Intraoperative fluorescence vascular imaging using indocyanine green for assessment of transplanted kidney perfusion.

INTRODUCTION AND OBJECTIVE: Indocyanine green (ICG) emits infrared light with exposure to laser light. When intravenously injected, it binds to plasma proteins and predominantly persists in the vasculature, which is very useful for definition of the vascular network. The HyperEye Medical System (HEMS; Mizuho Ikakogyo Co., LTD, Tokyo, Japan) is a new device able to identify both near-infrared and visible rays "in situ" without needing to dim the operation room lighting. We speculated that intraoperative ICG imaging would be applicable for kidney transplantation, by providing "in situ" determination of successful vascular anastomosis. MATERIALS AND METHODS: Four patients underwent intraoperative ICG imaging following intravenous administration of 1 mL of a solution containing 0.25% ICG. After performing vascular anastomosis, the allograft was examined using the HEMS light source device. Fluorescent signals were transmitted to a digital video processor connected to a television monitor and evaluated in real time. RESULTS: In all 4 patients, intraoperative ICG imaging provided excellent resolution of blood flow at each step in real time, namely, coming from the recipient's artery to the allograft renal artery, circulating throughout the whole grafted kidney, and draining through the allograft renal vein to the recipient's vein. HEMS provides ICG fluorescence image in color, allowing surgeons to clearly discriminate the positional relationship between the target tissue and the surrounding tissue. No complications associated with ICG injection were noted. CONCLUSION: Our preliminary results indicate that HEMS is a feasible and safe ICG imaging system that helps prevent technical failure during vascular anastomosis, and also demonstrates blood supply to the grafted kidney.

Insulin-like growth factor binding protein-related protein 1 (IGFBP-rP1) has potential tumour-suppressive activity in human lung cancer.

The expression of insulin-like growth factor binding protein-related protein 1 (IGFBP-rP1) is decreased in various tumours, but the role of IGFBP-rP1 in lung cancer is not yet clear. In this study, IGFBP-rP1 expression in lung cancer cell lines was evaluated and reduced expression of IGFBP-rP1 was found. In tissue microarrays containing 138 primary tumours and 20 normal lung tissues analysed by immunohistochemistry, 58 tumours (42%) exhibited no expression of IGFBP-rP1, while all 20 normal lung tissues showed high expression. In squamous cell lung cancer, low expression of IGFBP-rP1 was significantly linked to high-grade tumours. Treatment with 5-aza-2'-deoxycytidine restored the expression of IGFBP-rP1 in three of four lung cancer cell lines. Sequencing of PCR products of sodium bisulphite-treated genomic DNA from the three lung cancer cell lines revealed a heterogeneous methylation pattern in the region of exon 1 and intron 1. Stable transfection of IGFBP-rP1 full-length cDNA into the H2170 lung cancer cell line led to increased expression of IGFBP-rP1 protein. IGFBP-rP1-positive transfectants exhibited remarkably reduced colony-forming ability in soft agar, suppression of tumour growth rate in nude mice, and increased apoptotic cell number as well as activated caspase-3 expression level. The data suggest that IGFBP-rP1 is a tumour suppressor inactivated by DNA methylation in human lung cancer.

[Bentall operation for the annuloaortic ectasia which merged liver cirrhosis and pericarditis; report of a case].

We report a case of successful aortic root replacement using a stented bioprosthetic valved conduit and pericardiectomy in a patient with liver cirrhosis and constrictive pericarditis. A 72-year-old man treated for alcoholic liver cirrhosis was referred for the aortic regurgitation and dilatation of sinus of Valsalva. He underwent Bentall operation using a stented bioprosthetic valved conduit and pericardiectomy successfully. For patients whose anticoagulation is contraindicated, aortic root replacement using valved conduit with bioprosthesis is useful option. Concomitant pericardiectomy for constrictive pericarditis may provide better long-term results.

Gene transfer of dominant-negative mutants of extracellular signal-regulated kinase and c-Jun NH2-terminal kinase prevents neointimal formation in balloon-injured rat artery.

We previously reported that extracellular signal-regulated kinase (ERK) and c-Jun NH2-terminal kinase (JNK), belonging to mitogen-activated protein kinases, are rapidly activated in balloon-injured artery. Therefore, we examined the role of these kinase activations in neointimal formation by using an in vivo gene transfer technique. We made the dominant-negative mutants of ERK (DN-ERK) and JNK (DN-JNK) to specifically inhibit endogenous ERK and JNK activation, respectively. Before balloon injury, these mutants were transfected into rat carotid artery using the hemagglutinating virus of Japan liposome method. In vivo transfection of DN-ERK and DN-JNK significantly suppressed the activation of ERK and JNK, respectively, after balloon injury, confirming successful expression of the transfected genes. Neointimal formation at 14 and 28 days after injury was prevented by gene transfer of DN-ERK or DN-JNK. Furthermore, bromodeoxyuridine labeling index and total cell-counting analysis at 7 days showed that either DN-ERK or DN-JNK remarkably suppressed smooth muscle cell (SMC) proliferation in both the intima and the media after injury. Gene transfer of wild-type ERK (W-ERK) or JNK (W-JNK) significantly enhanced neointimal hyperplasia at 14 days after injury. Furthermore, DN-ERK and DN-JNK significantly suppressed serum-induced SMC proliferation in vitro. We obtained the first evidence that in vivo gene transfer of DN-ERK or DN-JNK prevented neointimal formation in balloon-injured artery by inhibiting SMC proliferation. Thus, ERK and JNK activation triggers SMC proliferation, leading to neointimal formation. These kinases may be the new therapeutic targets for prevention of vascular diseases.

Murine and human SDF2L1 is an endoplasmic reticulum stress-inducible gene and encodes a new member of the Pmt/rt protein family.

We isolated murine and human cDNAs for SDF2L1 (stromal cell-derived factor 2-like1) and characterized the genomic structures. Northern blot analysis of the gene expression in various tissues revealed that both murine Sdf2l1 and human SDF2L1 genes are expressed ubiquitously, with particularly high expression in the testis. The SDF2L1 protein has an endoplasmic reticulum (ER)-retention-like motif, HDEL, at the carboxy (C)-terminus. Interestingly, SDF2L1 protein also shows significant similarity to the central hydrophilic part of protein O-mannosyltransferase (Pmt) proteins of Saccharomyces cerevisiae, the human homologues of Pmt (POMT1 and POMT2) and Drosophila melanogaster rotated abdomen (rt) protein. In a murine hepatocellular carcinoma cell line, Sdf2l1 was strongly induced by tunicamycin and a calcium ionophore, A23187, and weakly induced by heat stress but was not induced by cycloheximide. In conclusion, SDF2L1 protein is a new member of Pmt/rt protein family and Sdf2l1 is a new ER stress-inducible gene.

Dominant negative c-jun gene transfer inhibits vascular smooth muscle cell proliferation and neointimal hyperplasia in rats.

We previously reported that activator protein-1 (AP-1), containing c-Jun, is rapidly activated in balloon-injured artery. Therefore, we examined the role of c-Jun in vascular smooth muscle cell (SMC) proliferation, by using in vitro and in vivo gene transfer techniques. (1) Serum (2%) stimulation significantly increased AP-1 DNA binding activity in aortic SMCs, followed by the increase in both 3H-thymidine incorporation and cell number. Aortic SMCs were infected with recombinant adenovirus containing TAM67, a dominant negative c-Jun lacking transactivation domain of wild c-Jun (Ad-DN-c-Jun), to specifically inhibit AP-1. Ad-DN-c-Jun significantly inhibited serum-induced SMC proliferation, by inhibiting the entrance of SMC into S phase. (2) The effect of DN-c-Jun was examined on balloon injury-induced intimal hyperplasia in rats. Before balloon injury, DN-c-Jun was transfected into rat carotid artery using the hemagglutinating virus of Japan-liposome method. In vivo transfection of DN-c-Jun significantly inhibited vascular SMC proliferation in the intima and the media and subsequently prevented intimal thickening at 14 days after balloon injury. We obtained the first evidence that DN-c-Jun gene transfer prevented vascular SMC proliferation in vitro and in vivo, and c-Jun was involved in balloon injury-induced intimal hyperplasia. Thus, AP-1 seems to be the new therapeutic target for treatment of vascular diseases.

In vivo activation of rat aortic platelet-derived growth factor and epidermal growth factor receptors by angiotensin II and hypertension.

It is unclear whether the previous in vitro evidence of a link between angiotensin II (Ang II) and growth factor receptors can apply to the in vivo situation. In this study, we examined vascular platelet-derived growth factor (PDGF) and epidermal growth factor (EGF) receptor activation in stroke-prone spontaneously hypertensive rats (SHRSP) and the role of Ang II. Tyrosyl phosphorylation of the growth factor receptors was determined by Western blot analysis coupled with immunoprecipitation. Tyrosyl phosphorylation of the aortic PDGF beta-receptor, but not the EGF receptor, was chronically increased in SHRSP with hypertension, compared with normotensive rats, being accompanied by increased extracellular signal-regulated kinase (ERK) activity. Treatment of SHRSP with ACE inhibitors (perindopril or enalapril) significantly reduced aortic PDGF beta-receptor tyrosyl phosphorylation and ERK activity, whereas treatment with hydralazine failed to reduce these activities. Therefore, these aortic changes in SHRSP were mediated by Ang II in response to vascular ACE. Ang II was infused into rats to examine the effects on aortic growth factor receptors. Chronic Ang II infusion, via the angiotensin type 1 receptor, significantly increased activation of the aortic PDGF beta-receptor but not the EGF receptor. Thus, the aortic PDGF beta-receptor, activated by ACE-mediated Ang II, seems to be responsible for vascular remodeling in hypertensive rats.

Important role of angiotensin II-mediated c-Jun NH(2)-terminal kinase activation in cardiac hypertrophy in hypertensive rats.

In vitro studies on the role of the mitogen-activated protein (MAP) kinase family (extracellular signal-regulated kinase [ERK], c-Jun NH(2)-terminal kinase [JNK], and p38) in cardiac hypertrophic response have produced confusing and contradictory results. We examined the in vivo role of the angiotensin II type 1 (AT(1)) receptor in cardiac MAP kinase activities during both the onset and development of cardiac hypertrophy in stroke-prone spontaneously hypertensive rats (SHRSP). In both the acute and chronic phases of cardiac hypertrophy in SHRSP, cardiac JNK activities were significantly increased compared with those in normotensive rats, whereas there was no prominent increase in cardiac ERK or p38 activities in SHRSP. Losartan, an AT(1) receptor antagonist, prevented the onset of cardiac hypertrophy and regressed the progression of cardiac hypertrophy in SHRSP, being accompanied by the reduction of JNK activity and activator protein-1 (AP-1) activity in SHRSP. However, in spite of the normalization of blood pressure, hydralazine did not prevent or regress cardiac hypertrophy and did not decrease JNK or AP-1 activity in SHRSP. Inversely, hydralazine significantly increased the cardiac ERK activity in SHRSP by enhancing its phosphorylation. In conclusion, we have obtained the first evidence that the AT(1) receptor is involved in the enhanced cardiac JNK activity in both the onset and development of cardiac hypertrophy of hypertensive rats. We propose that JNK is involved in AT(1) receptor-mediated cardiac hypertrophy in vivo, in part mediated by the activation of AP-1.

Fate of residual fragments after successful extracorporeal shock wave lithotripsy.

PURPOSE: The aim of the present study was to investigate the reason residual fragments from upper urinary tract calculi failed to clear after successful extracorporeal shock wave lithotripsy (ESWL). METHODS: Risk factors were analyzed in 161 patients with residual fragments (< or = 4 mm) that had remained for more than 3 months after ESWL. The factors examined in the present study were gender, a history of urolithiasis, the number, location and size of stones, hydronephrosis 3 months after ESWL and bacteriuria before ESWL. The mean follow-up period was 20.0 months (range 6-69 months). RESULTS: The overall stone-free rate was 14.3%. The stone-free rate in patients with multiple stones or hydronephrosis 3 months after ESWL was significantly lower than that in patients without these conditions (P < 0.05 and P < 0.01, respectively). The cumulative non-clearance rate in patients with hydronephrosis was significantly higher than in patients without this condition (P < 0.05). Results of Cox's proportional hazards model indicated that hydronephrosis was the most important and only significant factor for failure to clear of the seven factors investigated (P < 0.05). CONCLUSION: Hydronephrosis was most highly correlated with the fate of residual fragments after ESWL.

Hormone Refractory Prostate Cancer and Fibroblast Growth Factor Receptor.

In prostate cancer, a distinct series of alterations in the fibroblast growthfactor (FGF) family occurs during the progression from a hormone-dependent to independent state that disrupts communication between stroma and epithelium and results in autonomy of cancer cells. Changes include (i) loss of FGFR2IIIb, whichbinds stromal-derived FGF-7, which promotes growth, growth limitation and differentiation and (ii) activation of FGFR1, the expression of which is normally limited to stroma, along with activation of FGFs that act on FGFR1 in an autocrine manner. Transfection of the FGFR2IIIb isoform into hormone-independent prostate cancer cells not only causes growth inhibition, but also induces differentiation. However, introduction of FGFR1 by transfection in hormone-dependent prostate cancer cells accelerates their progression to malignancy. These results suggest distinct targets for therapy aimed at both inhibition of the malignant phenotype and restoration of homeostasis.

A case of testicular teratoma located in the opposite side of the upper abdominal wall.

We report a case of a testicular teratoma located in the opposite side of the upper abdominal wall. A 2-year-old boy presented with a non-palpable right testis and underwent right inguinal exploration for right cryptorchidism. During surgery, the tumor was found in the opposite side of the upper abdominal wall across the midline. Histological investigation of the tumor revealed a mature teratoma occurring in the intra-abdominal testis. No such case has been previously reported.

The dynamic changes of plasma tissue-type plasminogen activator level and the activity of its inhibitor during coronary vasospasm.

This study aimed to examine the dynamic changes of the fibrinolytic system during coronary vasospasm. Tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor (PAI) and fibrinopeptide A (FPA) levels were measured in the great cardiac venous and arterial blood of 9 patients with clinically and angiographically proven vasospastic angina and 11 controls. Before ergonovine provocation, although there was no difference between the above 2 groups in t-PA levels in the aorta or the great cardiac vein, the PAI level in patients with variant angina was lower than in the controls both in the aorta (4.2 +/- 3.5 IU/ml vs 10.9 +/- 5.2 IU/ml) and in the great cardiac vein (2.3 +/- 2.9 IU/ml vs. 11.9 +/- 4.9 IU/ml). During ergonovine-induced coronary vasospasm in patients with variant angina, the t-PA level in the great cardiac vein significantly increased from 3.4 +/- 0.7 ng/ml to 4.4 +/- 0.5 ng/ml (p less than 0.05), but it did not change in the aorta. The maximal dose of ergonovine (0.4 mg) induced mild diffuse coronary vasoconstriction in the controls, and this diffuse coronary vasoconstriction induced a reduction of PAI levels in the great cardiac vein from 11.9 +/- 4.9 IU/ml to 9.5 +/- 4.8 IU/ml (p less than 0.05). FPA levels in the great cardiac vein did not change during ergonovine-induced coronary vasospasm in either group. Thus, the coronary vasospasm induced the release of t-PA from endothelial cells of coronary vessels and resulted in the reduction in the PAI activity in the great cardiac vein.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoproteins are inhibitors of endothelium-dependent relaxation of rabbit aorta.

The present study was performed to investigate plasma inhibitors of endothelium-dependent relaxation other than hemoglobin and low-density lipoprotein (LDL). We purified an inhibitor that contained a protein of 28,000 Da from human plasma by ammonium sulfate precipitation and serial chromatography. NH2-terminal sequence analysis revealed the protein to be homologous with human apolipoprotein A-I (Apo A-I), a major apolipoprotein of high-density lipoprotein (HDL). Very low-density lipoprotein (VLDL), LDL, and HDL obtained from rabbit plasma reversed endothelium-dependent relaxation of rabbit aorta induced by acetylcholine (ACh) and A23187 but did not inhibit relaxations induced by nitroglycerin or nitric oxide. These inhibitory activities were lost by delipidation of lipoproteins, and there were no differences in the inhibitory activity among these three lipoproteins on the basis of phospholipid concentration. Moreover, phospholipids such as phosphatidylcholine, phosphatidylinositol, and sphingomyelin reversed relaxations by ACh and A23187. Thus all lipoproteins inhibit endothelium-dependent relaxation, and this nonspecific inhibition seems to be due to the inhibition of production or release of endothelium-derived relaxing factor by phospholipids in the lipoprotein complex.

Indications, complications, and short-term clinical outcome of percutaneous transvenous mitral commissurotomy.

Percutaneous transvenous mitral commissurotomy was performed in 106 consecutive patients. Significant symptomatic improvement was achieved in 97 patients (92%). Mean left atrial pressure decreased (from 18 +/- 8 to 11 +/- 8 mm Hg, p less than 0.00001), mean mitral diastolic pressure gradient decreased (from 12 +/- 7 to 7 +/- 6 mm Hg, p less than 0.00001), and mitral valve area increased (from 1.40 +/- 0.40 to 2.00 +/- 0.50 cm2, p less than 0.00001). Based on echocardiographic characteristics of the mitral apparatus, patients were grouped retrospectively in three categories: pliable (group 1, n = 37), semipliable (group 2, n = 59), and rigid (group 3, n = 10). Clinical success was achieved in 36 patients of group 1 (97%) and in 55 patients of group 2 (93%). Only six patients in group 3 (60%) improved symptomatically (p less than 0.001 vs. group 1, p less than 0.001 vs. group 2). The severity of mitral regurgitation increased in five patients of group 1 (14%), in 12 of group 2 (20%), and in three of group 3 (33%). Six patients had recurrent symptoms at 9 months after commissurotomy. Recurrence of symptoms was significantly more frequent in group 3 compared with the other two groups (group 1, 3%; group 2, 4%; and group 3, 50%; p less than 0.0001 vs. groups 1 and 2). Multiple regression analysis identified the previously mentioned echocardiographic characteristics of the mitral apparatus as the significant predictor for clinical outcome. Thus, percutaneous transvenous mitral commissurotomy can be considered a safe and effective treatment for patients with pliable valves. Patients with semipliable or with rigid valves should be selected for operation very carefully.

[Precordial ST-segment elevation caused by right coronary artery occlusion].

Among 57 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery, eight patients showed precordial ST-segment elevation in leads V1-3 during the procedure. The mechanism of this ST elevation was investigated reviewing the coronary angiographic findings. All patients had angina pectoris, but none had evidence of myocardial infarction. The balloon inflation time was limited to 60 sec, and 12 lead electrocardiograms were recorded every 15 sec. In the eight patients who had precordial ST-segment elevation, six had the anatomically dominant right coronary artery, and two had proportioned (balanced) left and right coronary arteries. Six patients, however, had functionally dominant left coronary arteries because of good collaterals supplying the right coronary artery from the left coronary artery. Thus, functionally, six had the dominant left coronary artery, one had proportioned coronary supply, and only one had the dominant right coronary artery. In all eight patients, the most proximal portion of the right coronary artery was occluded during PTCA, obstructing both the conus branches and the right ventricular branches. This often induced precordial ST-segment elevation in cases with the functionally dominant left or proportioned coronary artery. This ST-segment elevation seemed to represent right ventricular ischemia, as the inferior wall was protected from ischemia by good collaterals. However, precordial ST-segment elevation was rare in the functionally dominant right coronary artery even when the most proximal portion of the right coronary artery was occluded. This fact seemed due to masking of electrocardiographic manifestations of right ventricular ischemia by the dominant electrical forces of inferior wall ischemia.

[Clinical application of cefsulodin to Pseudomonas aeruginosa infections in the surgical field (author's transl)].

Cefsulodin (CFS), a new antipseudomonas cephalosporin, was clinically evaluated for treatment of the Pseudomonas aeruginosa infections in the surgical field to obtain the following results. 1. CFS was administered to total 11 cases of the surgical infections caused by P. aeruginosa, comprising of 5 cases with wound infections, 3 cases with infected burn and 1 case each with muscular abscess, decubitus and postoperative pneumonia in 0.5 approximately 1 g twice a day by intravenous bolus or drip infusion. Good clinical responses were obtained in 9 out of 11 cases (81.8%). 2. Bacteriological responses were observed in all cases. P. aeruginosa was eradicated in 9 cases and suppressed in 2 cases by CFS treatment. However, replacement of pathogens with the other organisms was observed in 6 out of 8 cases caused by P. aeruginosa only. 3. Neither objective and subjective side effects nor abnormalities of laboratory tests associated with CFS treatment were observed. 4. It can be, therefore, concluded that CFS is one of the useful drugs for treatment of the surgical infections caused by P. aeruginosa.

[Chemotherapy of peritonitis with particular reference to concentrations of sulbenicillin in human ascites (author's transl)].

Twenty-seven patients with peritonitis to whom a drain was applied were given sulbenicillin (SBPC), a broad-spectrum antibiotic, which has so little hepatic and renal toxicity that massive doses may be feasible, and examination was made as to its therapeutic effects and concentrations of the antibiotic in the ascites. Daily dosage of SBPC was 10g in two divided doses in most cases given by the intravenous infusion. Medication was continued for 3 approximately 15 days. The highest daily dosage was 20g and the largest total dosage reached 190g, but there was no adverse reaction except for one case of a slight anemia. Peritonitis complicated appendicitis, adnexitis, duodenal ulcer perforation, intestinal obstruction or trauma as its primary disease. No difference in the therapeutic effect existed among the primary diseases. The response to SBPC treatment was excellent in 8 of the 27 patients and good in 17. Two patients failed to respond to the therapy. When SBPC was given just before operation, the SBPC concentration in ascites obtained at operation was 112 microgram/ml in 2 cases. The SBPC concentrations in ascites were examined following intravenous infusion of 5g over an hour, and a peak concentration of 94.7 microgram/ml was obtained at the completion of infusion (an hour after the start of infusion), which gradually decreased thereafter. In the ascites excreted from the drain after operation, a high concentration of 12.7 approximately 90.2 microgram/ml (mean: 51.7 +/- 7.7 microgram/ml) was obtained on the day after the operation day, but the concentration was lower thereafter. The SBPC concentrations in ascites were compared as regards the sites of drainage (Winslow's foramen, ileocecum and Douglas' fold), but no particular difference was observed. The SBPC concentrations in ascites after operation were in inverse proportion to the alleviation of peritonitis. They were higher when the inflammation was severer.