Effects of mineralocorticoid receptor antagonists in patients with hypertension and diabetes mellitus: a systematic review and meta-analysis.

Blood pressure (BP) control is important to ameliorate cardiovascular events in patients with diabetes mellitus (DM). However, achieving the target BP with a single drug is often difficult. The objective of this study was to evaluate the antihypertensive effects of mineralocorticoid receptor antagonists (MRAs) as add-on therapy to renin-angiotensin system (RAS) inhibitor(s) in patients with hypertension and DM. Studies were searched through October 2014 in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Randomized, controlled trials or prospective, observational studies regarding concomitant administration of MRA and RAS inhibitor(s) in patients with DM were included. Articles were excluded if the mean systolic BP (SBP) was <130 mm Hg before randomization for interventional studies or at baseline for prospective cohort studies. We identified nine eligible studies (486 patients): five randomized placebo-controlled trials; three randomized active drug-controlled trials; and one single-arm observational study. The mean differences in office SBP and diastolic BP (DBP) between the MRA and placebo groups were -9.4 (95% confidence interval (CI) -12.9 to -5.9) and -3.8 (95% CI, -5.5 to -2.2) mm Hg, respectively. Subgroup analysis results for study type, age, baseline office SBP and follow-up duration were similar to those of the main analysis. MRA mildly increased serum potassium (0.4 mEq l(-1); 95% CI, 0.3-0.5 mEq l(-1)). A consistent reduction of albuminuria across these studies was also demonstrated. MRA further reduced SBP and DBP in patients with hypertension and DM already taking RAS inhibitors. Serum potassium levels should be monitored to prevent hyperkalemia.

Sudden cardiac arrest immediately after aortic cross clamping during abdominal aortic aneurysm repair.

We report a case of sudden cardiac arrest immediately after aortic cross clamping during surgery for infrarenal abdominal aortic aneurysm in a patient with coronary artery disease. The cause, treatment, and necessary monitoring for the case are discussed.

Square wave voltammetric sensing of uric acid using the self-assembly of mercaptobenzimidazole.

The self-assembled monolayer of a heterocyclic thiol, mercaptobenzimidazole (MBI) on gold (Au) electrode is successfully utilized for the voltammetric sensing of uric acid (UA). The self-assembly of MBI separates the voltammetric signal of UA from the interfering ascorbate (AA). Selective detection of UA in the presence of a large excess of AA or the simultaneous detection of UA and AA is achieved at the MBI monolayer-modified electrode. This electrode can detect as low as 1 microM of UA in the presence of 100-fold excess of AA with excellent reproducibility. The practical utility of the electrode is demonstrated by measuring the concentration of UA in human serum.

A case of muscular hamartoma of the breast.

We describe a 74-year-old female presenting with a right breast mass. She had found the mass on self-examination. Physical examination revealed a 2.2 x 2.5 cm, firm, smooth, and mobile lump in the upper medial portion of the right breast. Mammography revealed a well marginated, oval-shaped, and isodense nodule. Calcification was not evident. On ultrasonography, the lesion was 17 x 18 x 9 mm and located 5 mm below the overlying skin. Excisional biopsy under local anesthesia was performed. The tumor was easily excised. Histopathologically, the lesion was composed of intersecting bundles of spindle-shaped smooth muscle cells, and involved peripheral ducts and fat tissue. Immunohistochemical staining showed positivity for alpha-smooth muscle actin (SMA), but was negative for S-100 protein, myoglobin, keratin, and vimentin. From these findings a muscular hamartoma of the breast, a rare subtype of hamartoma, was diagnosed.

Drastic up-regulation of Fcepsilonri on mast cells is induced by IgE binding through stabilization and accumulation of Fcepsilonri on the cell surface.

It has been shown that IgE binding to FcepsilonRI on mast cells results in increased FcepsilonRI expression, which in turn enhances IgE-dependent chemical mediator release from mast cells. Therefore, prevention of the IgE-mediated FcepsilonRI up-regulation would be a promising strategy for management of allergic disorders. However, the mechanism of IgE-mediated FcepsilonRI up-regulation has not been fully elucidated. In this study, we analyzed kinetics of FcepsilonRI on peritoneal mast cells and bone marrow-derived mast cells. In the presence of brefeldin A, which prevented transport of new FcepsilonRI molecules to the cell surface, levels of IgE-free FcepsilonRI on mast cells decreased drastically during culture, whereas those of IgE-bound FcepsilonRI were stable. In contrast, levels of FcgammaRIII on the same cells were stable even in the absence of its ligand, indicating that FcepsilonRI alpha-chain, but not beta- and gamma-chains, was responsible for the instability of IgE-free FcepsilonRI. As far as we analyzed, there was no evidence to support the idea that IgE binding to FcepsilonRI facilitated synthesis and/or transport of FcepsilonRI to the cell surface. Therefore, the stabilization and accumulation of FcepsilonRI on the cell surface through IgE binding appears to be the major mechanism of IgE-mediated FcepsilonRI up-regulation.

Contractile responses of the basilar artery isolated from rabbits exposed to 8-day head-down tilt.

In the present study, the effects of head-down tilt (HDT) on contractile responses of basilar and popliteal arteries were investigated in vitro. The arteries were isolated from rabbits exposed to 8 d of 45 degrees HDT. Isometric tension and intracellular calcium were measured in an organ bath perfused with physiological salt solution. In the HDT rabbits, contractile response to norepinephrine (NE) was attenuated in the basilar artery, but not in the popliteal artery compared with control rabbits. HDT did not change the responses to either KCl or 5-hydroxytryptamine in both arteries. In the response of basilar artery to NE, the difference in both [Ca(2+)](i) transient and Ca sensitivity between control and HDT rabbits were statistically not significant. The response of the basilar artery to phenylephrine, a selective alpha(1)-adrenergic agonist, was also attenuated by HDT. Treatment with propranolol, a beta-adrenergic blockade, did not affect the response to NE in the basilar arteries isolated from control rabbits, but it significantly enhanced the response in the basilar arteries from HDT rabbits. These results suggest that exposure to 8-d HDT decreases a contractile response of the basilar artery to NE in rabbits. The reduction of NE-induced contraction is probably attributable to both decreased Ca transient and decreased Ca sensitivity, and decreased alpha(1)-adrenoceptor activity and increased beta-adrenoceptor activity seem to be involved in the mechanism.

Mouse CD94 participates in Qa-1-mediated self recognition by NK cells and delivers inhibitory signals independent of Ly-49.

Inhibitory receptors expressed on NK cells recognize MHC class I molecules and transduce negative signals to prevent the lysis of healthy autologous cells. The lectin-like CD94/NKG2 heterodimer has been studied extensively as a human inhibitory receptor. In contrast, in mice, another lectin-like receptor, Ly-49, was the only known inhibitory receptor until the recent discovery of CD94/NKG2 homologues in mice. Here we describe the expression and function of mouse CD94 analyzed by a newly established mAb. CD94 was detected on essentially all NK and NK T cells as well as small fractions of T cells in all mouse strains tested. Two distinct populations were identified among NK and NK T cells, CD94(bright) and CD94(dull) cells, independent of Ly-49 expression. The anti-CD94 mAb completely abrogated the inhibition of target killing mediated by NK recognition of Qa-1/Qdm peptide on target cells. Importantly, CD94(bright) but not CD94(dull) cells were found to be functional in the Qa-1/Qdm-mediated inhibition. In the presence of the mAb, activated NK cells showed substantial cytotoxicity against autologous target cells as well as enhanced cytotoxicity against allogeneic and "missing self" target cells. These results suggest that mouse CD94 participates in the protection of self cells from NK cytotoxicity through the Qa-1 recognition, independent of inhibitory receptors for classical MHC class I such as Ly-49.

Inverted left atrial appendage.

An unexpected left atrial mass was found during postoperative echocardiography in a 17-years old man following aortic valve replacement, suggesting thrombus, vegetation and neoplasm. Reoperation showed that the mass to be an inverted left atrial appendage. Left ventricular venting may cause such inversion. To prevent this complication, we suggest the use of careful monitoring and intraoperative transesophageal echocardiography.

Block of sodium channels by divalent mercury: role of specific cysteinyl residues in the P-loop region.

Divalent mercury (Hg(2+)) blocked human skeletal Na(+) channels (hSkM1) in a stable dose-dependent manner (K(d) = 0.96 microM) in the absence of reducing agent. Dithiothreitol (DTT) significantly prevented Hg(2+) block of hSkM1, and Hg(2+) block was also readily reversed by DTT. Both thimerosal and 2,2'-dithiodipyridine had little effect on hSkM1; however, pretreatment with thimerosal attenuated Hg(2+) block of hSkM1. Y401C+E758C rat skeletal muscle Na(+) channels (mu1) that form a disulfide bond spontaneously between two cysteines at the 401 and 758 positions showed a significantly lower sensitivity to Hg(2+) (K(d) = 18 microM). However, Y401C+E758C mu1 after reduction with DTT had a significantly higher sensitivity to Hg(2+) (K(d) = 0.36 microM) than wild-type hSkM1. Mutants C753Amu1 (K(d) = 8.47 microM) or C1521A mu1 (K(d) = 8.63 microM) exhibited significantly lower sensitivity to Hg(2+) than did wild-type hSkM1, suggesting that these two conserved cysteinyl residues of the P-loop region may play an important role in the Hg(2+) block of the hSkM1 isoform. The heart Na(+) channel (hH1) was significantly more sensitive to low-dose Hg(2+) (K(d) = 0.43 microM) than was hSkM1. The C373Y hH1 mutant exhibited higher resistance (K(d) = 1.12 microM) to Hg(2+) than did wild-type hH1. In summary, Hg(2+) probably inhibits the muscle Na(+) channels at more than one cysteinyl residue in the Na(+) channel P-loop region. Hg(2+) exhibits a lower K(d) value (<1. 23 microM) for inhibition by forming a sulfur-Hg-sulfur bridge, as compared to reaction at a single cysteinyl residue with a higher K(d) value (>8.47 microM) by forming sulfur-Hg(+) covalently. The heart Na(+) channel isoform with more than two cysteinyl residues in the P-loop region exhibits an extremely high sensitivity (K(d) < 0. 43 microM) to Hg(+), accounting for heart-specific high sensitivity to the divalent mercury.

[Aortic valve replacement for aortic valve stenosis due to congenital bicuspid aortic valve with abnormal positioning of coronary orifice, pseudotendon, and persistent left superior vena cava, report of a case].

A patient was a 65-year-old female who had a complaint of palpitation was diagnosed aortic valve stenosis due to congenital bicuspid aortic valve with pseudotendon by the echocardiographic examination. We suspected left single coronary artery by the aortography and the coronary artery angiography. Aortic valve replacement and resection of pseudotendon was performed with Carbomedics supra-annular aortic valve (21 A). During surgery, persistent left superior vena cava was detected. High-posterior take-off right coronary artery was casually detected at aortic closure. Ventricular fibrillation due to insufficient supply of cardioplegic solution at right coronary area frequently occurred after cardio-pulmonary bypass and percutaneous cardiopulmonary support was required. The patient was discharged 32 days after the operation. Preoperative and intraoperative evaluation was important in the case of aortic valvular disease.

[A case of successful reoperation for distal aortic arch pseudoaneurysm after replacement of descending aorta].

The patient was a 69-year-old man who had undergone replacement of descending aorta under close clump technique. Hoarseness occurred 8 years after the operation. Computed tomography and aortography revealed a saccular aneurysm of the distal aortic arch. During surgery, the pseudoaneurysm originated from a intimal defect close to the proximal anastomotic site of the graft. Total aortic arch replacement was successfully performed under retrograde and selective cerebral perfusion. The postoperative course has been uneventful.

Reliability of clinical judgment of patients' competency to give informed consent: a case vignette study.

The competency of psychiatric patients to give informed consent is important in respecting patients' decisions as well as protecting patients from undue exploitation. A total of 176 members of the Japanese Society of Psychiatry and Neurology gave a clinical judgment in a questionnaire of competency in five case transcriptions. Their interrater reliability of competency judgment was slight (generalized kappa 0.31). Clinicians' global judgment of patients' competency was not reliable, but it may be improved by the use of a structured interview.

Immunoglobulin beta signaling regulates locus accessibility for ordered immunoglobulin gene rearrangements.

The antigen receptor gene rearrangement at a given locus is tightly regulated with respect to cell lineage and developmental stage by an ill-defined mechanism. To study the possible role of precursor B cell antigen receptor (pre-BCR) signaling in the regulation of the ordered immunoglobulin (Ig) gene rearrangement during B cell differentiation, a newly developed system using mu heavy (H) chain membrane exon (microm)-deficient mice was employed. In this system, the antibody-mediated cross-linking of Igbeta on developmentally arrested progenitor B (pro-B) cells mimicked pre-BCR signaling to induce early B cell differentiation in vivo. Analyses with ligation-mediated polymerase chain reaction revealed that the Igbeta cross-linking induced the redirection of Ig gene rearrangements, namely, the suppression of ongoing rearrangements at the H chain locus and the activation of rearrangements at the light (L) chain locus. Upon the cross-linking, the kappaL chain germline transcription was found to be upregulated whereas the V(H) germline transcription was promptly downregulated. Notably, this alteration of the accessibility at the H and L chain loci was detected even before the induction of cellular differentiation became detectable by the change of surface phenotype. Thus, the pre-BCR signaling through Igbeta appears to regulate the ordered Ig gene rearrangement by altering the Ig locus accessibility.

Establishment of antigen-specific IgE transgenic mice to study pathological and immunobiological roles of IgE in vivo.

We have established transgenic mice that carry the genes coding for heavy and light chains of TNP-specific IgE. They produced high titers of TNP-specific IgE (20-40 microg/ml in serum) and their mast cells were heavily loaded with IgE. The level of FcepsilonRI expression on their mast cells was 6-8 times higher than that in non-transgenic littermates. The expression of low-affinity IgE receptor FcepsilonRII (CD23) on splenic B cells was also 6-8 times higher in the transgenic mice. Consistent with this, substantial amounts of IgE were detected on B cells in the transgenic mice. When challenged with i.v. administration of the corresponding antigen, the transgenic mice exhibited systemic anaphylactic symptoms such as a drastic drop of body temperature and extravasation of administered dye. Biphasic (immediate and delayed) ear swelling response was also elicited in a TNP-specific manner by epicutaneous antigen challenge without any prior sensitization. Thus, IgE produced in the transgenic mice was found to be biologically active to induce both local and systemic allergic reactions in vivo upon the challenge of the corresponding antigen. Taken together, the antigen-specific IgE transgenic mice established for the first time in this study appear to provide an attractive model system to study the pathological roles of IgE in acute and chronic phases of allergic inflammation as well as their immunobiological roles in vivo. They may also be useful to develop novel therapeutic strategies for atopic disorders.

Molecular cloning of the human gene STK10 encoding lymphocyte-oriented kinase, and comparative chromosomal mapping of the human, mouse, and rat homologues.

LOK is a new and unique member of the STE20 family with serine/threonine kinase activity, and its expression is restricted mostly to lymphoid cells in mice. We cloned the cDNA encoding the human homologue of LOK. The amino acid sequence deduced from the cDNA shows a high similarity to that of mouse LOK, with 88% identity as a whole. The kinase domains at the N-terminus and the coiled-coil regions at the C-terminus are particularly conserved, showing 98% and 93% identity, respectively. Western blot analysis with mouse LOK-specific antibody detected 130 000 Mr LOK proteins in human and rat lymphoid cell lines and tissues. The gene encoding the LOK (STK10/Stk10) gene was mapped by fluorescence in situ hybridization to chromosome 5q35.1 in human, chromosome 11A4 in mouse, and chromosome 10q12.3 in rat. By virtue of polymorphic CA repeats found in the 3' untranslated region of the mouse Stk10 gene, the Stk10 locus was further pinpointed to chromosome 11 between D11Mit53 and D11Mit84, using the intersubspecific backcross mapping panel. These results established STK10 as a new marker of human chromosome 5 to define the syntenic boundary of human chromosomes 5 and 16 on mouse chromosome 11.

Flow cytometric diagnosis of the cell lineage and developmental stage of acute lymphoblastic leukemia by novel monoclonal antibodies specific to human pre-B-cell receptor.

Three novel monoclonal antibodies (MoAbs) have been established that recognize distinct epitopes of a human pre-B-cell receptor (pre-BCR) composed of a mu heavy (muH) chain and a lambda5/VpreB surrogate light (SL) chain. HSL11 reacts with lambda5 whereas HSL96 reacts with VpreB. Intriguingly, HSL2 does not bind to each component of the pre-BCR but does bind to the completely assembled pre-BCR complex. Flow cytometric analyses with cytoplasmic staining of a panel of human cell lines showed that HSL11 and HSL96 specifically stained cell lines derived from the pro-B and pre-B-cell stages of B-cell development. In contrast, HSL2 stained exclusively cell lines derived from the pre-B-cell stage. These results prompted us to explore the possibility of clinical application of these MoAbs for the determination of the cell lineage and developmental stage of acute lymphoblastic leukemia (ALL). Whereas none of mature B-lineage ALLs (B-ALLs), T-lineage ALLs (T-ALLs), and acute myeloid leukemias analyzed were stained in the cytoplasm with these three MoAbs, the vast majority of non-B- and non-T-ALLs (53 out of 56 cases) were found positive for either lambda5, Vpre-B, or both in their cytoplasm. Among these 53 cytoplasmic SL chain-positive ALLs, 19 cases were also positive for cytoplasmic muH chain, indicative of pre-B-cell origin. Interestingly, 6 out of these 19 pre-B-ALL cases were found negative for cytoplasmic staining with HSL2. From these results, we propose a novel classification of B-ALL in which five subtypes are defined on the basis of the differential expression of SL chain, muH chain, pre-BCR, and light chain along the B-cell development.

[A case of tuberculous granulomatous mediastinitis and constrictive pericarditis simulating malignant mediastinal tumor].

A case is 40-year-old man. He presented anterior chest pain. Pericardial effusion was pointed out and a tuberculin skin test was positive. Tuberculous pericarditis was highly suspected, so INH and RFP were medicated. After 6-month medication pericardial effusion decreased, but right pleural effusion appeared on chest X-ray. Chest CT revealed a thickening of pericardium extend to anterior mediastinal mass. Echocardiogram revealed a pressure gradient in right ventricle, which was compressed by the thickened pericardium. We underwent median sternotomy in order to rule out neoplastic diseases. Intraoperative pathologic diagnosis was granulomatous mediastinitis and pericarditis, so we resected granuloma as much as possible to decompress the heart. Although Mycobacterium tuberculosis was not found in the resected granuloma, it was most probable pathogen. He received additional antituberculous chemotherapy for 6 months.