were collected for histological examination, and blood samples collected for IFN-gamma measurement. The results showed that whilst MoAb treatment on day 15 or 25 did not influence DTH responses, EAO development, and appearance of IFN-gamma in the circulation, treatment on day 20 significantly suppressed all of them. Thus, a single injection with anti-IFN-gamma MoAb may successfully down-regulate testicular autoimmunity, provided that the treatment is given at an optimal time point during disease development.

Outcome after external decompression for massive cerebral infarction

Acute ischemic stroke involving the entire vascular distribution of a carotid or middle cerebral artery can cause massive cerebral edema. This study evaluated external decompression for the treatment of massive stroke and analyzed possible prognostic factors. Twenty-four patients with acute massive cerebral infarction, which had progressed to tentorial herniation and impending death, underwent external decompression after medical therapy failed to achieve an effective response. The neurological outcome 2 months after surgery using the Glasgow Outcome Scale was severe disability in 14 patients, vegetative state in two, and death in eight. The overall mortality was 33%. Various characteristics (age, sex, etiology, side of hemispheric infarction, pupillary asymmetry, Japan Coma Scale, distribution of infarction, hemorrhagic infarction, midline shift, tentorial herniation) were evaluated to determine the factors associated with high mortality after surgical intervention. There was no statistically significant relationship between any variable and mortality. Mortality was especially high in the patients with preoperative consciousness level of 200, anterior, middle, and posterior cerebral artery territory infarction, and stage III of tentorial herniation. Postoperatively, all patients with severe disability returned to a clear level of consciousness. Six patients with dominant hemisphere stroke had some measure of communicative skills in spite of aphasia. External decompression is a life-saving treatment for patients with massive cerebral infarction and can provide a reasonable quality of life even for those with dominant hemisphere strokes. Decompressive surgery should be considered and performed as soon as possible if computed tomography demonstrates signs of descending tentorial herniation.

[Dor operation for end-stage ischemic cardiomyopathy]

Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.

[Early result of volume reduction left ventriculoplasty (Batista operation) for dilated cardiomyopathy]

The Batista operation is intended to improve cardiac function by reducing the diameter of the left ventricle by excising of a sizable amount of the left ventricular free wall. Candidates for this operation are patients awaiting cardiac transplantation due to end-stage dilated cardiomyopathy and those unsuitable for transplantation because of age, physical or economical reasons. We performed this operation in 10 patients between December 1996 and October 1997. The baseline indication is left ventricular diastolic dimension > or = 70 mm and New York Heart Association (NYHA) class III or IV. There were eight men and two women aged from 16 to 60 years (mean 46 years). All had non-ischemic cardiomyopathy including seven idiopathic and one each of hypertrophic, arrhythmogenic right ventricular and valvular (sarcoidosis) cardiomyopathy. Eight patients were in NYHA class IV and six needed inotropic drip therapy prior to the operation. Nine patients had significant mitral regurgitation and six had tricuspid insufficiency concomitantly. Eight patients underwent mitral valve replacement and one was treated with mitral valve plasty. Six patients also had tricuspid plasty combined with partial left ventriculectomy. Eight patients survived. Mean value of left ventricular end-diastolic diameter was reduced from 77.8 mm to 59.8 mm, left ventricular end-diastolic volume index was reduced from 189.3 to 99.2 ml/m2, ejection fraction was increased from 19.0% to 33.8% and NYHA class improved from 3.8 to 1.8. Six months later, left ventricular dilatation was not noticed in four patients examined. The Batista operation offers real hope for patients with end-stage dilated cardiomyopathy, but we still have much to learn.

Clinical investigation of the relationship between Borna disease virus (BDV) infection and schizophrenia in 67 patients in Japan

The relationship between Borna disease virus (BDV) infection and schizophrenia in the clinical time course was investigated. By nested reverse-transcribed polymerase chain reaction (RT-PCR) and Western blotting, BDV-specific RNA and anti-BDV antibodies were examined in the EDTA-treated blood from 67 schizophrenic patients (according to DSM-III-R) in Japan. A significantly higher proportion (45%) of anti-BDV antibody and/or BDV RNA carriers were found among these 67 schizophrenic patients than in 26 controls (0%). There were no apparent associations of BDV infection with age, age at onset, period of hospitalization, accompanying somatic diseases, a past history of tuberculosis, a history of transfusion, a family history, or doses of psychotropic drugs. It is possible that, at least, BDV infection in schizophrenic patients may not be a nosocomial (hospital-acquired) infection, although the route of BDV infection in humans remains unidentified. More studies on the relationship between BDV infection and clinical psychosomatic features should be performed in order to elucidate the pathogenesis of schizophrenia.