Phosphorylated neurofilament subunit NF-H as a biomarker for evaluating the severity of spinal cord injury patients, a pilot study.

STUDY DESIGN: A pilot cross-sectional study of patients with acute cervical spinal cord injury (SCI). OBJECTIVES: The precise evaluation of the severity of SCI is important for developing novel therapies. Although several biomarkers in cerebrospinal fluid have been tested, few analyses of blood samples have been reported. A novel biomarker for axonal injury, phosphorylated form of the high-molecular-weight neurofilament subunit NF-H (pNF-H), has been reported to be elevated in blood from rodent SCI model. The aim of this study is to investigate whether pNF-H values in blood can serve as a biomarker to evaluate the severity of patients with SCI. SETTING: Tokyo Metropolitan Bokutoh Hospital and National Rehabilitation Center, Japan. METHODS: This study enrolled 14 patients with acute cervical SCI. Sequential plasma samples were obtained from 6 h to 21 days after injury. Patients were classified according to American Spinal Injury Association impairment scale (AIS) at the end of the follow-up (average, 229.1 days). Plasma pNF-H values were compared between different AIS grades. RESULTS: In patients with complete SCI, pNF-H became detectable at 12 h after injury and remained elevated at 21 days after injury. There was a statistically significant difference between AIS A (complete paralysis) patients and AIS C (incomplete paralysis) patients. CONCLUSIONS: Plasma pNF-H was elevated in accordance with the severity of SCI and reflected a greater magnitude of axonal damage. Therefore, pNF-H is a potential biomarker to independently distinguish AIS A patients (complete SCI) from AIS C-E patients (incomplete SCI). However, further studies are required to evaluate its utility in predicting prognosis of patients in the incomplete category.

[Surgical strategy for critical aoritc stenosis with small aortic annulus in the elderly patients].

BACKGROUND: There are an increasing number of elderly patients with critical aortic stenosis. This study was performed to evaluate the surgical outcome of aortic valve surgery for elderly patients with aortic stenosis. METHODS: Eleven patients aged over 75 years old (mean 79.7 +/- 4.4) underwent aortic valve replacement with stented bioprosthesis from May 2001 to August 2004. All of the patients had a history of congestive heart failure, syncope, or angina pectoris with multiple medical problems including renal dysfunction, diabetes mellitus, cerebral infarction, or coronary artery disease. The New York Heart Association (NYHA) classification ranged II to IV (mean 2.8 +/- 0.7). Their logistic Euro score ranged from 2.56 to 41.61 (mean 8.6 +/- 10.9). The concomitant procedures were annular enlargement in 2 and coronary artery bypass grafting (CABG) in 3 patients. RESULTS: All patients tolerated these procedures well and were discharged except 1 patient who died from arrhythmia on the postoperative day 14. Postoperative echocardiogram after 3 months showed satisfactory decrease in peak left ventricular-aortic pressure gradient as well as left ventricular mass regression. All surviving patients are in NYHA class I. CONCLUSIONS: Aortic valve replacement provided satisfactory results for elderly patients. Surgical treatment should be considered even for the elderly patients with critical aortic stenosis under meticulous perioperative management.

Acceptors of poly(ADP-ribosylation) in differentiation inducer-treated and untreated Friend erythroleukemia cells.

Acceptors of poly(ADP-ribosylation) were identified and compared between inducer-treated and untreated Friend erythroleukemia cells. When permeabilized Friend cells were pulse labeled with 0.6 microM [32P]NAD for 1 min and labeled proteins analyzed by SDS-polyacrylamide gel electrophoresis, nucleosome core histones were found to be the primary acceptors, with an additional minor radioactive peak at a position corresponding to Mr = 170 000. Friend cells induced to differentiate by DMSO treatment showed a similar distribution of radioactivity, but with a 60% reduction in the overall level of poly(ADP-ribosylation) under identical labeling conditions. When isolated nuclei were pulse labeled with 0.6 microM [32P]NAD, radioactive peaks were not restricted mainly at the positions of core histones but widely dispersed in the area from 10 to 50 kDa with another peak at 170 kDa. Increase of NAD concentration resulted in the overall shift of peaks to higher molecular weight positions. When pulse-labeled nuclei or permeable cells were chased with 1 mM NAD, radioactive peaks migrated to positions of very high molecular weight (greater than Mr = 180 000). Remarkable suppression of poly(ADP-ribose) synthesis was observed when DMSO, hexamethylene bisacetamide, butyric acid, or hemin were used as the inducers.

[Yolk sac tumor of the anterior mediastinum and pulmonary metastases; report of a case].

A 31-year-old female was clinically diagnosed as having a anterior mediastinal yolk sac tumor because of the elevation of the AFP (17,500 ng/ml), a large mass lesion (9 x 5 cm) in the anterior mediastinum and bilateral lung metastases. After 4 courses of chemotherapy with cisplatin (CDDP), etoposide (VP-16) and bleomycin hydrochloride (BLM), the mediastinal mass reduced in size significantly and the serum AFP level reached within normal range. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed a weak uptake in the mediastinum, accordingly the operation was performed. The tumor was completely removed and there were no viable foci of the tumor in part of the tumor. After the operation, 4 courses of chemotherapy with carboplatin (CBDCA), VP-16 and ifosfamide (IFM) were performed. She is alive without evidence of recurrence in 5 months after operation. It was noticed that the serum AFP is a useful indicator for determing the chance of operation after chemotherapy.

Autophagy in embryonic erythroid cells: its role in maturation.

Yolk sac-derived embryonic erythroid cells differentiate synchronously in the peripheral blood of Syrian hamster. The stage of differentiation on day 10 of gestation is equivalent to polychromatophilic erythroblast stage and that on day 13 is equivalent to the reticulocyte stage in adult animals. The cytoplasm of embryonic erythroid cells became scant and devoid of most organelles on day 12 of gestation. In addition, there were very few non-erythroid cells in circulation before day 13. Thus the embryonic erythroid cells serve a pure and synchronous system to study the mechanisms of terminal differentiation. The number of mitochondria in the embryonic erythroid cells decreased to about 10% of the initial number during the period between day 10 and day 12 of gestation. In contrast, the frequency of autophagy of mitochondria increased 4.6-fold in the same period. The cytochrome c content of the cell decreased as the mitochondria became extinct. However, release of cytochrome c into the cytoplasm was not detectable through day 10-13 of gestation, suggesting that the mitochondria were digested within a closed compartment. Decomposed mitochondria and ferritin particles were detected in lysosomes by electron microscopy on and after day 12 of gestation, which also suggested digestion in a closed compartment. Mitochondrial ATP synthase subunit c, which is known to be a protease-refractory protein, was retained in the cells even after the disappearance of mitochondria, indicating that most of the mitochondria were not extruded from the cells. The digestion of mitochondria in autolysosomes may allow the cells to escape from rapid apoptotic cell death through concomitant removal of mitochondrial death-promoting factors such as cytochrome c.

Effect of intermittent deep hypothermic circulatory arrest on brain metabolism.

The effect of intermittent systemic reperfusion during deep hypothermic circulatory arrest was investigated in dogs to learn how the total arrest period may be prolonged. The animals were cooled on cardiopulmonary bypass to 18 degrees C and divided into the following three experimental groups: group I (n = 7), 60 minutes of uninterrupted circulatory arrest; group II (n = 7), 120 minutes of circulatory arrest with 10 minutes of intermittent systemic perfusion every 30 minutes during the arrest period; group III (n = 7), 120 minutes of circulatory arrest with 10 minutes of intermittent systemic perfusion every 20 minutes during the arrest period. Cerebral oxygen extraction rate increased significantly during the arrest periods (p < 0.05) and returned to normal after each 10-minute period of systemic reperfusion in every group. During circulatory arrest, cerebral excess lactate increased in a time-dependent manner after 20 minutes (r = 0.78; p < 0.001). Anaerobic metabolism did not increase throughout the circulatory arrest period in group III, although it increased significantly in groups I and II (p < 0.05). The present data demonstrate that cerebral energy metabolism becomes predominantly anaerobic within the first 20 minutes of deep hypothermic circulatory arrest. The present findings suggest that intermittent systemic recirculation for brief 10-minute periods every 20 minutes during circulatory arrest should prevent cerebral anaerobic metabolism during long periods of arrest that are required to complete complicated surgical repairs.

Leukocyte and platelet depletion with a blood cell separator: effects on lung injury after cardiac surgery with cardiopulmonary bypass.

This study was undertaken to assess the effects of leukocyte and platelet depletion on postoperative lung injury in 42 patients who underwent heart operations. Blood was serially sampled before, during, and after cardiopulmonary bypass, and leukocyte count, platelet count, and thromboxane B2 6-keto-PGF1 alpha, leukocyte elastase, thrombin-antithrombin III complex, and D-dimer levels were determined. Postoperative respiratory function was assessed based on analyses of oxygenation and carbon dioxide elimination. Leukocyte and platelet depletion was performed in 21 patients (experimental group) but not in another (control group). In the experimental group, leukocytes and platelets were removed continuously by means of the blood cell separator CS-3000, beginning immediately after the start of the operation and ending 1 hour after the release of aortic occlusion. Leukocyte elastase, thromboxane B2, ratio of thromboxane B2 to 6-keto-PGF1 alpha, thrombin-antithrombin III complex, and D-dimer were significantly lower in the experimental group than in the control group. Of the various indexes of oxygenation, arterial oxygen tension was significantly higher in the experimental group and the alveolar-arterial oxygen pressure difference and respiratory index were significantly lower in the experimental group. The positive end-expiratory pressure needed to achieve an appropriate arterial oxygen tension was significantly lower in the experimental group. The elimination of carbon dioxide was lower in the experimental group. Depletion of leukocytes and platelets reduced respiratory dysfunction after heart operations with cardiopulmonary bypass. It was particularly effective in patients with a low preoperative oxygenation capacity and in those for whom an extended period of cardiopulmonary bypass was required.

Prolongation of total permissible circulatory arrest duration by deep hypothermic intermittent circulatory arrest.

OBJECTIVE: We determined whether the duration of permissible circulatory arrest could be prolonged by deep hypothermic intermittent circulatory arrest. METHODS: Twenty-five beagles were cooled on bypass to 18 degrees C to initiate deep hypothermia that was maintained for 3 hours. Five protocols were then studied: group 1, uninterrupted bypass during hypothermia; group 2, arrest for 40 minutes during hypothermia; group 3, arrest for 60 minutes during hypothermia; group 4, arrest for 80 minutes during hypothermia; and group 5, intermittent circulatory arrest, consisting of six cycles of 20 minutes of arrest followed by 10 minutes of systemic recirculation during hypothermia (total, 120 minutes of arrest). The oxyhemoglobin concentration in the brain was measured with near infrared spectrophotometry. RESULTS: In groups 2, 3, and 4, the oxyhemoglobin concentration in the brain decreased continuously after arrest, finally reaching a plateau after 24.9 +/- 1.2 minutes. This finding suggested that the available cerebral oxyhemoglobin was depleted. In contrast, the available cerebral oxyhemoglobin was not depleted during hypothermic intermittent arrest in group 5. The mitochondrial respiratory control index was significantly lower in group 4 than in the other groups (p < 0.05). However, there were no significant differences in the respiratory control index for groups 1, 2, 3, and 5. Moreover, the formation of brain edema was significantly lower in group 5 than in the other groups (p < 0.05). CONCLUSIONS: These results indicate that deep hypothermic intermittent arrest can increase the duration of total permissible circulatory arrest and will be a useful modality when prolonged arrest is anticipated.

Butyrate-binding protein from rat and mouse liver.

A novel component which specifically binds butyrate was found in rat and mouse liver. This component, termed butyrate binding protein (BBP), is localized in the cytosolic fraction and exhibits protein characteristics, such as heat- and protease-sensitivity. The size of BBP was found to be 7.6S, while it was converted to subunits of 45,000--48,000 dalton by treatment with sodium dodecyl sulfate. The dissociation constant of the binding of BBP with butyrate was 2.22 X 10(-6) M in the standard assay. 30-Fold purification of BBP was achieved by batch-wise adsorption and elution from CM-cellulose and hydroxylapatite column chromatography. BBP is clearly distinguishable from the fatty acid-binding protein found previously on the basis of its size and binding specificity.

Poly(ADP-ribose) and differentiation of Friend Erythroleukemia cells. Restriction of the chain lenght.

1. Poly(ADP-ribose) synthesized in nuclei isolated from Friend erythroleukemic cells was characterized. Although the activity of poly(ADP-ribose) synthesis of cells induced to differentiate was suppressed to about one-third of that of uninduced cells, the chain length were identical, and were clearly restricted within a narrow band in polyacrylamide gels, moving at about half the speed of bromphenol blue. 2. The restriction of chain length was also observed in rat liver nuclei, though some poly(ADP-ribose) chains could be degraded into smaller pieces during incubation. Treatment of nuclei with a high concentration of detergent and sonication before incubation caused aberrant synthesis of poly(ADP-ribose) chains which were not restricted in size. 3. In contrast, the average chain length of the 3H-labeled portion of poly(ADP-ribose) synthesized during incubation of nuclei with 3H-NAD+ was found to be reduced to 50% of that in the induced cells. 4. Under our reaction conditions, about 95% of newly synthesized poly(ADP-ribose) was linked to non-histone nuclear proteins. The total content of the non-histones was reduced to about 50% by treatment with inducers. 5. In view of the above findings, it is suggested that the decrease of chain initiation frequency caused by the partial loss of available acceptor sites may be correlated with the suppression of poly(ADP-ribose) synthesis in induced cells.

Comparison of nuclear proteins of differentiation-induced and uninduced Friend erythroleukemia cells.

Nuclear non-histone protein content decreased to about 50% during the course of differentiation of Friend cells (Morioka, K., Tanaka K, & Ono, T. (1980) J. Biochem. 88 517-524). Judging from the patterns of Coomassie blue staining after SDS-polyacrylamide gel electrophoresis, the contents of non-histone proteins generally decreased, except for a few proteins such as IP25, while no marked change was observed in histones during differentiation.

High origin of the right coronary artery with congenital heart disease.

We encountered a case of anomalous high origin of the right coronary artery associated with ventricular septal defect and patent ductus arteriosus. The right coronary artery originated from the distal part of the ascending aorta resulting in unsuccessful induction of cardiac arrest by cardioplegia. We describe this rare case with anomalous origin of the right coronary artery.

Mitral valve repair in a patient with severe porcelain aorta.

We repaired the mitral valve in a patient with severe porcelain aorta. Significant mitral regurgitation developed in a 66-year-old woman with heavy calcification throughout the whole aorta. At operation, cardiopulmonary bypass was properly established by combined axillary and femoral arterial cannulations for sufficient systemic flow. Likewise, the combination of a superior mitral approach and profound hypothermic fibrillatory arrest in conjunction with low-flow cardiopulmonary bypass allowed us to repair the mitral valve successfully.

Effects of depletion of leukocytes and platelets on cardiac dysfunction after cardiopulmonary bypass.

BACKGROUND: This study examined the effects of the depletion of leukocytes and platelets from circulated blood on cardiac function after cardiopulmonary bypass in 37 patients who underwent coronary artery bypass grafting or aortic valve replacement. METHODS: Leukocytes and platelets were removed continuously using a blood cell separator, beginning immediately after the start of the operation and ending 1 hour after the release of the aortic cross-clamp in 19 patients (LPD group), but not in the remaining 18 patients (control group). Blood cell counts and levels of thromboxane B2, 6-keto-prostaglandin F1alpha, leukocyte elastase, complements C3a and C4a, thrombin-antithrombin III complex, and D-dimer were determined periodically during and after the operation. The cardiac index, the difference between the central and peripheral core temperatures, and the doses of catecholamines and vasodilators required to support the circulation in the early postoperative period also were assessed. RESULTS: Leukocyte and platelet counts and levels of leukocyte elastase, thromboxane B2, thromboxane2/6-ketoprostaglandin F1alpha, thrombin-antithrombin III complex, and D-dimer were significantly lower in the LPD group than in the control group before and after the release of the aortic cross-clamp and during the perioperative period. There were no significant differences in the levels of 6-keto-prostaglandin F1alpha or complements C3a and C4a between the two groups. The catecholamine dose was significantly lower in the LPD group than in the control group (1.1 +/- 2.5 versus 5.0 +/- 5.2 mg/kg, respectively). Fewer patients required the use of nitroprusside as a vasodilator in the LPD group than in the control group (1/19 versus 12/18, respectively). CONCLUSIONS: The depletion of leukocytes and platelets using a blood cell separator prevents the deterioration of cardiac function after cardiac operations using cardiopulmonary bypass.

Surgical management of aortic regurgitation associated with ventricular septal defect.

Surgical treatment for congenital aortic regurgitation (AR) with ventricular septal defect (VSD) in pediatric patients carried out between 1979 and 1994 was reviewed. Aortic commissural valvuloplasty (AVP) was performed on prolapsed cusps in 34 patients (mean age 6.3 +/- 3.3 years (range: 2 to 24 years) with AR and VSD. The preoperative grade of AR was 2.6 +/- 0.8 measured angiographically by Sellers' classification. Patients had greater than moderate AR in conjunction with subpulmonary (n = 16), perimembranous (n = 15) or mixed type VSD (n = 3). In total, 25 right coronary cusps (RCC), five non-coronary cusps (NCC) and one left coronary cusp were repaired. In two cases, both RCC and NCC were plicated. One case had bicuspid valve and both cusps were repaired. There were no operative or late deaths. Moreover, the AR grade of the 25 cases has been below mild during a mean of 11.3 years follow up, though seven cases (22%) have developed above moderate AR. The two cases with persistent AR required redo AVP, with one having aortic valve replacement eventually after redo surgery. The operative findings showed cusp perforation on the repair site, or cusp elongation. However, the overall event-free rate analyzed by the Kaplan-Meier method was sufficiently favorable, with 96.6 +/- 3.4% for 5 years and 92.8 +/- 4.9% for 10 years. We conclude that aortic valvuloplasty for aortic regurgitation and VSD in pediatric patients is beneficial, with low mortality and reoperation rates.

Mid-term results of mitral valve replacement combined with chordae tendineae replacement in patients with mitral stenosis.

BACKGROUND AND AIMS OF THE STUDY: Although many studies have found that preservation of the continuity between the mitral annulus and the papillary muscles during mitral valve replacement improves postoperative left ventricular performance in patients with mitral regurgitation, much less research has been done in this respect in patients with mitral stenosis. We reviewed our experience with mitral valve replacement combined with chordae tendineae replacement in 29 patients with mitral disease, 26 of whom had mitral stenosis. METHODS: During mitral valve replacement, continuity between the papillary muscle and annulus was restored with expanded polytetrafluoroethylene (ePTFE) mattress sutures, which were threaded into the compact portion of each papillary muscle and placed at the 2, 4, 8 and 10 o'clock positions in the mitral annulus. Postoperatively, the patients were followed by echocardiographic assessment and exercise (stress) radionuclide angiography testing. The stress test results were compared with those in patients who had undergone traditional mitral valve replacement, and also those in normal people. RESULTS: There were no hospital deaths, complications, or cardiac deaths or events during a median follow up of two-and-a-half years. Echocardiography showed no postoperative cardiac dilatation. The stress tests found no significant differences between the ejection fraction in mitral stenosis patients who underwent conventional mitral valve replacement and in those who had valve replacement combined with ePTFE chordae tendineae replacement. CONCLUSIONS: A direct advantage of chordae-preserving mitral valve replacement over conventional replacement with respect to postoperative global left ventricular performance in patients with mitral valve stenosis has not been demonstrated. However, postoperative regional left ventricular contraction in patients with mitral stenosis has been observed to be better among those who have undergone the chordae-preserving procedure. Additional investigations are needed to elucidate the effects of this procedure in mitral stenosis, but we believe that the technique improves left ventricular performance and may decrease the risk of left ventricular rupture.

Remarkable growth of the internal mammary artery used for systemic-to-pulmonary artery shunt in a patient with cyanotic heart disease.

The left internal mammary artery-to-the left pulmonary artery shunt was created in a 16-year-old boy with single ventricle, severe pulmonary stenosis palliated by Glenn shunt at the age of two. Four years follow-up angiogram demonstrated a significant increase of the diameter of the left internal mammary artery from 4 to 7 mm. The internal mammary artery is a good alternative conduit for a systemic-to-pulmonary artery shunt for a cyanotic heart disease because of its growth potential.

Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery.

OBJECTIVE: To assess the value of monitoring of regional cerebral oxygen saturation (rSO2) during aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) in conjunction with profound hypothermic circulatory arrest (HCA). METHODS: The rSO2 of 12 consecutive patients was monitored non-invasively using near-infrared spectroscopy (NIRS) and the data were analyzed statistically. RESULTS: The mean duration of HCA with CRCP was 62-/+14.1 min. The mean CRCP flow rate was 226+/-163 ml/min. Surgical outcomes were favorable with only a single hospital death (8.3%). However, the rSO2 decreased gradually in all patients during HCA, even combined with CRCP, and fell to 46+/-8.7% on average. It did not change so greatly before HCA and returned finally to its initial level at the end of re-warming. Only one patient developed a permanent neurologic deficit; this patient showed the greatest decrease of rSO2 from 56% to 29% after the longest HCA of 88 min. Two parameters, End-rSO2 (the ratio of post- to pre-HCA rSO2) and delta-rSO2 (the rate of decrease from preto post-HCA rSO2) were obtained since the initial values of rSO2 before surgery differed. There were linear correlations between the CRCP flow rate and each of these two parameters. A multiple regression analysis also revealed a linear equation relating the parameters, which allowed prediction of the safe duration of HCA in different conditions of CRCP and a more favorable adjustment of the CRCP condition in each patient. CONCLUSIONS: The study suggests that the combination of HCA and CRCP has a limit of safe duration in spite of its potential usefulness for brain protection, and that rSO2 monitored by NIRS is useful in testing for adequate brain protection. It is hoped that monitoring of rSO2 can facilitate prediction of the safe duration of HCA with CRCP and a more favorable adjustment of CRCP.

Transmyocardial laser revascularization induced angiogenesis correlated with the expression of matrix metalloproteinases and platelet-derived endothelial cell growth factor.

OBJECTIVE: Transmyocardial laser revascularization (TMLR) has been widely evaluated as a treatment for ischemic myocardium. However, its mechanism remains unclear. One mechanism is angiogenesis. This study examines the relationship between TMLR and angiogenesis from the viewpoint of matrix metalloproteinases and platelet-derived endothelial cell growth factor. METHODS: The left anterior descending coronary artery (LAD) was ligated permanently in 12 beagle dogs. TMLR was accomplished in six of the 12 dogs using a carbon dioxide laser. No laser treatment was done in the six control dogs. Two weeks after the initial operation, dogs were euthanized and transmural samples (each of approximately 0.5 g) were cut from the center of the infarcted LAD territory, right ventricular wall, left circumflex artery perfuse area and interventricular septum except the LAD perfuse area. They were snap-frozen in liquid nitrogen for matrix metalloproteinases and platelet-derived endothelial cell growth factor activity analysis. Hematoxylin and eosin staining, double immunohistologic staining with anti-proliferating cell nuclear antigen and von Willebrand factor antibody, and immunohistologic staining with antibody against platelet-derived endothelial cell growth factor were performed for histologic studies. The activities of matrix metalloproteinases were examined by gelatin zymography. The activity of platelet-derived endothelial cell growth factor was examined by a spectrophotometric method. RESULTS: The channels were found to be infiltrated with granulation tissue and fibrosis. In the laser group, the active matrix metalloproteinase-2 and platelet-derived endothelial cell growth factor activity in the area of the left anterior descending coronary artery was significantly higher than in the control group (P<0.0001 and P=0.037, respectively). Within the channel remnants or close to these areas, the number of von Willebrand factor positive microvessels and proliferating cell nuclear antigen with correlating von Willebrand factor positive microvessels were significantly higher than in the control group (P=0.001 and P=0.0006, respectively). These increases in microvessels significantly correlated with the expression of matrix metalloproteinases and platelet-derived endothelial cell growth factor. CONCLUSION: Based on these findings it was concluded that transmyocardial laser revascularization induced angiogenesis correlated with the expression of active matrix metalloproteinases-2 and platelet-derived endothelial cell growth factor.

Left main bronchus compression after aortic reconstruction for interruption of aortic arch.

A case of the left main bronchus obstruction after an aortic reconstruction for interruption of the aortic arch is reported. Clinical features and successful management are described, and a mechanism for this complication is speculated on.