Clinical care in craniofacial microsomia: a review of current management recommendations and opportunities to advance research.

Craniofacial microsomia (CFM) is a complex condition associated with microtia, mandibular hypoplasia, and preauricular tags. It is the second most common congenital facial condition treated in many craniofacial centers and requires longitudinal multidisciplinary patient care. The purpose of this article is to summarize current recommendations for clinical management and discuss opportunities to advance clinical research in CFM.

Paediatric presentation and outcome of congenital protein C deficiency in Japan.

Severe heritable protein C (PC) deficiency is quite rare, although heterozygous PROC mutation is the second leading cause of genetic predisposition to thrombosis in Japanese adults. The aim of the study was to search the optimal management, the paediatric onset and outcomes of PC deficiency were characterized in Japan. The genetic study, postmarketing survey of activated PC(aPC) concentrate (Anact(®)C) and intensive review in Japan for 20 years enabled the analysis of the disease onset, genotype, treatment and prognosis. Symptomatic PC deficiency was determined in 27 Japanese children. All but two patients presented within 16 days after birth (three prenatal and six neonatal onsets). Postnatal-onset cases had normal growth at full-term delivery. Of the 27 patients, 19 suffered intracranial thrombosis or haemorrhage (ICTH) (three foetal hydrocephalies), 16 developed purpura fulminans (PF) and 10 had both at the first presentation. ICTH preceded PF in both affected cases. Low PC activities of 18 mothers and/or 12 fathers indicated 20 inherited PC deficiencies (2 homozygotes, 11 compound heterozygotes and 7 heterozygotes) and seven unidentified causes of PC deficiency. Nine of 11 patients studied had PROC mutations. Four unrelated patients (50%) carried PC nagoya (1362delG). No PC-deficient parents had experienced thromboembolism. Of the 18 patients with aPC therapy, two died and eight evaluable survivors had neurological sequelae. This first comprehensive study of paediatric PC deficiency suggested that perinatal ICTH was the major presentation, occurring earlier than neonatal PF. PC nagoya was prevalent in paediatric, but not adult, patients in Japan. Early maternal screening and optimal PC therapy are required for newborns at risk of PC deficiency.

[Surgical repair of type A aortic dissection with severe atherosclerosis; report of a case].

We report a case of type A aortic dissection with severe atherosclerosis. An 81-year-old man with acute type A aortic dissection was referred to our hospital. Computed tomography revealed DeBakey type II dissection with severe atherosclerosis. Ascending aortic replacement was performed urgently, and an autologous pericardium strip was placed in the lumen to prevent atheroembolization and to reinforce the friable atherosclerotic intima This technique was useful for avoiding cerebral vascular accidents. The patient was discharged on the 24th operative day with no complications.

Endoscope disinfection using chlorine dioxide in an automated washer-disinfector.

Although 2% glutaraldehyde is often the first-line agent for endoscopic disinfection, its adverse reactions are common among staff and it is less effective against certain mycobacteria and spore-bearing bacteria. Chlorine dioxide is a possible alternative and an automated washer-disinfector fitted with this agent is currently available. This study was conducted to evaluate the effectiveness of chlorine dioxide in endoscopic disinfection after upper gastrointestinal examination. In vitro microbicidal properties of chlorine dioxide solutions were examined at high (600 ppm) and low (30 ppm) concentrations against various microbes including Pseudomonas aeruginosa, Helicobacter pylori, Mycobacterium avium-intracellulare and Bacillus subtilis in the presence or absence of bovine serum albumin (BSA). Immediately following endoscopic procedures and after application to the automated reprocessor incorporating chlorine dioxide at 30 ppm for 5 min, endoscopic contamination with infectious agents, blood, H. pylori ureA gene DNA and HCV-RNA was assessed by cultivation, sensitive test tape, polymerase chain reaction (PCR) and reverse transcriptase-PCR analysis, respectively. Chlorine dioxide at 30 ppm has equivalent microbicidal activity against most microbes and faster antimicrobial effects on M. avium-intracellulare and B. subtilis compared with 2% glutaraldehyde, but contamination with BSA affected the microbicidal properties of chlorine dioxide. Endoscopic contamination with microbes, blood and bacterial DNA was eliminated after application of the automated reprocessor/chlorine dioxide system. Thus, chlorine dioxide is a potential alternative to glutaraldehyde. The use of automated reprocessors with compatibility to chlorine dioxide, coupled with thorough pre-cleaning, can offer effective, faster and less problematic endoscopic disinfection.

Effects of 1,3-chelation induced by cis-diamminedichloroplatinum(II) on the stability of DNA duplexes.

Several 1,3-intra-strand cross-linked decadeoxynucleotide duplexes, modified with cis-diamminedichloroplatinum(II) (cis-DDP), and their base substitution analogues at the complementary site to the intervening base of the coordination sites, were synthesized and measured for UV-melting profiles to determine melting temperature (Tm) values. The results indicated the thermal stability of the oligonucleotide duplexes containing Pt-induced 1,3-intra-strand cross-linking did not depend on the kind of intervening base of the coordination site but rather on its complementary base. These results may explain the mutagenicity of cis-DDP from a chemical aspect.

Antithrombin therapy for severe preeclampsia: results of a double-blind, randomized, placebo-controlled trial. BI51.017 Study Group.

A double-blind, randomized, placebo-controlled trial was conducted to evaluate whether treatment with Antithrombin (AT) concentrates improved the clinical and perinatal outcome in patients with severe preeclampsia. Severe preeclamptic patients (24 to 35 weeks of gestation. Gestosis Index (GI) > or = 6 points) were randomized into two groups: 66 received AT and 67 received placebo. There were no statistical differences in the clinical profiles of the two groups. Study drugs were given intravenously once daily for 7 consecutive days. Maternal symptoms were evaluated from the difference of GI between before and after treatment, and fetal findings were evaluated from the changes of the biophysical profile score and the estimated fetal weight gain. Improvement was significantly greater in the AT group for both the GI (p = 0.020) and the estimated fetal weight gain (p = 0.029). The improvement of coagulation parameters was also evaluated. The D-dimer levels increased significantly in the placebo group (p = 0.026), but did not change in the AT group. Gestation was significantly prolonged (p = 0.007), and the number of low-birth weight infants was significantly smaller (p = 0.011) in the AT group. No adverse events related to AT were observed. It is revealed that AT concentrate therapy for preeclampsia is effective and safe, leading to an improved perinatal outcome.

A case of congenital afibrinogenemia: fibrinogen Hakata, a novel nonsense mutation of the fibrinogen gamma-chain gene.

Congenital afibrinogenemia due to a novel homozygous nonsense mutation of the fibrinogen gamma-chain gene, fibrinogen Hakata, was found in an 18-year-old Japanese girl who had received supplemental fibrinogen therapy since she was 4 months old. The plasma fibrinogen concentrations of the proband were measured as less than 10 mg/dl by a functional method and less than 17 mg/dl by an immunological method. Fibrinogen concentrations of her family were in the range of 94-164 mg/dl. The proband and her family had no other clinical symptoms. Genomic DNA of the proband and her family was isolated from leukocytes, and all exons of fibrinogen subunits and their intron/exon boundaries were analyzed. A genetic mutation, a guanine-to-thymine (G-to-T) transversion at the nucleotide position of 5860, was identified on exon 7 of the gamma-chain gene. This mutation changed the codon for the 231st residue of the gamma-chain from GAG (Glu) to TAG (stop). No other mutation was observed. Aalpha, Bbeta and gamma chains were observed in plasma of the heterozygous family members. However, only a trace amount of Aalpha chain and no gamma chain was detected in the plasma of the proband.

Effects of the antihypertensive agent, cicletanine, on noradrenaline release and vasoconstriction in perfused mesenteric artery of SHR.

1. The mechanism by which cicletanine (CIC) exerts its antihypertensive effects has not been fully elucidated. The present study was undertaken to examine the effects of in vivo and in vitro treatment with CIC on the pressor response and noradrenaline (NA) overflow during periarterial nerve stimulation (PNS) in perfused mesenteric arterial beds isolated from spontaneously hypertensive rats (SHR). 2. CIC at a dose of 50 mg kg(-1) day(-1) was administered orally to both SHR and normotensive Wistar-Kyoto rats (WKY) from the 6th to 10th week of age. At the 10th week, the isolated mesenteric arterial bed was perfused with Krebs-Henseleit buffer and changes in perfusion pressure and NA overflow during PNS were measured. 3. Chronic treatment with CIC suppressed the age-related elevation of systemic blood pressure in SHR but not in WKY. 4. The PNS (20 Hz)-induced mesenteric vasoconstrictor response and NA overflow were greater in SHR than in WKY. In the vasculature of SHR chronic treatment with CIC resulted in a significant attenuation of the vasoconstriction and the NA overflow during PNS, whereas it did not alter vasoconstrictor responses to bolus injections of KCl and phenylephrine. 5. Treatment with 30 microM CIC in vitro diminished the PNS-induced vasoconstriction and NA overflow but not the NA- and KCl-induced vasoconstriction in the vasculature of untreated SHR. 6. In the vasculature of SHR PNS-induced NA overflow was attenuated by prostaglandin E2 (0.05 microM), whereas it was augmented by the cyclo-oxygenase inhibitor diclofenac-Na (30 microM). In the presence of diclofenac, in vitro treatment with CIC did not attenuate the NA overflow during PNS. 7. The results suggest that the antihypertensive effect of CIC in SHR is partially due to the presynaptic inhibition of NA release during sympathetic nerve activation. Transjunctional inhibition of NA release by prostaglandins may contribute to the inhibitory action of CIC on NA release in the vasculature of SHR.

A novel splice acceptor site mutation of protein S gene in affected individuals with type I protein S deficiency: allelic exclusion of the mutant gene.

Sequencing studies of the protein S gene (PROS1) in a Japanese patient suffering from recurrent thrombosis revealed the following. The proband and his first daughter, but not the second daughter, were having the type I protein S (PS) deficiency due to a novel point mutation from A to G at the intronic acceptor splice site in intron 13 of the PROS1. In the affected daughter, exclusion of the aberrant allele was assessed by the BstX1 dimorphism of PROS1 at Pro626 (CCG/CCA). The reduced PS activities in the proband and his first daughter were apparently due to defective production of mRNA from the mutant allele.

Failure in the detection of aberrant mRNA from the heterozygotic splice site mutant allele for protein S in a patient with protein S deficiency.

A 29-year-old male patient with acute arterial obstruction and a medical history including thrombosis in the deep veins and pulmonary infarction presented with a reduced level of both protein S (PS) activity and free PS. Sequencing of the genomic PS gene in this patient revealed that the patient was heterozygous for the mutant PS allele, in which a nucleotide substitution occurred at the donor splice site in intron 12 (GT to GA). The patient was heterozygous for PS genes having dimorphic codons for Pro626 (CCA/CCG) and the aberrant allele in this patient was associated with the CCA form. Allelic exclusion of PS expression was demonstrated by use of Pro626 (CCA/CCG) dimorphism and only a normal mRNA sequence derived from the CCG-allele was identified in the patient. These findings suggested that the mutation at the splice site in the PS gene caused either defective production of mRNA or the gene may have produced extremely unstable RNA products, leading to reduced levels of PS activity and free PS in this patient.

Instantaneous and delayed outward currents of the bullfrog atrial muscle in Ca-free or Na-deficient conditions.

Effects of Ca-free or Na-deficient Ringer solutions on the membrane currents of the bullfrog atrial muscle were studied using the double sucrose-gap method. Instantaneous outward current (Ik1) decreased in Ca-free and increased in Na-deficient conditions. The amplitude of nominal "fully activated delayed outward current" diminished under both sets of conditions. The diminution, however, was greater in Na-deficient medium (10 mM Na) and its activation curve shifted about 13.5 mV toward a more negative potential. In Ca-free Ringer, no such shift was observed, and the activation of the delayed outward current became slower and sigmoidal while the deactivation was faster than in the control. Contrarily, in Na-deficient Ringer, the activation became faster and exponential and the deactivation was slower. The current tail was composed of two exponentially declining components, and the slower, K-accumulation-related component (Ia) was suppressed in Ca-free and the faster component (Ixs) diminished in Na-deficient media. These findings may indicate that in the atrial muscle the instantaneous outward current is modified by a Na-Ca exchange mechanisms and that the delayed outward current consists of two components, Ixs and Ia, which are susceptible to Na and Ca ions, respectively.

Interaction of adenosine and acetylcholine on the bullfrog atrium.

As adenosine has a potent stabilizing action on catecholamine stimulation in the myocardium, the mode of interaction of adenosine and acetylcholine (ACh) was studied with regard to the membrane potential, current and tension components of the bullfrog atrium, using the single or double-sucrose gap method. Adenosine (10(-4)-3 x 10(-3)M) augmented the twitch contraction in the presence of ACh(10(-9)-5 x 10(-7)M) by lengthening the duration of the action potential. The dose-tension response curve for ACh was modified by adenosine, producing a rise of the inhibitory threshold of ACh, and the modification showed a non-competitive interaction of these compounds. Under the voltage clamp, ACh-induced steady current (IACh) was inhibited by adenosine non-competitively. The known inhibition of slow inward current (Is) by ACh was enhanced by adenosine, while the delayed outward current (Ix) was markedly suppressed. Is-dependent and -independent tension components were both inhibited by adenosine, thereby suggesting a decrease in intracellular concentrations of calcium. The potent suppression of IACh and Ix induced by adenosine, however, appeared to mitigate the inhibitory action of ACh on the action potential and twitch contraction.

Antagonistic action of alpha- and beta-agonists on the bullfrog atrium.

Action of alpha- and beta-agonists on the membrane potential, current and tension components on the bullfrog atrial muscle were studied by means of the single or double sucrose-gap technique. Isoproterenol (10(-9)-10(-5) M) as well as adrenaline (10(-7)-10(-4) M) produced a dose-dependent positive inotropic effect, while methoxamine (10(-8)-10(-4) M) and phenylephrine (10(-8)-10(-3) M) with propranolol (10(-6) M) elicited a negative inotropic effect. The positive inotropic effect was accompanied by slight hyperpolarization and marked increase of over-shoot and plateau level of action potential, and the negative inotropic effect, by opposite changes. Under voltage clamp, isoproterenol and adrenaline produced enhancement of slow inward current (Is), delayed outward current (Ix) and Is-dependent phasic tension, while Is-independent tonic tension was inhibited. Contrarily, methoxamine and phenylephrine depressed these currents and elicited beta-antagonistic inotropic actions, especially when isoproterenol was present. Specific feature of alpha-agonist action in the presence of isoproterenol was an inward shift of the semi-steady I-V relationship. It is thus suggested that, in the bullfrog atrium, alpha-agonists produce a strong beta-receptor blocking action and an inward shift of the background current. A possible relationship between the latter effect and inhibition of the Na-K pump is also suggested.

Interferon activity and its characterization in the sera of patients with premalignant lesions arising in oral mucosa.

The interferon (IFN) assay of the sera from the 26 patients with premalignant lesions such as lichen planus and leukoplakia arising in oral mucosa was performed by the plaque-reduction assay with vesicular stomatitis virus in FL cells derived from human amniotic membrane. When the serum IFN activity was characterized by acid treatment, significant increase of acid-stable IFN in the patients was found as compared with those in the normal controls. The titers of gamma-like IFN defined by anti-HuIFN-alpha and anti-HuIFN-beta in the sera of patients of 50-79 years age group (n = 17, P less than 0.002) showed a highly significant increase as compared with the relevant normal controls (n = 20). All of the 26 patients were treated with topical administration of HuIFN-beta. When the correlation between prognosis of the disease and titers of serum IFN was investigated by measuring gamma-like IFN and acid-stable IFN in the sera of patients, all of 13 patients with good prognosis after the HuIFN-beta therapy showed significantly decreased levels of gamma-like IFN (P less than 0.01), whereas the serum level of acid-stable IFN after HuIFN-beta therapy showed a significant increase compared to that before the therapy (P less than 0.05). These findings indicate that the endogenous IFN system may be associated with the pathophysiology in patients with the oral mucosal lesions.

Comparison of the microbicidal activities of superoxidized and ozonated water in the disinfection of endoscopes.

The microbicidal activities of superoxidized water (electrolysed strong acid water [ESAW] or electrolysed weak acid water [EWAW]), ozonated water, 0.05% chlorhexidine and 2% glutaraldehyde were tested against seven strains of clinical micro-organism isolates. Following incubation of bacterial suspensions in ESAW and EWAW for 10 s, the number of micro-organisms was reduced below the detection limit. The microbicidal activities of ESAW and EWAW were similar to that of glutaraldehyde, and superior to ozonated water and 0.05% chlorhexidine. The microbicidal activities of ESAW, EWAW and ozonated water were markedly diminished in the presence of albumin. Microbial contamination of upper gastrointestinal endoscopes was detected after 90 endoscopic procedures, but treatment of the endoscope with ESAW, EWAW or ozonated water eradicated the microbes. These results indicate that ESAW and EWAW are effective disinfectants after mechanical cleaning of upper gastrointestinal endoscopes, and can, therefore, be used in the endoscopy unit.

[Protein S deficiency in three patients with thrombosis].

Protein S (PS) deficiency, which is caused by various factors including congenital and acquired disorders, is a risk factor for thrombophilia. We described 3 patients with different backgrounds, who all exhibited PS deficiency. The first patient was a 47-year-old woman who suffered from frequent cerebral infarctions, deep-vein thrombosis (DVT) of her lower extremities, and pulmonary thromboembolism. Her son suffered from skin necrosis due to PS deficiency and both had the same mutant allele of the PS gene. The second patient was a 50-year-old woman who experienced a cold sensation in her fingers. Her relatives had a history of cerebrovascular disease. No mutation was detected in her PS gene. The third patient was a 27-year-old man with antiphospholipid antibody. He suffered from thrombocytopenia, skin necrosis, DVT of his lower extremities, and pulmonary thromboembolism. A mutation was identified in the steroid hormone-binding globulin-like (SHBG) domain of his PS gene. Neither his parents nor siblings had a history of thrombosis. The mutations found in the first and third patients were both missense mutations in the SHBG domain that have not been reported previously. The third patient had a mutation in the site that is involved in binding to C4b-binding protein, which modifies the immune response. These three cases provide key insights into the pathophysiology of PS deficiency.

Relationship between RNA polymerase I activity and ornithine decarboxylase in rat liver tissues.

In order to examine the relationship between RNA polymerase I and ornithine decarboxylase (ODC), three lines of experiments were performed, with the following results. The glucocorticoid-induced increase of RNA polymerase I in rat liver nuclei was not abolished by administration of inhibitors of ODC synthesis and activity, namely 1,3-diaminopropane and 2-difluoromethylornithine respectively. Anti-ODC antibody did not cross-react with RNA polymerase I solubilized from rat liver nucleoli, indicating the absence of a common protein sequence in these enzymes. The ODC preparation which was treated with transglutaminase in the presence of putrescine could not stimulate the activity of RNA polymerase I in nuclei of liver and prostate. All these results suggest that the increases in ODC protein or activity are not a prerequisite to the increase in RNA polymerase I after hormonal or physiological stimuli, but rather that the increases in both enzymes are separate responses to the primary stimuli.