A retrospective observational study to assess adverse transfusion reactions of patients with and without prior transfusion history.

BACKGROUND AND OBJECTIVES: This study compares the frequency of adverse transfusion reactions (ATRs) after first transfusions with the frequency of ATRs for subsequent (non-first) transfusions. MATERIALS AND METHODS: Five hospitals agreed to systematically collect and share 2 years of data. This was a retrospective observational analysis of data including the number of transfusion episodes and ATRs for red blood cells (RBCs), fresh frozen plasma (FFP) and platelet concentrates (PCs) given to first-time transfusion recipients and to those previously transfused. RESULTS: First transfusion ATRs to RBCs, FFP and PCs were 1.08%, 2.84% and 3.34%, respectively. These are higher than ATR incidences to RBCs (0.69%), FFP (1.91%) and PCs (2.75%) on subsequent transfusions. Specifically, first transfusion incidences of febrile non-haemolytic transfusion reactions (FNHTRs) to RBCs (0.43%) and allergic reactions to FFP (2.51%) were higher than on subsequent transfusions (RBCs: 0.23%, FFP: 1.65%). CONCLUSION: There are risks of ATRs on the first transfusion as well as transfusions of patients with transfusion history.

Cardiac intervention using high-intensity focused ultrasound: creation of interatrial communication in beating heart of an anesthetized rabbit.

OBJECTIVE: Current fetal cardiac intervention for restrictive atrial septum is invasive and technically demanding. We investigated the feasibility of computer-assisted high-intensity focused ultrasound (HIFU) for cardiac intervention on the atrial septum of a beating heart. METHODS: To create an interatrial communication in the beating heart of nine anesthetized rabbits, the heart was exposed surgically and placed under a water-filled tank, in contact with the tank's membranous base. A HIFU transducer (3.3 MHz) coupled with a diagnostic ultrasound probe (10.0 MHz) was placed in the tank over the beating heart. The focus of the HIFU transducer was set so that it could create a hole in the target area on the atrial septum during the early diastolic phase. HIFU delivery was controlled based on ultrasound images captured with real-time image-recognition software. We attempted to create interatrial communication using HIFU and assessed the cardiac tissue specimen pathologically. RESULTS: In eight of nine rabbits, small holes in the atrial septum were successfully created. Serious complications occurred in two animals: a fatal atrioventricular block in one and a cardiac tamponade in the other. CONCLUSION: HIFU combined with a computer-assisted imaging system might be useful to create interatrial communication in beating hearts. This procedure may be helpful for making current fetal cardiac intervention less invasive.

[Ventricular assist device].

There are 2 kinds of artificial heart used for clinical patients with end-stage heart failure. One is a ventricular assist device (VAD) and the other is a total artificial heart (TAH). Only paracorporeal VADs are commercially available currently in Japan, such as Toyobo VAD and BVS 5000. Paracorporeal Zeon VAD and implantable Novacor LVAD were approved by the MHLW in the past but already disappeared from the Japanese market in 2005 and 2006. A little more than 1,000 LVADs had been implanted since 1980 in Japan until last autumn, while no TAH has been implanted in patients. In the world 1st generation pulsatile implantable LVADs have been taken over by the 2nd and 3rd generation non-pulsatile implantable LVADs in the past 10 years. In Japan 4 kinds of implantable LVADs are under clinical evaluation, HeartMate XVE (1st generation, HeartMate VE was used in the Japanese clinical trial), Jarvik 2000 (2nd generation), Evaheart (2nd generation), and DuraHeart (3rd generation). All 5 patients with HeartMate VE survived more than 1 year during the clinical trial, 13 patients with Evaheart were long survivors or successfully heart-transplanted. Although follow-up interval is relatively short, all 6 patients with DuraHeart and 5 of the 6 patients with Jarvik 2000 recovered from end-stage heart failure and are keeping very good condition. Most of them returned to their home and are waiting for heart transplantation. Especially the 3rd generation of non-pulsatile LVADs is expected to have long-term durability and less frequency of thromboembolic episode.

[Lung cancer operation in situs inversus totalis patient].

Situs inversus totalis represents a complete mirror image anatomy of the normal arrangement of the thoracic and abdominal viscera. This rare condition may pose possible surgical problems due to anatomical abnormality. There were few reports of surgical treatment for lung cancer patient with situs inversus totalis. In this case report, we describe a 74-year-old patient with situs inversus totalis and primary lung cancer who underwent successful left upper lobectomy and systemic lymph node dissection. For this rare condition, detail preoperative evaluation of mirror image anatomy with computed tomography and bronchofiber optic examination was thought to be a key to carry out safe operative procedure.

A second-generation profiling system for quantitative methylation analysis of multiple gene promoters: application to lung cancer.

Cancer-specific gene promoter methylation has been described in many types of cancers, and various semi-quantified results have shown their usefulness. Here, we show a more sensitive and specific second-generation system for profiling the DNA methylation status. This method is based on bisulfite reaction of DNA and real-time PCR using two TaqMan MGB probes labeled with different fluorescence, followed by clustering analysis. Primers were designed with CpG-less sequences, and TaqMan MGB probes were designed to contain three or four CpG sites and to be shorter than conventional TaqMan probes. We have added new criteria for primer and probe design for further specificity. We confirmed the reliability of this system and applied it to analysis of lung cancers. Using 10 promoters, 90 primary lung cancers were clustered into six groups consisting of cases having similar smoking status and pathological findings. EGFR mutation and p16 promoter DNA methylation were exclusive, as previously reported; however, DNA methylation in other genes was unrelated to EGFR mutation. This system was also useful to distinguish double primary lung cancers from a single cancer with intrapulmonary metastasis. As above, our system has widespread availability in clinical use and biological research.

[Safety measures of extracorporeal circulation by heart surgeons and perfusionists].

In the past, heart surgeons often set up the extracorporeal circulation (ECC) system, primed the circuit, and operated the ECC in Japan. As works of perfusionists recently became specialized, young Japanese heart surgeons seldom receive education on ECC, and rarely operate ECC. ECC accidents are rare, but once it occurs, even a well experienced perfusionist often becomes too upset to think of the next action, while surgeons at the operative table have little knowledge of the ECC system. Reconsideration of ECC education for heart surgeons is still rare. As a medical team, tragedies such as death and life-threatening complication due to an ECC accident are to be prevented at all costs. At an on-site training session for ECC troubles at the 59th annual meeting of Japanese Association for Thoracic Surgery, the basic ECC operations, recovering procedures after an accident, and the use of safety devices were taught to 30 teams of young heart surgeons and perfusionists as a measure to ensure safety of ECC. A questionnaire survey was conducted at the end and satisfactory results were obtained.

[Pulmonary thromboembolism after lung resection in patients with schizophrenia; report of 2 cases].

We report 2 cases of pulmonary thromboembolism after lung resection in patients with schizophrenia. The first case is a 67-year-old woman. She underwent right lower lobectomy for primary lung cancer and suddenly felt dyspnea 2 days after the operation. She was diagnosed pulmonary thromboembolism by computed tomography (CT) and lung perfusion scintigram, and recoverd soon. The second case is a 42-year-old man. He underwent partial resection of the right lung for metastatic germ cell tumor. Six days after the operation, he fell into acute respiratory failure and died in spite of resuscitation. The autopsy showed that the cause of death was pulmonary thromboembolism. Because patients with schizophrenia have high-risk of pulmonary thromboembolism, extreme care must be exercised to avoid it.

[Posterior mediastinal hemangioma successfully resected with cardiopulmonary bypass; report of a case].

Mediastinal hemangioma is a rare tumor. We report a case of a 62-year-old woman with a posterior mediastinal hemangioma. She had a history of right breast cancer and a follow-up chest radiography revealed a mass located in the left posterior mediastinum. The size was about 80 mm in diameter. The tumor surrounded the descending thoracic aorta and involved intercostal arteries. Complete excision could be achieved by decompressing the descending aorta with the aid of partial cardiopulmonary bypass and the aortic cross-clamp. Histologically, the tumor was diagnosed as a benign hemangioma. It was reported that hemangioma would reccur after subtotal excision. To employ cardiopulmonary bypass was a very effective approach for the purpose of complete excision in our case.

Gene therapy for attenuating cardiac allograft arteriopathy using ex vivo E2F decoy transfection by HVJ-AVE-liposome method in mice and nonhuman primates.

Cardiac allograft arteriopathy, which limits the long-term survival of recipients, is characterized by diffuse intimal thickening composed of proliferative smooth muscle cells. The transcription factor E2F plays a pivotal role in the coordinated transcription of cell-cycle regulatory genes. To test the hypothesis that double-stranded DNA with specific affinity for E2F (E2F decoy) is effective in preventing intimal hyperplasia, we performed ex vivo single intraluminal delivery of E2F decoy into cardiac allografts of mice and Japanese monkeys using the hemagglutinating virus of Japan (HVJ) artificial viral envelope-liposome method. In murine models, antisense cyclin-dependent kinase 2 (cdk2) kinase oligodeoxynucleotide (ODN) and no transfers were performed to compare the effects. Severe intimal thickening was observed, and multiple cell-cycle regulatory genes were enhanced in untreated allografts. E2F decoy prevented neointimal formation and suppressed these genes for up to 8 weeks, whereas antisense cdk2 kinase ODN had limited effects. In primate models, E2F decoy dramatically prevented neointimal thickening and suppressed multiple cell-cycle regulatory genes, whereas intimal thickening developed in the nontransfected or mismatch decoy-transfected allografts. Gel mobility shift assay proved the specific effects of E2F decoy, and reverse transcriptase-polymerase chain reaction documented that neither complication nor dissemination of HVJ into other organs was observed. We demonstrate that ex vivo gene delivery to allografts is a potent strategy to modify allograft gene expression, resulting in prevention of graft arteriopathy without systemic adverse effects.

Automated diagnosis of heart disease in patients with heart murmurs: application of a neural network technique.

This study was conducted to test a three-layered artificial neural network analysis of phonocardiogram recordings to diagnose, automatically and objectively, the condition of the heart in patients with heart murmurs. The data were recorded simultaneously in each of 49 patients with a heart murmur through eight microphones attached to the skin surface with adhesive tape, and were analysed by computer. The diagnosis was automated using a three-layered neural network technique. The neural network generated correct answers in over 70% of cases. Furthermore, about 80% of cases of two concurrent diseases were identified correctly. However, ventricular septal defects were incorrectly classified as aortic stenosis or aortic regurgitation, and patent ductus arteriosus was not diagnosed correctly. Accurate diagnoses can frequently be obtained using a neural network, but accuracy can be improved with further data accumulation.

Malignant transformation of rat embryo fibroblasts by cotransfection with eleven human mutant p53 cDNAs and activated H-ras gene.

Eleven different missense and one nonsense mutant-type p53 cDNAs, which have been frequently detected in human colorectal carcinomas, were constructed and examined for their ability to cooperate with activated human H-ras genes, pSK2 and pHs49, in transfection of rat embryo fibroblasts (REF). Each missense mutant-type p53 cDNA with either of the two activated H-ras genes transformed REF with a different frequency of transformation depending on the different kind of mutation, whereas wild-type p53 (with ras), nonsense mutant-type p53 (with ras), as well as mutant-type p53 (alone) and ras (alone), did not transform REF. Six transformed REF cell lines were established from cotransfection with missense mutant-type p53 cDNA and ras gene; all of them exhibiting exogenous human p53 DNA, RNA, protein, and H-ras DNA and RNA. All six transformed cell lines showed both tumorigenicity and lung metastatic potential in nude mice. They also exhibited 92 kilodalton gelatinase activity, which was not detected in parental REF. These results suggest that missense mutations in p53 gene have a role in malignant transformation as well as metastatic potential.

Effect of age on duodenal 1,25-dihydroxyvitamin D-3 receptors in Wistar rats.

We confirmed our previous observation that duodenal Ca2+ absorption and serum 1,25-dihydroxyvitamin D (1,25-(OH)2D) levels declined concurrently in old (24 months old) rats as compared to young (6 months old) rats. It is well known that 1,25-dihydroxyvitamin D-3 (1,25-(OH)2D3) expresses its action after binding to specific receptor molecules. In this paper, we compared certain properties of rat duodenal 1,25-(OH)2D3 receptors from old and young animals. Receptor preparations were incubated with [3H]1,25-(OH)2D3 to quantitate the number of unoccupied and total receptor sites and showed that total and unoccupied receptor sites decreased by 22 and 16%, respectively in old rats. Endogenously occupied sites were reduced by 43% in duodenum of the old rat and, consequently, the percentage of receptor occupancy also declined. Age did not affect the dissociation constant (KD) of 1,25-(OH)2D3 from the receptor; the sedimentation coefficient (3.3 S) of the tritiated 1,25-(OH)2D3-receptor complex in sucrose density centrifugation; or its affinity for DNA. The data are consistent with the hypothesis that the age-related decline in Ca2+ absorption in the intestine may be due, in part, to the decrement in the circulating level of 1,25-(OH)2D and a reduction of intestinal 1,25-(OH)2D3 receptor occupancy status.

Myocardial tactile stiffness: a variable of regional myocardial function.

OBJECTIVES: We developed a new sensor system for in situ measurement of myocardial tactile stiffness-stiffness in a direction perpendicular to the wall-and validated its use for providing a reasonable estimation of regional myocardial function. BACKGROUND: Numerous attempts have been made to directly assess regional myocardial function. The complexity and highly invasive nature of the measuring devices have hampered their in situ application. METHODS: In open chest mongrel dogs, myocardial tactile stiffness, ventricular pressure and ventricular volume were monitored. Under the preload reduction, these variables were measured to determine the relation between the end-systolic pressure-volume relation (ESPVR) and the end-systolic tactile stiffness-volume relation (ESSVR). The changes in myocardial tactile stiffness were monitored in the regional ischemic myocardial model and infarcted model to evaluate their usefulness as indexes of regional myocardial function. RESULTS: Myocardial tactile stiffness changed cyclically and followed a time course similar to left ventricular pressure. When preload was altered, the ESSVR was as linear as the ESPVR. The slope of the ESSVR and that of the ESPVR showed a strong correlation over a wide range of contractility. These results suggest that myocardial tactile stiffness can be a good index of regional wall stress or fiber stress. End-systolic myocardial tactile stiffness of ischemic and infarcted regions decreased significantly, with a concomitant increase in end-diastolic stiffness compared with that of intact myocardium. CONCLUSIONS: Using our tactile sensor system, regional myocardial tactile stiffness of a beating heart was measured with reasonable temporal resolution. We consider myocardial tactile stiffness to be a useful index of regional myocardial function.

Graft insertion technique for distal anastomosis in cases of ascending aortic aneurysm.

We describe a simple and reliable technique of making a secure graft for aorta anastomosis, involving sandwiching the friable aortic wall between the graft and a Teflon strip. This technique makes possible a secure anastomosis with the distal friable tissue and prevents bleeding from the junction.

Decrease of L-selectin expression on human CD34+ cells on freeze-thawing and rapid recovery with short-term incubation.

In the homing process of hematopoietic progenitor cells (HPCs) to bone marrow, several adhesion molecules play important roles. However, HPCs are subjected to dramatic alteration of freeze-thawing that could affect these molecules. In this study, we investigated the effect of cryopreservation on the expression of adhesion molecules on HPCs. The expression of different adhesion molecules on CD34+ cells was examined by flow cytometry using an immunofluorescence technique. Changes in expression before and after cryopreservation, and that of L-selectin on addition of dimethylsulfoxide (DMSO) or with serum incubation, were investigated. The relationship between expression and function was also determined using a transmigration assay system. L-selectin expression on CD34+ cells derived from mobilized peripheral blood (MPB), bone marrow (BM), and umbilical cord blood (CB) was significantly decreased from 37% to 23%, 48% to 11%, and 67% to 19%, respectively, by the freeze-thawing process, while the expression of other adhesion molecules was not appreciably changed. Within 30 minutes of incubation with DMSO, L-selectin expression on CD34(+) cells significantly decreased from 65% to 22%. Furthermore, this was completely prevented by the matrix metalloproteinase (MMP) inhibitor, KB-R8301, indicating that the loss of L-selectin was due to shedding mediated by an MMP. To determine if L-selectin expression can be upregulated after cryopreservation, thawed samples were cultured overnight with serum. Values were observed to return to or rise higher than those of the fresh samples, this being particularly rapid and pronounced when the CD34+ cells were cocultured with the human BM stromal cell line, HS-27A. Therefore, this adhesion molecule could possibly be restored in vivo after transplantation in a way similar to the in vitro case. Despite considerable damage to HPCs during cryopreservation, changes in these cells are reversible, in line with successful restoration of hematopoiesis after transplantation.

Eight novel mutations of the FBN1 gene found in Japanese patients with Marfan syndrome.

Marfan syndrome (MFS), an autosomal dominant connective tissue disorder, is caused by mutations in the gene encoding fibrillin 1 (FBN1). The clinical spectrum and severity of MFS disorder varies greatly both between and within families. Since there have been only a few reports on the relationship between FBN1 genotypes and clinical phenotypes in Japanese patients, the FBN1 gene was analyzed in 27 Japanese patients diagnosed with MFS. The nucleotide sequence of the 65 exons of the FBN1 gene was analyzed by PCR and direct sequencing. We have identified six polymorphisms and nine mutations including: four missense mutations (C1652Y, Q2054P, D2127Y, C2221R) in six patients, three nonsense mutations (R215X, S813X, R2220X) in three patients, and two frameshift mutations (2567insT, 7790insT) in three patients. Six of these nine mutations were in the calcium-binding epidermal growth factor-like domains all causative mutations detected except for C2221R were novel. It has been reported that the severe phenotypes of infantile MFS correlate with mutations in the mid region of FBN1, however, mutations were not detected in this region in the population analyzed in this study. Our results suggest that the location of the mutation is not the sole determinant of phenotypic severity; rather there is some difference in the genetic basis of MFS between Japanese and Caucasian populations.

Hydroxylation of 25-hydroxyvitamin D3 by renal mitochondria from rats of different ages.

The hydroxylation of 25-hydroxyvitamin D3 (25OHD3) in kidney mitochondria from female rats of different ages was studied. The specific activity of 1 alpha-hydroxylase was highest in mitochondria isolated from the 2-month-old rat (0.47 pmol/10 min X mg protein), falling gradually with age to 0.17, 0.10, 0.07, and 0.06 pmol/10 min X mg protein in 6-, 12-, 18-, and 24-month-old rats, respectively. The alteration in 1 alpha-hydroxylase activity with age was due to a change in the V'm of the system; the K'm for 25OHD3 was unchanged (3.9-4.0 microM). The specific activity of 24-hydroxylase was lowest in mitochondria isolated from the 2-month-old rat (8.2 pmol/10 min X mg protein), increasing to 37.8, 37.4, 38.2, and 55.7 pmol/10 min X mg protein in 6-, 12-, 18-, and 24-month-old rats, respectively. The alteration in 24-hydroxylase activity with age was due to a change in the V'm of the system; the K'm value for 25OHD3 was unchanged (1.1-1.2 microM). The age-dependent decrease in 1 alpha-hydroxylase and concomitant increase in 24-hydroxylase activities observed in mitochondria isolated from kidneys of 2-, 6-, 12-, 18-, and 24-month-old rats could not be attributed to changes in the bioenergetic properties, i.e. the respiratory chain, of the mitochondria. The relative mitochondrial content of the kidney, however, probably decreased with age. These findings support the view that the kidneys of aged rats produce less 1,25-dihydroxyvitamin D3 because of lower mitochondrial 1 alpha-hydroxylase specific activity and reduced number of mitochondria. This would be consistent with the lower levels of vitamin D hormone reported in the serum of senescent rats.