Factors Affecting Steady-state Plasma Concentrations of Enantiomeric Mirtazapine and its Desmethylated Metabolites in Japanese Psychiatric Patients.

INTRODUCTION: This study evaluated the effects of the CYP2D6*10 genotype on steady-state plasma concentrations of enantiomeric mirtazapine (MIR) and N-desmethylmirtazapine (DMIR) in Japanese patients. METHODS: Subjects were 77 Japanese patients treated with racemic MIR. Steady-state plasma concentrations of MIR and DMIR enantiomers were measured using stereoselective liquid chromatography. Polymerase chain reaction was used to determine the CYP2D6 genotypes. RESULTS: After correcting for dose and body weight, smokers (n=15) had significantly lower S-(+)-MIR than nonsmokers (n=55) (15.1±17.8 vs. 23.9±17.8 ng/mL/mg/kg, Kruskal-Wallis test, p=0.034). One-way analysis of variance revealed that CYP2D6*10 homozygotes had significantly higher corrected plasma concentrations of S-(+)-MIR than the no-variant allele group (p=0.034). Multiple regression analysis revealed a significant positive correlation between the number of CYP2D6*10 alleles and corrected plasma concentrations of S-(+)-MIR. These results yielded the following final model: corrected plasma concentration of S-(+)-MIR=15.9+7.30×(number of CYP2D6*10 alleles) (R=0.279, p=0.023, coefficient of determination (R(2))=0.078). CONCLUSION: Homozygous CYP2D6*10 alleles and smoking have a significant impact on the metabolism of S-(+)-MIR in Japanese patients.

[Resection of a right ventricular diverticulum of fibrous type by off-pump cardiac surgery; report of a case].

Right ventricular diverticulum is very rare and we experienced a case of isolated right ventricular diverticulum in an adult patient The patient was an 80-year-old man and a 3-cm-diameter round mass at the apex of the heart was pointed out by screening computed tomography (CT). A small and akinetic diverticulum having a narrow communication with the right ventricle was revealed by right ventriculography. Upon surgery, a 3-cm-diameter diverticulum was found at the acute margin of the right ventricle. The diverticulum was exposed using the off-pump coronary artery bypass grafting (CABG) technique. Two mattress sutures of 4-0 Prolene with Teflon felt strips were used to close the communication between the diverticulum and the right ventricle, then, the diverticulum was resected. His postoperative course was uneventful. Pathological examination revealed the endothelial-lined wall of the diverticulum consisting of internal elastic lamina and discontinuous thin smooth muscle layer with no myocardium. This type of right ventricular diverticulum could be resected by the off-pump CABG technique.

5-fluorouracil-induced histopathological changes in the central nervous system of rat fetuses.

5-Fluorouracil (5-FU), a thymidylate synthesis inhibitor, has been well known to induce developmental anomalies in the craniofacial tissues and limb buds. Recently it was reported that microencephaly was also induced in rat neonates after 5-Fu-treatement in late phase of pregnancy (Kumar et al., 2006). In this study, pregnant rats were treated with 5-Fu (15, 30 or 50 mg/kg) on day 13 of gestation, and their fetuses were examined for histopathological changes, especially in the fetal central nervous system (CNS) at 12, 24 and 48 hours after treatment (HAT). At 12 HAT, an enhancement of pyknosis of neuronal progenitor cells and subsequent loss of dead cells were detected in the CNS in a dose-dependent manner. The severity of such histopathological changes in the CNS was most prominent in the telencephalon (middle and dorsal layers of the ventricular zone) and spinal cord (dorsal area). Pyknotic cells decreased towards 48 HAT in the brain while they increased towards 48 HAT in the spinal cord. Almost all of the nuclei of pyknotic cells were positively stained by TUNEL method and showed characteristics of apoptotic cells under electron microscopy. Therefore, these pyknotic cells were considered to be apoptotic ones. Enhanced apoptosis and reduced mitosis in neuronal progenitor cells in the telencephalon seem to be responsible for the later induction of microencephaly reported by Kumar et al. (2006).

[Nonpenetrating traumatic injury of the thoracic aorta and left subclavian artery; report of a case].

Nonpenetrating traumatic injury of the thoracic aorta and/or its major branch is usually fatal and the treatment of this condition carries extremely high risk because of associated visceral organ injuries. Accurate diagnosis have been difficult. However, recently developed multi-slice helical computed tomography (CT) is highly sensitive in early detection of precise location of injury and associating injuries of other organs. Here we report our case with combined thoracic aortic and left subclavian artery injuries, diagnosed by 3-dimensional (3-D) CT and treated successfully.

Er:YAG laser irradiation increases prostaglandin E production via the induction of cyclooxygenase-2 mRNA in human gingival fibroblasts.

BACKGROUND AND OBJECTIVES: It has been reported that both prostaglandin E2 (PGE2) and Er:YAG laser irradiation accelerate wound healing. The stimulatory action of laser seems to occur during the proliferative stage of healing by stimulation of prostaglandin E2 and cyclooxygenase-2 (COX-2), which are crucial early mediators in the natural healing process. We have then investigated the effect of Er:YAG laser irradiation on PGE2 production and COX-2 gene expression in human gingival fibroblast in vitro. MATERIAL AND METHODS: Cultured fibroblasts were exposed to low-power Er:YAG laser irradiation with an energy density of 3.37 J/cm2. The amount of PGE2 production was measured by enzyme-linked immunosorbent assay (ELISA). COX-2 mRNA level, which is a critical enzyme for PGE2 production, was analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS: Er:YAG laser significantly increased PGE2 production by human gingival fibroblasts. COX-2 mRNA, which was hardly detectable in control, increased dramatically after irradiation. COX-2 inhibitor, NS398, completely inhibited the PGE2 synthesis stimulated by Er:YAG laser irradiation. CONCLUSION: Our results showed that Er:YAG laser irradiation appears to exert its stimulative action on gingival fibroblasts proliferation through the production of PGE2 via the expression of COX-2. This should be considered as one of the important regulatory pathways to accelerate wound healing after Er:YAG laser irradiation.

Myositis in primary Sjögren's syndrome: clinical and pathological report.

Abstract To clarify the clinical features of myositis complicated with primary Sjögren's syndrome (SS), we studied 89 patients with Sjögren's syndrome (one male and 88 females; mean age 56.0 ± 15.31 years). Myositis was diagnosed from clinical findings, muscle enzymes, electromyographic findings, and muscle biopsy findings. Myositis was diagnosed in 5 of 89 SS patients (5.6%). One patient developed myositis 7 months after the onset of SS. The other four patients were diagnosed with myositis and SS simultaneously. Muscular weakness was mild and slowly progressive over 4-14 months (mean 8.4 months). All patients were able to walk without any assistance at the start of prednisolone therapy. Muscular enzymes were slightly elevated (from 1.5- to 12-fold). All patients tested negative for anti-Jo1 antibody and tested positive for antinuclear antibody. Anti-Ro(SSA) antibody was positive in 4/5 (90%); anti-La(SSB) was positive in 2/5 (40%). Although the clinical features of all patients met the criteria for polymyositis of Bohan, they responded well to small or moderate doses of prednisolone, which could be decreased without a recurrence of muscular weakness in all patients. Myositis with Sjögren's syndrome showed relatively moderate symptoms and responded well to prednisolone. A prospective follow-up of patients may provide further information.

Transfection of single-stranded hepatitis A virus RNA activates MHC class I pathway.

Although infection of single-stranded RNA viruses can enhance expression of major histocompatibility complex (MHC) class I genes, the mechanism underlying this process remains unclear. Recent studies have indicated that exposure of non-immune cells to double-stranded deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of viral origin can directly increase the expression of MHC class I and related molecules without immune cell interaction. In this report, we show that transfection of single-stranded hepatitis A virus RNA into cultured hepatocytes results in the induction of genes for MHC class I, LMP2 and transporter for antigen processing (TAP1), in addition to the generation of viral proteins. We suggest that this stimulatory effect is due to the double-stranded RNA formed during replication of single-stranded viral RNA, and involves both double-stranded, RNA-dependent protein kinase PKR and the secretion of IFNbeta.

Sexual dimorphism of apoptosis in lactotrophs induced by bromocryptine.

Interruption of lactation provokes a massive degeneration of surplus lactotrophs in the rat pituitary gland. This process was determined to be non-apoptotic in nature, and this observation raised many questions as cell death by apoptosis has been described in several tissues after withdrawal of trophic hormones. In this study we explored various experimental conditions and gathered new information leading to a comprehensive interpretation of the factors involved in the induction of apoptosis in lactotrophs. With this aim, we investigated the apoptogenic role of bromocryptine on lactotrophs in several experimental models involving male and female rats. Even though bromocryptine increased the expression of P53 in all experimental models, apoptosis was only triggered in male and ovariectomised females. In both conditions the oestrogen stimulation is low or nil, and the occurrence of apoptosis can be correlated with the appearance of atypical lactotrophs and the level of P53 expression. The existence of apoptosis was validated with the observation of DNA laddering in electrophoresis. By contrast, in intact females the majority of lactotrophs present signs of an increased prolactin secretion and no DNA fragmentation was found. Endogenous oestrogens probably prevent the deep inhibitory effect of a dopamine agonist and thus block apoptosis. Besides, the morphological analysis of regressing pituitary revealed the coexistence of lactotrophs to be an important factor responsible for tissue remodelling in functional pituitary glands undergoing apoptotic and non-apoptotic cell deaths. The non-apoptotic cell death appeared to be an important factor responsible for tissue remodelling in functional pituitary glands. The present results suggest that the occurrence of apoptosis in regressing lactotrophs caused by bromocryptine is sexually dimorphic and probably associated with the survival effect of endogenous oestrogens in intact females.

Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling.

Massive hemispheric cerebral infarction, also known as malignant infarction, is characterized by rapid clinical deterioration due to brain swelling and downward transtentorial herniation, and is associated with a mortality of 80%. Early patient selection and establishment of the optimum therapeutic modality are important to improve the outcome. Early clinical, computed tomography (CT), and angiographic characteristics were analysed to identify patients with malignant infarction and external and internal decompression was performed, with unco-parahippocampectomy if needed, and the outcomes were compared with those of conservative treatment. Thirty-four of 55 patients admitted with large cerebral infarctions due to embolism showed rapid clinical deterioration due to brain swelling and herniation. These 34 patients were treated under a diagnosis of malignant infarction by decompressive surgical treatment (19 cases) or conservative treatment (15 cases). CT showed significantly higher infarction volume in patients with malignant infarction (288 +/- 62 cm3) compared to patients with non-malignant infarction (200 + 57 cm3, P < 0.001) and angiography showed a higher incidence of recanalization of the occluded vessels in patients with malignant infarction (58%) compared to patients with non-malignant infarction (15%, P < 0.05). Discriminant analysis revealed that an infarction volume of more than 240 cm3 was predictive of malignant infarction with 76.4% accuracy. Basic clinical characteristics on admission and deterioration were not statistically different between the surgically treated and conservatively treated groups of patients with malignant infarction. The shift of midline structures was significantly improved (14 +/- 3.5 to 10 +/- 4.7 mm) after surgical treatment (P < 0.05). compared to deterioration (12 +/- 5.8 to 15 +/- 4.5 mm) after conservative treatment. The mortality was 67% in the conservative group and 16% in the surgical group. Surgical treatment significantly improved the mortality and Glasgow Outcome Scale score (P < 0.01). However, the mean Barthel Index scores of the survivors were not significantly different. An infarct volume of more than 240 cm3 on CT and angiographic recanalization of the occluded artery are predictors of fatal brain swelling after massive cerebral infarction. Decompressive surgical treatment dramatically improves the mortality of massive hemispheric infarction.

[Right ventricular outflow tract reconstruction using monocusp valved outflow patch for pulmonary atresia with ventricular septal defect: influence of the presence of major aorto-pulmonary collateral arteries].

We have preferably utilized monocusp valved outflow patch (MVOP) for right ventricular outflow tract (RVOT) reconstruction in pulmonary atresia with ventricular septal defect (PA + VSD). The purpose of this study was to evaluate the influence of the presence of major aorto-pulmonary collateral arteries (MAPCAs) on probability of MVOP reconstruction and development of RVOT restenosis in midterm. 49 patients underwent complete repair (either MVOP reconstruction or Rastelli procedure) of PA + VSD in our service. These patients were divided into 2 groups: group 1; 21 patients with MAPCAs, group 2; 28 patients without MAPCAs. There was one operative death (group 1). The probably of MVOP reconstruction was similar between group 1 and group 2 (71 vs 79%, p = 0.57, chi 2 test). Follow-up was completed for 48 survivors with the period ranged 3-108 months (mean 47 months). In group 1, one patient died suddenly at home 10 months after surgery. For 47 long-term patients, the ratio of freedom from RVOT restenosis was 72% (95% CI: 52-92%, Kaplan-Meier method) at 5 year. There was no difference between 2 groups (group 1; 73%, 95% CI: 45-100%, group 2; 74%, 95% CI: 48-99%, respectively, p = 0.85 by Log-Rank test). The presence of MAPCAs in PA + VSD was not a risk factor for either the probably of MVOP reconstruction or development of RVOT restenosis in midterm.

Enzymatic properties of de novo-type mouse DNA (cytosine-5) methyltransferases.

We have purified GST-fused recombinant mouse Dnmt3a and three isoforms of mouse Dnmt3b to near homogeneity. Dnmt3b3, an isoform of Dnmt3b, did not have DNA methylation activity. Dnmt3a, Dnmt3b1 or Dnmt3b2 showed similar activity toward poly(dG-dC)-poly(dG-dC) for measuring de novo methylation activity, and toward poly(dI-dC)-poly(dI-dC) for measuring total activity. This indicates that the enzymes are de novo-type DNA methyltransferases. The enzyme activity was inhibited by NaCl or KCl at concentrations >100 mM. The kinetic parameter, K(m)(AdoMet), for Dnmt3a, Dnmt3b1 and Dnmt3b2 was 0.4, 1.2 and 0.9 microM when poly(dI-dC)-poly(dI-dC) was used, and 0.3, 1.2 and 0.8 microM when poly(dG-dC)-poly(dG-dC) was used, respectively. The K(m)(DNA) values for Dnmt3a, Dnmt3b1 and Dnmt3b2 were 2.7, 1.3 and 1.5 microM when poly(dI-dC)-poly(dI-dC) was used, and 3.5, 1.0 and 0.9 microM when poly(dG-dC)-poly(dG-dC) was used, respectively. For the methylation specificity, Dnmt3a significantly methylated CpG >> CpA. On the other hand, Dnmt3b1 methylated CpG > CpT >/= CpA. Immuno-purified Dnmt3a, Myc-tagged and overexpressed in HEK 293T cells, methylated CpG >> CpA > CpT. Neither Dnmt3a nor Dnmt3b1 methylated the first cytosine of CpC.

Collecting duct carcinoma with long survival treated by partial nephrectomy.

A case is reported of collecting duct carcinoma of the left kidney treated with partial nephrectomy. A 57-year-old woman presented for evaluation of the left renal mass, which was detected by screening ultrasonography. A computed tomography scan and magnetic resonance imaging showed a solid mass at the upper pole of the left kidney. The renal tumor biopsy revealed a low-grade renal cell carcinoma or a tubulopapillary adenoma. Subsequently, left partial nephrectomy was performed. Microscopically, the tumor showed tubulopapillary proliferation with a fibrous capsule. Histochemically, the tumor cells reacted with lectins or antibodies against the collecting duct. Twenty-four months after partial nephrectomy, the patient is alive and has no distant metastatic lesions. We review the literature on collecting duct carcinoma, in addition to the case of partial nephrectomy.

Altered expression of growth factors and cytokines in keratoconus, bullous keratopathy and diabetic human corneas.

The purpose of this study was to identify the growth factors and cytokines present in normal and diseased corneas. Total RNA was isolated from normal and diseased corneas. cDNA was synthesized from individual corneas and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed with primers to IL-1alpha, 1IL-8, PDGF-B, BMP-2, BMP-4, IGF-I, TGF-beta2, FGF-2, and VEGF. After normalization to beta2-microglobulin, several factors were identified that were significantly different from normal. Antibodies to IGF-I, BMP-2, VEGF and TGF-beta2 were used for immunohistochemistry. A total of 93 corneas were used for this study including 31 normal, 20 keratoconus, 19 bullous keratopathy (pseudophakic and aphakic, PBK/ABK), and 23 diabetic corneas. The VEGF RNA levels were significantly decreased in the keratoconus and PBK/ABK corneas but increased in the diabetic corneas. BMP-2 gene expression was lower than normal in the PBK/ABK and diabetic corneas. IGF-I and BMP-4 RNA levels were increased in PBK/ABK. In the immunohistochemical studies, the protein patterns paralleled those found at the mRNA level. The only exception was IGF-I in diabetic corneas that showed increased staining in the epithelium and its basement membrane without a significant increase in mRNA levels. TGF-beta2 mRNA and protein levels were similar to normal in all diseased corneas. Thus, no alterations in the tested growth factors/cytokines were unique to keratoconus corneas. In contrast, PBK/ABK corneas had specific significant elevations of BMP-4 and IGF-I. Diabetic corneas were unique in their increased VEGF mRNA levels. These data suggest that while some growth factor/cytokine alterations are non-specific and can be found in multiple corneal diseases, there are others that are unique to that disease.

Effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde for decreasing risk of transmission of hepatitis C virus.

OBJECTIVES: The effectiveness of manual cleaning and disinfection of gastroendoscopes with 3% glutaraldehyde in decreasing the risk of transmission of hepatitis C virus (HCV) was examined. METHODS: Gastroendoscopes used for treatment of endoscopic esophageal variceal ligation in patients with HCV infection were manually cleaned and disinfected with 3% glutaraldehyde (n = 25), 2% glutaraldehyde (n = 17), or 0.1% benzethonium chloride (n = 25). Samples were obtained by pouring 20 ml of 0.9% NaCl solution into the biopsy-suction channel of the scope before and after cleaning and disinfection. HCV was detected with the polymerase chain reaction. RESULTS: Of the 25 scopes in 3% glutaraldehyde group, nine (36%) were positive for HCV before cleaning and disinfection, but all became negative after cleaning and disinfection; the difference was statistically significant (p < 0.01). In contrast, in 2% glutaraldehyde group and in the routine cleaning group, there were no significant differences in the number of positive samples between before and after cleaning and disinfection. CONCLUSION: Manual cleaning and disinfection of gastroscopes with 3% glutaraldehyde is useful for decreasing the risk of transmission of HCV among patients.

Cigarette smoking depletes cells spontaneously secreting Th(1) cytokines in the human airway.

Cigarette smoking may modify the immune balance in the airway since it alters the course of diseases in which immune system has an important role. This study examined whether cigarette smoking could affect the distribution of cells secreting Th(1) or Th(2) cytokines in the human airway. We utilized cytokine ELISPOT assay to detect and quantitate the frequencies of cells spontaneously secreting cytokines in bronchoalveolar lavage fluid (BALF). BALF was collected from six non-smokers and four heavy cigarette smokers without clinical airway symptoms. Cytokine ELISPOT assay was performed to quantitate cells secreting interleukin (IL-)2, IL-4 and interferon (IFN-)gamma with or without phorbor 12-myristate 13-acetate (PMA) stimulation. There were no cells spontaneously secreting IL-2 detected in all samples from smokers whereas most of non-smokers had detectable IL-2-secreting cells. The number of IFN-gamma-secreting cells was also extremely decreased in smokers. Mitogen-stimulated Th(1) cytokine-secreting cells were again significantly decreased in smokers' airways. The frequency of IL-2-secreting cells and CD4/CD8 ratio in BALF had a weak positive correlation. IL-4-secreting cells were not detected in any samples from both groups. These results show that cigarette smoking depletes Th(1) cytokine-secreting cells in the human airway. It may explain the susceptibility of smokers to certain airway disease conditions such as viral or mycobacterial infections and allergic diseases.

[Case report of systemic lupus erythematosus patient with hemophagocytic syndrome, treated with plasma exchange, with specific reference to clinical profile and serum cytokine levels].

A 42-year-old woman was diagnosed as systemic lupus erythematosus (SLE), because of the findings of polyarthritis, leukopenia, positive antinuclear antibody, and positive anti DNA antibody. She was treated with predonisolone (PSL) at 10 mg per day. She was admitted to our hospital on October 2000 because of spiking high fever, skin eruption, and lymph node swelling. Since her illness of SLE was considered to be worsening, high dose of corticosteroids were given. However, high fever persisted and liver dysfunction was developed with increased serum ferritin. Her bone marrow smear showed hemophagocytosis. We made a diagnosis of hemophagocytic syndrome (HPS) complicated by disseminated intravascular coagulation (DIC). HPS was thought to be induced by viral infection, even though causative viral infection was not detected. Her general condition worsened with persistent high fever and liver dysfunction. Plasma exchange was carried for two consecutive days, followed by cyclosporine A and lipo-dexamethasone, which improved her fever rapidly. Her general condition gradually improved. Serum levels of ferritin, soluble interleukin 2 receptor (sIL 2-R), interferon-gamma and interleukin 6 decreased associated with improvements of her clinical condition. We thought plasma exchange could be effective to decrease serum levels of cytokine, which was suggested to be the pathogenic to HPS. However serum levels of IFN-gamma and IL 6 after plasma exchange did not change in this case. Further studies are required to confirm the effects of plasma exchange for HPS.

Behaviour of a somatotroph population under a growth hormone releasing peptide treatment.

In this investigation, we studied the effects of Momany peptide (GHRP-5), on somatotroph secretory activity. Acute and chronic administration of GHRP-5 provokes a significant release of growth hormone that can be closely correlated with ultrastructural changes in somatotroph populations. After 3,5 and 7 days of GHRP-5 treatment, two somatotroph cell subpopulations coexist. One of them has an enhanced secretory activity and the other presents a quiescent appearance. Therefore, pituitary growth hormone content was not affected in the first seven days of GHRP-5 treatment. After 14 days, there was a significant depletion of growth hormone pituitary content coincident with the highest levels of serum growth hormone. These results concur with the surge of a new hyperactive somatotroph subtype characterised by numerous immature secretory granules that are discharged bypassing the maturation step. Acute and chronic treatments caused no changes in somatotroph cell density, the area immunostained for growth hormone and the levels of total mRNA for transcription factor pit-1. The results of pituitary cell cultures incubated with specific blockers for different signalling pathways demonstrated an involvement of the phospholipase C-inositol phosphate system in GHRP-5 stimulated somatotroph secretion. GHRP-5 treatment enhanced significantly the release of growth hormone, thereby eliciting ultrastructural modifications in somatotrophs that can be correlated with an increased secretory activity devoid of cell density changes.

Small choroidal melanoma with massive extraocular extension: invasion through posterior scleral emissary channels.

Massive orbital extension arising from a small posterior pole uveal melanoma is rare. A 75-year-old male followed for an asymptomatic choroidal nevus developed a two and a half month history of mild decrease in visual acuity. Upon clinical examination minimal enlargement of the tumor with surrounding serous retinal detachment was observed. Pre-operative magnetic resonance imaging disclosed massive extrascleral extension. Histopathology revealed that the tumor was composed of spindle B malignant melanoma cells. Multiple serial sections of the entire tumor area failed to demonstrate permeation through scleral lamellae. Instead, peripapillary perivascular short posterior ciliary vessel invasion was observed. This route of dissemination may explain the rapid growth and clinically undocumented behavior of small malignant melanomas at this location.