Liver support systems as perioperative care in liver transplantation-historical perspective and recent progress in Japan.

A meta-analysis of the efficacy of artificial liver support (ALS) systems for fulminant hepatic failure (FHF) by the Cochrane Hepato-Biliary Group suggested that all ALS systems previously developed are ineffective for FHF. This supports the view that the only treatment of choice for FHF is immediate liver transplantation. Plasma exchange, in combination with high-volume hemodiafiltration or high-flow continuous hemodiafiltration using large pore membranes, which was excluded from the Cochrane meta-analysis because of the lack of randomized control trials, has become a standard ALS system in Japan. This system is safe, and it efficiently removes more low and middle molecular weight toxic substances than other methods by using a large volume of buffers (more than 200 L per session), resulting in recovery from coma in patients with severe FHF comparable to an ahepatic state. These artificial liver support systems are effective tools for sustaining patients with FHF in a favorable condition until liver function recovers or liver transplantation becomes available.

Direct hemoperfusion with a cytokine-adsorbing device for the treatment of persistent or severe hypercytokinemia: a pilot study.

BACKGROUND/AIMS: Cytokine overproduction has been noted during the aggravation of clinical conditions. Countermeasures to control hypercytokinemia are therefore important in critical care. We investigated the clinical efficacy of hemoadsorption therapy using a new cytokine-adsorbing device in critically ill patients with persistent or severe hypercytokinemia. METHODS: Direct hemoperfusion using the CYT-860, a cytokine-adsorber column (CYT-860-DHP), was performed in critically ill patients with hypercytokinemia. To evaluate the efficacy of CYT-860-DHP, changes in pathological and clinical parameters were examined. RESULTS: Seven patients with hypercytokinemia and a SOFA score of > or = 5 underwent CYT-860-DHP treatment. Four patients survived 28 days after CYT-860-DHP treatment. Significant decreases in blood levels of cytokines were observed. PaO2/F(I)O2 improved significantly. CONCLUSION: The possibility that CYT-860-DHP treatment can reduce blood cytokine levels and thereby improve the general condition of patients was suggested. These findings warrant the initiation of a prospective randomized trial to evaluate the clinical efficacy of CYT-860-DHP treatment.

GABA-mediated component in the feedback response of turtle retinal cones.

The negative feedback from horizontal cells to cone photoreceptors contributes to the formation of the receptive-field surround in cone photoreceptors. Recently, studies on the modulation of voltage-gated Ca(2+) currents in cone photoreceptors have led to great progress in our understanding of the mechanism of horizontal-cone feedback. Another highly probable hypothesis is that GABA mediates this feedback. This hypothesis is supported by the facts that cone photoreceptors respond to GABA and that horizontal cells release GABA. However, GABA-mediated synaptic inputs from horizontal cells to cone photoreceptors have not been demonstrated. In the present study, we examined whether cone photoreceptors receive GABAergic inputs from horizontal cells using a slice patch technique in the turtle retina. When 1 mM of GABA was applied to the cone photoreceptors, GABA-induced currents were activated. GABA-induced currents reversed their polarity at the equilibrium potential of Cl-. The application of 30 microM of SR95531, an antagonist of GABAA receptors, alone did not produce any change in the holding currents. When 200 microM of pentobarbital was introduced to potentiate the GABAergic inputs to the cone photoreceptors, however, the inhibitory action of SR95531 on GABAergic inputs became detectable. The amplitude of the GABAergic inputs, potentiated by pentobarbital, increased when the horizontal cells were depolarized by the application of 20 microM of kainate, while the amplitude decreased when the horizontal cells were hyperpolarized by the application of 10 microM of CNQX. When the cone photoreceptors were voltage clamped at a potential at which the voltage-gated Ca(2+) current was inactive, horizontal-cone feedback was not observed. However, the horizontal-cone feedback became detectable when the GABAergic inputs to the cone photoreceptors were potentiated by pentobarbital. We concluded that the contribution of GABAergic inputs from horizontal cells to cone pedicles in the formation of the receptive-field surround in cone photoreceptors is very limited but that the modulation of voltage-gated Ca(2+) currents in cone photoreceptors is a physiologically relevant mechanism for horizontal-cone feedback.

Bony entrapment of ulnar nerve after closed forearm fracture: a case report.

We report a case of ulnar nerve palsy following forearm fracture in a 13-year-old girl. Significant anterior angulation and displacement of the ulna were noted. Operation was performed 3 months after the injury, when no recovery of numbness and claw hand deformity were demonstrated. Intra-operatively the ulnar nerve was found to be embedded between fragments of the fractured ulna, which showed lack of callus formation on the preoperative radiograph. The patient achieved complete recovery of sensory and motor functions 4 months after the surgery.

Kienböck disease treated by excisional arthroplasty with a palmaris longus tendon ball: a comparative study of cases with or without bone core.

We hypothesised that using a palmaris longus tendon ball (PLTB) with bone core (w bc) after excisional arthroplasty for Kienböck disease would maintain post-operative carpal height compared to a PLTB without bone core (w/o bc). Seventeen hands of 16 consecutive patients with Kienböck disease at Lichtman stage IIIA or IIIB were treated by replacement of the lunate with a PLTB w bc or w/o bc. We evaluated the clinical and radiological outcomes at one, three and 12 months after surgery. According to Dornan and Lichtman criteria respectively, there were no significant differences between the two groups. In the w bc group, the post-operative values of the carpal height ratio (CHR) were maintained at the same level as pre-operative values for one year, while the post-operative CHR values in the w/o bc group were significantly lower than those in the w bc group. Our results indicate that in Kienböck disease, arthroplasty using a PLTB w bc can maintain CHR at one year after surgery compared to arthroplasty using a PLTB w/o bc.

Current topics on cytokine removal technologies.

It has been widely accepted that cytokines play important roles in the development of organ failure in various pathophysiological conditions of critically ill patients. Various new technologies, including continuous renal replacement therapy, have been developed for the removal of causative humoral mediators in sepsis or other critical conditions. Nonselective blood purification technologies, such as hemofiltration and plasma exchange, are applied in cytokine removal technology. However, the more selective blood purification technologies, such as adsorption, and the combination of those technologies, should be considered in future applications. Only through a prospective randomized controlled study can it be elucidated whether or not these technologies have efficacy in the treatment of sepsis and critically ill patients with hypercytokinemia. We should join and discuss the design of future clinical trials with a standardized strategy for the evaluation of the technologies.

Isoform-dependent interaction of BRDG1 with Tec kinase.

Tec is the prototype of an emerging family of protein-tyrosine kinases. Tec and Btk, another member of this family, together participate in the development of B-cell immune system. We previously identified one of the downstream messengers for human Tec kinase, BRDG1. BRDG1 is associated with Tec and becomes tyrosine-phosphorylated in B-cells by the engagement of B-cell antigen receptor (BCR). Here we show that overexpression of BRDG1 strongly augments BCR-mediated activation of cAMP-response element binding protein (CREB) but not that of c-Jun and the promoters of c-MYC and BCL-xL genes. Furthermore, we isolated the murine orthologue of BRDG1. Three isoforms of BRDG1 are generated by alternative splicing of the message. Two of them have a deletion of 33 amino acids in a Pleckstrin homology (PH) domain of BRDG1. Both the tyrosine-phosphorylation and CREB-activating ability of BRDG1 were isoform-dependent, suggesting a role of the PH domain of BRDG1. These data have identified a novel regulatory mechanism of CREB family of transcriptional factors.

Usefulness of plasma exchange plus continuous hemodiafiltration to reduce adverse effects associated with plasma exchange in patients with acute liver failure.

OBJECTIVE: To efficiently remove middle-molecular-weight substances such as hepatic toxins and minimize adverse effects associated with plasma exchange implementation, we have performed plasma exchange slowly in combination with continuous hemodiafiltration. This study was designed to determine the usefulness of plasma exchange with continuous hemodiafiltration in reducing the adverse effects associated with implementation of plasma exchange alone. DESIGN: A retrospective clinical study. SETTING: University teaching hospital. PATIENTS: The study involved 90 patients with liver failure who had been treated with plasma exchange in our department over the past 12 yrs. We examined these patients by dividing them into two groups (48 patients treated with plasma exchange alone and 42 patients treated with plasma exchange plus continuous hemodiafiltration at the time of plasma exchange implementation). MEASUREMENTS AND MAIN RESULTS: Baseline blood Na+ concentration, HCO3- concentration, and colloid osmotic pressure were followed after implementation of plasma exchange to compare the frequency of development of three adverse effects (hypernatremia, metabolic alkalosis, and sharp decrease in colloid osmotic pressure) in the two groups. Hypernatremia was found in 26.7% of treatments in the group with plasma exchange alone and 3.3% in the group of plasma exchange plus continuous hemodiafiltration, and metabolic alkalosis was found in 30.6% of treatments in the group with plasma exchange alone and 4.9% in the group of plasma exchange plus continuous hemodiafiltration; both percentages were significantly higher in the group with plasma exchange alone (p <.001). A sharp decrease in colloid osmotic pressure occurred in 13.3% of treatments in the group with plasma exchange alone but was not observed at all in the patients treated with plasma exchange plus continuous hemodiafiltration. CONCLUSIONS: We conclude that adverse effects associated with plasma exchange for artificial liver support for liver failure can be alleviated with use of plasma exchange plus continuous hemodiafiltration instead of plasma exchange alone.

Blocking AMPA receptor desensitization prolongs spontaneous EPSC decay times and depolarizes H1 horizontal cells in carp retinal slices.

Desensitization of H1 horizontal cell (H1 HC) glutamate receptors was investigated in carp retinal slices using cyclothiazide (CTZ), an inhibitor of AMPA receptor desensitization. 100 microM CTZ depolarized H1 HCs and increased the amplitude of light responses, without any prominent changes in their kinetics. Spontaneous EPSCs (sEPSCs) in H1 HCs were observed in the presence of 2.5 mM heptanol, an uncoupling agent of gap junctions. 20 microM GYKI52466 (an AMPA receptor antagonist) blocked the sEPSCs, consistent with the sEPSCs being mediated by AMPA receptors. 100 microM cobalt suppressed the frequency of sEPSCs without changing their mean peak amplitude, suggesting that calcium-dependent transmitter release from cones was not affected by heptanol. CTZ increased the total inward charge transferred per sEPSC by increasing the sEPSC decay time constant twofold, without any significant change in their frequency and mean peak amplitude. This suggests that the depolarizing effect of CTZ on H1 HCs was due to blocking desensitization of AMPA receptors, increasing the inward current induced by glutamate released from cone synaptic terminals. The desensitization of glutamate receptors may function to extend the dynamic range of H1 HC light responses.

Activation of visual cortex in REM sleep measured by 24-channel NIRS imaging.

To visualize dreaming brain functions we studied hemodynamic changes in the visual cortex during the transition from non-rapid eye movement (NREM) to rapid eye movement (REM) sleep, using a 24-channel Near-Infrared Spectroscopy (NIRS) imaging method. Results were compared to the activation in visual cortex by visual stimulation during wakefulness. Subjects were four healthy males between 25 and 49 years of age. Five all-night polysomnographic and NIRS recordings were made. Increases in the oxygenated hemoglobin concentration in visual cortex were observed from nine of 14 REM periods. The activated areas were broader during REM sleep than during visual stimulation. These findings suggest that activation of visual cortex in REM sleep might represent dream-related brain activity.

Analysis of spontaneous EPSCs in retinal horizontal cells of the carp.

Spontaneous excitatory postsynaptic currents (sEPSCs) were recorded under Whole-cell voltage clamp from carp type 1 horizontal cells (H1 cells) uncoupled by dopamine in retinal slices. Red light steps, which hyperpolarise cones and reduce glutamate release, induced outward current responses accompanied by a suppression of sEPSCs. sEPSCs decayed exponentially with a mean time constant of 0.71+/-0.07 ms and had a reversal potential near 0 mV. Power spectral analysis of sEPSCs revealed a similar decay time constant. They were suppressed by a non-NMDA receptor antagonist, CNQX at 10 microM, and a relatively specific AMPA receptor antagonist, GYKI52466 at 20 microM. The presence of sEPSCs suggests that the release of glutamate from cone synaptic terminals is vesicular. The reduction in mean sEPSC frequency with red light was not accompanied by a significant change in the mean sEPSC conductance increase (482+/-59 pS), suggesting that a decrease in the vesicular release rate from cones does not alter the vesicular glutamate concentration (quantal contents). The results suggest that the spontaneous events in H1 cells were contributed by non-NMDA (possibly AMPA) type glutamate receptors modulated by the red cone input.

Close relationship of tissue plasminogen activator-plasminogen activator inhibitor-1 complex with multiple organ dysfunction syndrome investigated by means of the artificial pancreas.

BACKGROUND: Glucose tolerance (GT) has not been taken into consideration in investigations concerning relationships between coagulopathy and multiple organ dysfunction syndrome (MODS), and endothelial cell activation/endothelial cell injury (ECA/ECI) in septic patients, although coagulopathy is known to be influenced by blood glucose level. We investigated those relationships under strict blood glucose control and evaluation of GT with the glucose clamp method by means of the artificial pancreas in nine septic patients with glucose intolerance. The relationships between GT and blood stress related hormone levels (SRH) were also investigated. METHODS: The amount of metabolized glucose (M value), as the parameter of GT, was measured by the euglycemic hyperinsulinemic glucose clamp method, in which the blood glucose level was clamped at 80 mg/dl under a continuous insulin infusion rate of 1.12 mU/kg per min, using the artificial pancreas, STG-22. Multiple organ failure (MOF) score was calculated using the MOF criteria of Japanese Association for Critical Care Medicine. Regarding coagulopathy, the following parameters were used: disseminated intravascular coagulation (DIC) score (calculated from the DIC criteria of the Ministry of Health and Welfare of Japan) and the parameters used for calculating DIC score, protein-C, protein-S, plasminogen, antithrombin III (AT-III), plasminogen activator inhibitor-1 (PAI-1), and tissue plasminogen activator-PAI-1 (tPA-PAI-1) complex. Thrombomodulin (TM) was measured as the indicator of ECI. RESULTS: There were no significant correlations between M value and SRH, parameters indicating coagulopathy and the MOF score. The MOF score and blood TM levels were positively correlated with DIC score, thrombin-AT-III complex and tPA-PAI-1 complex, and negatively correlated with blood platelet count. CONCLUSIONS: GT was not significantly related to SRH, coagulopathy and MODS under strict blood glucose control. Hypercoagulability was closely related to MODS and ECI. Among the parameters indicating coagulopathy, tPA-PAI-1 complex, which is considered to originate from ECA, seemed to be a sensitive parameter of MODS and ECI, and might be a predictive marker of MODS. The treatment for reducing hypercoagulability and ECA/ECI were thought to be justified as one of the therapies for acutely ill septic patients.

A novel polymorphism of the brain-derived neurotrophic factor (BDNF) gene associated with late-onset Alzheimer's disease.

Several lines of evidence have suggested altered functions of the brain-derived neurotrophic factor (BDNF) in the pathogenesis of neurodegenerative diseases including Alzheimer's disease (AD). In the search for polymorphisms in the 5'-flanking and 5'-noncoding regions of the BDNF gene, we found a novel nucleotide substitution (C270T) in the noncoding region. We performed an association study between this polymorphism and AD in a Japanese sample of 170 patients with sporadic AD (51 early-onset and 119 late-onset) and 498 controls. The frequency of individuals who carried the mutated type (T270) was significantly more common in patients with late-onset AD than in controls (P = 0.00004, odds ratio: 3.8, 95% CI 1.9-7.4). However, there was no significant difference in the genotype distribution between the patients with early-onset AD and the controls, although this might be due to the small sample size of the early-onset group. Our results suggest that the C270T polymorphism of the BDNF gene or other unknown polymorphisms, which are in linkage disequilibrium, give susceptibility to late-onset AD. We obtained no evidence for the possible interactions between the BDNF and apolipoprotein E (APOE) genes, suggesting that the possible effect of the BDNF gene on the development of late-onset AD might be independent of the APOE genotype.

No evidence for an association between the Glu298Asp polymorphism of the NOS3 gene and Alzheimer's disease.

Recently a significant association of a missense mutation (Glu298Asp) of the endothelial nitric oxide synthase (NOS3) gene with late-onset Alzheimer's disease (LOAD) was reported. We tried to replicate this finding in a Japanese sample of 121 patients with LOAD, 51 with early-onset AD (EOAD), and 165 medical controls. However, the genotype and allelic distributions for the Glu298Asp polymorphism were similar for these three groups, suggesting that the Glu298Asp polymorphism of the NOS3 gene has no relevance to the development of AD in Japanese.

[A case of Klinefelter's syndrome with schizophrenia-like symptoms].

A case of Klinefelter's syndrome with schizophrenia-like symptoms is reported. He was given a diagnosis of schizophrenia at the age of 39. After being treated with medication for many years, he stopped taking them at the age of seventy-two and involuntary movements appeared in his limbs and the trunk. Upon admission to our hospital, he was experiencing delusion and psychosocial excitement. A physical examination showed him to be a thin man of 175.5 cm height, suffering from a mild degree of gynecomastia, testicular atrophy. Serum LH and FSH were both high 10.9 and 47.8 mU/ml respectively. Serum testosterone concentration was 0.2 ng/ml, much lower than the normal range (2.7-10.7 ng/ml). On the Wechsler adult intelligence scale (Revision), his total IQ was 103 (performance IQ 100, verbal IQ105). Karyotype analysis revealed an XXY pattern. Although slight auditory hallucinations remained, the delusional symptoms as well as the involuntary movements diminished after the administration of psychotrophics. Personality changes such as apathy and abulia was subsided. The psychological symptoms were very similar to these of cases in other reports of Klinefelter's syndrome associated with schizophrenia-like symptoms. Some reports about the relationships between sex hormones and schizophrenia including other psychotic disorders suggest that the X-chromosome plays an important part in the mechanism of psychosocial symptoms and in the prognosis in Klinefelter's syndrome.

Activation of the visual cortex imaged by 24-channel near-infrared spectroscopy.

Near-infrared spectroscopy (NIRS) is a noninvasive technique for continuous monitoring of the amounts of total hemoglobin (total-Hb), oxygenated hemoglobin, (oxy-Hb) and deoxygenated hemoglobin (deoxy-Hb). The purpose of the present study was to demonstrate the utility of NIRS in functional imaging of the human visual cortex. A new NIRS imaging system enabled measurements from 24 scalp locations covering a 9 cm sq area. Topographic images were obtained from interpolations of the concentration changes between measurement points. Five healthy subjects between 25 and 49 years of age were investigated. After a resting baseline period of 50 s, the subjects were exposed to a visual stimulus for 20 s, followed by a 50 s resting period in a dimly lit, sound attenuating room. The visual stimulus was a circular, black and white, alternating checkerboard. In four of five subjects the visual cortex was the most activated area during visual stimulation. This is the first reported use of a NIRS-imaging system for assessing hemodynamic changes in the human visual cortex. The typical hemodynamic changes expected were observed; the total-Hb and oxy-Hb increased just after the start of stimulation and plateaued after 10 s of the stimulation period.

Alzheimer's disease and 5-HTTLPR polymorphism of the serotonin transporter gene: no evidence for an association.

Recently two independent research groups consistently reported a significant association between the serotonin transporter (5-HTT) gene and late-onset sporadic Alzheimer's disease (AD). They found that the "short" allele of the 5-HTT gene-linked polymorphic region (5-HTTLPR), which is associated with reduced transcriptional activity of the gene, increases the risk of developing late-onset AD. The present study tried to replicate this finding in a Japanese sample. We genotyped 41 patients with early-onset AD (<65 years), 82 with late-onset AD, and 336 controls. There was no significant difference in genotype or allele distribution between either patient group and controls in our sample, suggesting that the 5-HTTLPR does not play a major role in the pathogenesis of AD in Japanese.

Comparison of Sepsis-related Organ Failure Assessment (SOFA) score and CIS (cellular injury score) for scoring of severity for patients with multiple organ dysfunction syndrome (MODS).

OBJECTIVE: To evaluate the usefulness of cellular injury score (CIS) and Sepsis-related Organ Failure Assessment (SOFA) score for determination of the severity of multiple organ dysfunction syndrome (MODS). DESIGN: A prospective observational study. SETTING: A medical and surgical intensive care unit (ICU) of a teaching hospital. PATIENTS: Forty-seven consecutive MODS patients. MEASUREMENTS AND RESULTS: SOFA score and CIS were measured every day for 12 months for 47 MODS patients. Comparison was made of the SOFA score and CIS for usefulness in the scoring of severity of MODS in 26 survivors and 21 non-survivors. In addition, receiver operating characteristics (ROC) analysis was used to determine the usefulness of these two indexes as predictors of prognosis. No significant differences were found on admission between the survivors and non-survivors, but significant differences between the two subgroups (p < 0.001) were found in maximum value within 1 week after admission and maximum value during the course of treatment for both indexes. Analysis of changes after admission indicated that significant differences between survivors and non-survivors began to appear on day 3 of admission for both indexes; at that time SOFA score began to deteriorate in the non-survivors while CIS began to improve in the survivors. ROC analysis demonstrated that the area under the ROC curve was 0.769 for SOFA scores and 0.760 for CIS. CONCLUSIONS: Both SOFA score and CIS sequentially reflected the severity of MODS. Furthermore, they were comparable in diagnostic value as predictors of prognosis. These findings may indicate the possibility that MODS is a summation of effects of cellular injury. In addition, sequential evaluation of both SOFA score and CIS would provide a more accurate prediction of prognosis than conventional methods.

[Evaluation of severity in shock].

Shock is defined as organ failure due to the disturbance of perfusion in vital organs and various humoral mediators. Multiple organ failure (MOF) is a typical pathophysiologic condition subsequent to shock. Therefore the severity of shock should be evaluated based on the severity of organ failure. Recent advances in our understanding of the pathophysiology of shock have demonstrated that organ failure is the summation of cellular dysfunction in vital organs caused by tissue hypoxia and various humoral mediators. We have developed and clinically applied the cellular injury score (CIS) as a severity scoring system in patients with shock and resultant MOF. The CIS is derived from the scoring of three parameters of intracellular metabolism: the arterial ketone body ratio (AKBR); osmolality gap (OG); and blood lactate level. The CIS correlates well with the degree of organ failure and mortality rate in patients with MOF and accurately indicates the severity of shock in individual patients. Our results suggest that the CIS is a useful scoring system based on the pathophysiology of shock, not only to predict the outcome and evaluate the severity in patients with shock and MOF but also to predict the development of MOF subsequent to shock.