The post-operative changes in the level of inflammatory markers after posterior lumbar interbody fusion.

Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth. We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion. The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.

Acute mercuric chloride poisoning: effect of co-ingested milk on outcome and continued hyperamylasemia.

Thirty-six h after intentionally ingesting 25 g of mercuric chloride powder mixed with 5O mL of milk, an elderly woman presented to the emergency department with diffuse upper gastrointestinal erosions and acute renal failure. The patient was treated with dimercaprol and hemodialysis, and was discharged from the hospital without clinically apparent sequelae. However, elevated serum concentrations of amylase and proteases persisted for several months despite normal findings by computed tomography including contrast administration. Delayed absorption and weakened corrosive effect may have resulted from the binding of mercuric chloride to thiol-containing proteins in milk, improving the clinical outcome.

Anchoring and bola cationic amphiphiles for nucleotide delivery. Effects of orientation and extension of hydrophobic regions.

Novel cationic amphiphiles, based on lithocholic acid derivatives with two structural motifs, anchoring lipids and bola lipids, were designed and synthesized. Both bear extended hydrophobic space-filling substituents. A significant effect of the orientation and extension of hydrophobic regions around the ether linkage at the 3-position was found on the efficiency of DNA delivery.

Midazolam for continuous sedation in Japanese patients in the critical care setting: phase II study.

This prospective, phase II study was carried out to evaluate the efficacy and safety of midazolam as a sedative agent in nine critically ill Japanese patients without coma who had been admitted to an intensive care unit. An adequate level of sedation (sedative score [SS] 4-6) was induced by midazolam 0.14 - 0.39 mg/kg and maintained with a dose range of 0.08 - 0.24 mg/kg per h. One patient was excluded from the efficacy analysis since optimum sedation was not maintained by continuous infusion. The percentage of time during which SS 5 was achieved varied among the patients. The most frequent adverse events were hypotension, partial pressure of carbon dioxide elevation and premature ventricular contraction. Population pharmacokinetic analysis suggested that lower drug clearance rates were correlated with the presence of complications. The 50% of effective concentration values of SS 5, estimated by logistic regression analysis, varied greatly (mean, 251 ng/ml). In conclusion, midazolam infusion achieved successful sedation in this critical care setting. The optimum dose differed among the patients, however, and was influenced by the presence of complications.

Structural features of aliphatic N-nitrosamines of 7-azabicyclo[2.2.1]heptanes that facilitate N-NO bond cleavage.

N-Nitrosamines can be considered as potential nitric oxide (NO)/nitrosonium ion (NO(+)) donors. However, the relation of the structures of N-nitrosamines, in particular of aliphatic N-nitrosamines, to the characteristics of release of NO or NO(+) remains unclear. Here we show that aliphatic N-nitrosoamines of 7-azabicyclo[2.2.1]heptanes can undergo heterolytic N-NO bond cleavage. On the basis of the observation of reduced rotational barriers of the N-NO bonds in solution and nitrogen-pyramidal structures of the N-nitroso group in the solid state, we postulate that N-NO bond cleavage of N-nitrosamines is enhanced by a reduction of the resonance in the N-NO group. Computational studies suggest that these structural features of the N-nitrosamines of 7-azabicyclo[2.2.1]heptane are derived from angle strain imposed on the CNC angles.

Usefulness and limitation of DiBAC4(3), a voltage-sensitive fluorescent dye, for the measurement of membrane potentials regulated by recombinant large conductance Ca2+-activated K+ channels in HEK293 cells.

The usefulness of bis-(1,3-dibutylbarbituric acid)-trimethine oxonol (DiBAC4(3)), a voltage-sensitive fluorescent dye, for the measurement of membrane potentials (MPs) was evaluated in HEK293 cells, where alpha or alpha plus beta1 subunits of large conductance Ca2+-activated K+ (BK) channels were expressed (HEKBK alpha and HEKBK alphabeta). The fluorescent intensity of DiBAC4(3) was measured at various potentials under voltage-clamp for calibration to estimate the absolute MP semi-quantitatively. The resting MPs measured with DiBAC4(3) were roughly comparable to those recorded with a microelectrode; the MP in HEKBK alphabeta was 10-20 mV more negative than that in native HEK. In HEKBK alpha, the membrane hyperpolarization induced by 10 microM Evans blue, a BK channel opener, was detected with DiBAC4(3). NS-1619, another BK channel opener, induced gradual but substantial change in F/F(K) even in native HEK, while the BK channel opening effect was detected. Oscillatory membrane hyperpolarization was induced in HEKBK alphabeta by application of 10 microM acetylcholine via increase in intracellular Ca2+ concentration. The oscillatory hyperpolarization was, however, detected only as a slow hyperpolarization with DiBAC4(3). It can be concluded that relatively slow effects of BK channel modulators can be semi-quantitatively measured by use of DiBAC4(3) in HEKBK, while the limited temporal resolution and possible artifacts should be taken into account.

Partial characterization of genes whose transcripts accumulate preferentially in cell clusters at the earliest stage of carrot somatic embryogenesis.

We attempted to identify genes that are preferentially expressed immediately after somatic cells divide to form cell clusters at the earliest stage of carrot somatic embryogenesis when they are not or barely expressed in non-embryogenic suspension-cultured cells in the presence of 2,4-D. Using the differential display technique, we isolated three cDNA clones, designated No. 43, No. 87 and No. 93. The No. 43 transcript was preferentially expressed in the earliest cell clusters, its level decreased drastically at the globular and heart-shaped and torpedo-shaped stages, and it was not detected in non-embryogenic suspension-cultured cells. No. 43 cDNA encoded a protein with homology to thaumatin-like proteins and the deduced positions of seven cysteine residues in the 63 amino acid sequence from the carboxyl terminus were identical to those in thaumatin-like proteins. The full-length nucleotide sequence of No. 93 cDNA was determined and its product was about 80% homologous to precursor of the 14 kDa proline-rich DC 2.15 protein of carrot at the amino acid level. However, the deduced amino acid sequence lacked the characteristic core of repeating Pro-X motifs found in DC 2.15. The No. 93 transcript accumulated preferentially in the earliest cell clusters but it was also detected at a low level in non-embryogenic suspension-cultured cells, unlike DC 2.15 transcripts that begin to accumulate in heart-shaped embryos before their level falls in torpedo-shaped embryos. No. 87 transcripts were expressed preferentially in the earliest cell clusters that has been incubated with 2,4-D but were also detected at a low level in suspension-cultured cells subcultured in the continued presence of 2,4-D. The No. 87 cDNA exhibited no significant homology to any sequences in databases.

Case report: right subclavian artery pseudoaneurysm due to perforation of esophageal cancer.

A 51-year-old man presented with massive hematemesis. Perforation of upper esophageal cancer, which had already occurred at least six days earlier, progressed to upper mediastinitis. The mediastinitis contiguous to the right subclavian artery was considered to have caused a pseudoaneurysm. Rupture of the pseudoaneurysm into the esophagus resulted in massive hematemesis. Both enhanced computed tomography and angiography were diagnostic for the pseudoaneurysm. Transluminal endovascular stent-grafts placement was successful in preventing subsequent hemorrhage.

Space-filling effects in membrane disruption by cationic amphiphiles.

We studied the hemolytic activity towards bovine erythrocytes of novel synthetic steroid-polyamine conjugates consisting of a rigid hydrophobic steroid unit, and a flexible hydrophilic polyamine unit connected by a linker. The steroid structure, polyamine chain length, and the presence of a hydrophobic substituent on the steroid, all influenced the activity. Analysis of the time dependence of hemolysis suggested that these structurally related cationic amphiphiles have different mechanisms of membrane perturbation.

Reanalysis of unruptured intracranial aneurysm management: effect of a new international study on the threshold probabilities.

OBJECTIVE: This report updates previous clinical decision analysis for patients with unruptured intracranial aneurysm (UN-AN) based on newly published data and discusses the role of reanalysis in individual decision making. METHODS: The authors employed probabilities for the natural history of UN-AN and results of preventive surgery based on the report by the International Study of Unruptured Intracranial Aneurysms. Probabilistic sensitivity analysis with Monte Carlo simulation and traditional n-way sensitivity analyses were used to assess the uncertainty of clinical decisions. RESULTS: The baseline decision in favor of preventive surgery is reversed by new data from the international study. Probabilistic sensitivity analyses revealed several populations showing heterogeneity in terms of strategy selection. One- and two-way sensitivity analyses detected two important factors for decision making: annual rupture rate and utility for knowingly living with UN-AN. CONCLUSIONS: Annual UN-AN rupture rate and the utility for knowingly living with UN-AN are key factors when deciding on a therapeutic strategy. Also, updating published decision analyses can improve clinical decision making by integrating clinical judgment and newly available clinical data.

Mutation spectrum of o-aminoazotoluene in the cII gene of lambda/lacZ transgenic mice (MutaMouse).

The o-aminoazotoluene (AAT) has been evaluated as a possible human carcinogen by the International Agency for Research on Cancer. In rodents, it is carcinogenic mainly in the liver, and also in lung following long term administration. We previously examined in lambda/lacZ transgenic mice for the induction of lacZ mutations in liver, lung, urinary bladder, colon, kidney, bone marrow, and testis. AAT induced gene mutations strongly in the liver and colon. In the present report, we reveal the molecular nature of mutations induced by AAT in the lambda cII gene (the cII gene, a phenotypically selectable marker in the lambda transgene, has 294bp, which makes it easier to sequence than the original target, the 3kb lacZ gene). The cII mutant frequency in liver and colon was five and nine times higher, respectively, in AAT-treated mice than in control mice. Sequence analysis revealed that AAT induced G:C to T:A transversions, whereas spontaneous mutations consisted primarily of G:C to A:T transitions at CpG sites.

[Nitrogen pyramidal amides and related compounds].

A planar amide bond is a fundamental linkage in the structures of peptides and proteins. The rigid planarity of the amide linkage, due to a conjugation between carbonyl and amine groups, may be requisite for encoded protein folding and many other biological processes. Non-planar amides in the ground state will decode the significance of the planarity and rigidity of the amide linkage. We show here that simple amides of 7-azabicyclo[2.2.1]heptane, free from steric bias, including parent N-benzoyl 7-azabicyclo[2.2.1]heptane, are nitrogen-pyramidal amides in the crystalline state. We can suggest that pyramidalized amide nitrogen is a general feature and intrinsic to the 7-azabicyclo[2.2.1]heptane motif. Low rotational barriers of the amide C-N bond in a series of N-benzoyl amides of 7-azabicyclo[2.2.1]heptane, compared to monocyclic amides, may imply that ground-state nitrogen pyramidalization of the former amides also exist in solution. The 7-azabicyclo[2.2.1]heptane motif also favors nitrogen pyramidalization of sulfonamides and N-nitrosoamines, which can lead to pharmacophores after appropriate modification.

Gluteal muscle necrosis following transcatheter angiographic embolisation for retroperitoneal haemorrhage associated with pelvic fracture.

Transcatheter angiographic emobilisation has been used as an effective control of haemorrhage associated with pelvic fracture. Although few complications of this procedure have been reported, gluteal muscle necrosis occurs occasionally. We assessed the type of pelvic fracture, concomitant injury, embolic site, embolic materials, and outcome in cases of gluteal muscle necrosis associated with angiographic embolisation for pelvic fracture-related haemorrhage, and investigated the factors associated with the development of gluteal muscle necrosis, one of the fatal complications of transcatheter angiographic embolisation. Five out of the 151 patients (incidence, 3.3%) who underwent transcatheter angiographic embolisation for haemorrhagic shock due to pelvic fracture developed gluteal muscle necrosis after embolisation. The five cases had injury severity scores ranging from 26 to 59 (mean 46.4). Three patients died (mortality, 60%) of subsequent sepsis and disseminated intravascular coagulation. These cases showed that transcatheter angiographic embolisation with gelatin sponge and/or steel coil, while effectively controlling bleeding, may also result in gluteal muscle necrosis. Aggressive management including intraarterial antibiotic treatment may have a role, but our numbers are too small to confirm this.

Tight Sylvian cisterns associated with hyperdense areas mimicking subarachnoid hemorrhage on computed tomography--four case reports.

Four patients with supratentorial mass lesions (two chronic subdural hematomas, one acute epidural hematoma, and one acute subdural hematoma) showed hyperdense sylvian cisterns on computed tomography (CT). Association of subarachnoid hemorrhage was suspected initially, but was excluded by intraoperative observation or postoperative lumbar puncture. CT showed disappearance of the hyperdense areas just after evacuation of the mass lesions. The hyperdense areas are probably a result of the partial volume phenomenon or concentrations of calcium deposits rather than abnormally high hematocrit levels, which were not found in these patients.

Traumatic basilar artery occlusion caused by a fracture of the clivus--case report.

A 56-year-old man presented with a rare traumatic basilar artery occlusion caused by a fracture of the clivus. He fell from the height of 2 meters and immediately fell into a coma. Head computed tomography (CT) revealed an open depressed fracture, an acute epidural hematoma 1 cm thick in the left middle frontal fossa, and a longitudinal fracture of the clivus. Emergency removal of the hematoma was performed with cranioplasty. Head CT 8 hours 50 minutes after injury showed infarctions in the brain stem, cerebellum, and occipital lobes. Cerebral angiography revealed occlusion of the basilar artery in the middle part of the clivus. The patient died after 3 days. Autopsy revealed that the basilar artery was trapped in the clivus fracture site. Vertebrobasilar artery occlusion due to trapping in a clivus fracture has a very poor prognosis. Diagnosis is difficult and generally only confirmed at autopsy. Cerebral angiography is recommended in a patient in a deep coma without massive brain contusion at the early stage of head injury to identify the possibility of vertebrobasilar artery occlusion in a clivus fracture.

Effect of neutral endopeptidase inhibitor on bradykinin-induced bronchoconstriction.

To evaluate whether neutral endopeptidase (NEP) inhibitors have adverse respiratory effects, the influence of a NEP inhibitor on bradykinin (BK)-induced bronchoconstriction was investigated. In anesthetized and artificially ventilated guinea pigs, changes in airway opening pressure (Pao) were measured as an index of bronchoconstriction. An infusion of phosphoramidon (3 mg kg(-1) h(-1)), a NEP inhibitor, significantly enhanced the bronchoconstriction induced by high-dose BK (30 nmol kg(-1), i.v.). Capsaicin (0.1 mg kg(-1), i.v.) and SR48968 (0.3 mg kg(-1), i.v.), an NK2 receptor antagonist, significantly inhibited the phosphoramidon-induced enhancement of BK-induced bronchoconstriction, although FK888 (3 mg kg(-1), i.v.), an NK1 receptor antagonist, did not. Both neurokinin A (NKA) (0.1-3 nmol kg(-1), i.v.) and substance P (SP) (0.1-3 nmol kg(-1), i.v.) induced dose-dependent bronchoconstriction which was enhanced by phosphoramidon infusion, although these enhancements were more prominent in the NKA series. Phosphoramidon partially inhibited BK degradation in lung homogenate, and both NKA and SP degradation in the lung homogenate were significantly suppressed by phosphoramidon. In bronchoalveolar lavage fluid (BALF), levels of NKA and SP were significantly elevated after a bolus of BK with a phosphoramidon infusion. These results suggest that NEP inhibitors may have adverse respiratory effects resulting from inhibition of the degradation of neurokinins, but mainly of NKA, when a large amount of BK is generated.

Alkaline esophagitis evaluated by endoscopic ultrasound.

CASE REPORT: Two patients with corrosive esophagitis caused by alkaline household agents were examined with endoscopic ultrasound using a 20-MHz probe. In the first case, endoscopic ultrasound revealed circumferentially thickened mucosa and muscularis propria, and lack of differentiation between the mucosa and submucosa. However, esophageal stricture did not develop during 3 months of follow-up, suggesting that the deep lesion may have involved a narrow section of esophagus only. In the second case, a markedly thickened mucosa was seen, resulting in no sequelae. Endoscopic ultrasound offers a more accurate evaluation of the depth of the lesions in alkaline esophagitis compared to standard endoscopy or computed tomography. Longitudinal studies are needed to identify lesions at greatest risk for progression to stricture.

[Clinical analysis of hypothermia in children with severe head injury].

Therapeutic hypothermia may improve outcome after severe head injury, but its efficacy has not been established in children with a severe head injury. The authors evaluated the effects of hypothemia (33-34 degrees C) in 9 severely closed head-injured children (under 16 years old). The cooling period was 3 to 21 days (mean 9.3). Hypothermia significantly reduced ICP when it reached 33-34 degrees C. From 3 to 6 months after injury, 6 (67%) of the 9 patients had good outcome (good recovery in 2 and moderate disability in 4), but 3 (33%) had poor outcome (severe disability in 2 and vegetative state in one). Complications, including infectious disorders (pneumonia, meningitis, sepsis), cardio-vascular system dysfunction (cardiac arrhythmia, hypotension), decreased platelet counts, hypokalemia, diabetes insipidus, acute pancreatitis occurred during hypothermia in 7 patients (78%). The results of this study suggest that treatment with hypothermia in children with severe head injury is often accompanied complications, but it is an effective method to control intracranial hypertension and may have improved the outcome.

The effect of a hemofilter during extracorporeal circulation on hemodynamics in patients with SIRS.

OBJECTIVE: To evaluate the hypothesis that extracorporeal hemopurification with a hemofilter contributes to the stabilization of hemodynamics in patients with systemic inflammatory response syndrome (SIRS) due to a mechanism other than the removal of cytokines. DESIGN: Prospective study. SETTING: Intensive care unit (ICU) in a university hospital. PATIENTS: Seven critically ill patients who met criteria for SIRS with unstable hemodynamics requiring vasopressors after emergency surgery. INTERVENTIONS: Before initiation of continuous hemofiltration (CHF) extracorporeal circulation through the hemofilter (ECC) with a hollow-fiber polyacrylonitrile hemofilter was performed for 6 h. MEASUREMENTS AND RESULTS: Vital signs were monitored continuously and hemodynamics were evaluated intermittently. The blood level of endotoxin and the plasma levels of cytokines were measured at 0 and 6 h. Changes in plasma levels of cytokines passing through the hemofilter were evaluated at 3 h. A significant decrease of body temperature (P < 0.05 at 3 and 6 h vs 0 h), a significant elevation of mean arterial pressure (P < 0.05 at 0.5 h, P < 0.01 at 3 and 6 h vs 0 h), and a significant increase of urinary flow rate (P < 0.05 at 0 to 3 h vs -3 to 0 h) were observed with ECC. Neither the blood level of endotoxin nor the plasma levels of cytokines decreased. A significant increase of plasma IL-6 as it passed through the hemofilter was noted. CONCLUSIONS: The beneficial effects of hemopurification with a hemofilter on SIRS patients are possibly due to mechanisms other than the elimination of cytokines with ultrafiltration, diffusion, or adsorption.

Gene transfection activities of amphiphilic steroid-polyamine conjugates.

The design and evaluation of a novel potent class of DNA delivery agents based on steroid-polyamine conjugates bearing a flexible linker are reported. The hydrophobic regions are based on steroids, i.e. chlolestane and lithocholic acid motifs. The linker, which couples a hydrophobic steroid and a hydrophilic polyamine, in this study can be regarded as a two-atom extension of the conventional carbamate linker. We found that the gene transfection activity of the steroid-polyamine conjugates is influenced by the polyamine chain length and steroid structure. Molecular modeling of the relevant amphiphilic molecules revealed low-energy structures in which the polyamine chains are folded rather than stretched. This work suggests a significant effect of space-filling, i.e. the shape and orientation of the hydrophilic and hydrophobic regions, upon the efficiency of gene transfection.