Detection of elevated levels of α-synuclein oligomers in CSF from patients with Parkinson disease.

BACKGROUND: To date, there is no accepted clinical diagnostic test for Parkinson disease (PD) that is based on biochemical analysis of blood or CSF. The discovery of mutations in the SNCA gene encoding α-synuclein in familial parkinsonism and the accumulation of α-synuclein in the PD brain suggested a critical role for this protein in PD etiology. METHODS: We investigated total and α-synuclein oligomers levels in CSF from patients clinically diagnosed with PD, progressive supranuclear palsy (PSP), or Alzheimer disease (AD), and age-matched controls, using ELISA developed in our laboratory. RESULTS: The levels of α-synuclein oligomers and oligomers/total-α-synuclein ratio in CSF were higher in the PD group (n = 32; p < 0.0001, Mann-Whitney U test) compared to the control group (n = 28). The area under the receiver operating characteristic curve (AUC) indicated a sensitivity of 75.0% and a specificity of 87.5%, with an AUC of 0.859 for increased CSF α-synuclein oligomers in clinically diagnosed PD cases. However, when the CSF oligomers/total-α-synuclein ratio was analyzed, it provided an even greater sensitivity of 89.3% and specificity of 90.6%, with an AUC of 0.948. In another cross-sectional pilot study, we confirmed that the levels of CSF α-synuclein oligomers were higher in patients with PD (n = 25) compared to patients with PSP (n = 18; p < 0.05) or AD (n = 35; p < 0.001) or control subjects (n = 43; p < 0.05). CONCLUSION: Our results demonstrate that levels of α-synuclein oligomers in CSF and the oligomers/total-α-synuclein ratio can be useful biomarkers for diagnosis and early detection of PD.

Renal involvement in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary systemic arteriopathy presenting with migraines, mood disorders, focal neurologic deficits, recurrent ischemic attacks and dementia in young adults. The genesis of this disease relates to missense mutation of the Notch3 gene. We report here a newly identified CADASIL patient and discuss unique vascular lesions observed in the kidney. A 64-year-old female was admitted to our hospital for the investigation of proteinuria, hematuria and progressive neurological abnormalities. Her mother and brother died of cerebral infarction at a relatively young age despite a lack of apparent risk factors for arteriosclerosis. Over the past 4 months before admission, she had suffered from frequent transient ischemic attacks despite appropriate antiplatelet therapy. Blood examination revealed mild renal insufficiency and urinalysis revealed moderate protein excretion and dysmorphic hematuria. Magnetic resonance imaging of the brain revealed multiple infarcts and leukoencephalopathy. Histopathological analysis of the kidney revealed focal segmental mesangial proliferation, the loss and degeneration of arterial medial smooth muscle cells and arterial intimal thickening. Immunofluorescence analysis of glomeruli revealed IgA deposition in the mesangial area. Electron microscope analysis revealed electron-dense deposition also in the mesangial area. In addition, granular osmophilic material (GOM) was observed in the extraglomerular mesangial area and around the vascular smooth muscle cells. Genetic analysis of Notch3 revealed an R141C missense mutation and she was diagnosed with CADASIL complicated with IgA nephropathy. In immunohistological analysis, Notch3 stains were positive in vascular smooth muscle cells of the interlobular arteries and both afferent and efferent arterioles, and weak in the glomerular mesangial area. Antihypertensive treatment using angiotensin II receptor blocker and a low protein diet were initiated, and her urinary protein excretion decreased to 0.2 g/day. However, due to the progression of her neurological abnormalities, she became socially withdrawn. In CADASIL, GOM, abnormal accumulation of Notch3 ectodomain, is thought to induce the degeneration and loss of vascular smooth muscle cells and subsequent intimal thickening. Analysis of our cases provided that these morphological abnormalities were also observed in the CADASIL patient kidney.

[Sudden death due to massive pulmonary thromboembolism after pneumonectomy; report of a case].

A 76-year-old woman underwent a left pneumonectomy for a primary adenocarcinoma. On the fourth postoperative day, when walking to the toilet, she suddenly developed syncope followed by dyspnea and cardiopulmonary arrest. Although we performed cardiopulmonary resusciation, she died 1 hour later. With her family's approval, we performed autopsy. We found massive pulmonary thromboembolism was identified in the right main artery. To prevent postoperative thromboembolic complications, we use postoperatively continuous intravenous heparin sodium infusion (5,000-6,000/24 h) for the patients underwent thoracotomy and examine the ultrasonography for deep vein thrombosis before they begin to walk.

Development of apoptosis and changes in lymphocyte subsets in thymus, mesenteric lymph nodes and Peyer's patches of mice orally inoculated with T-2 toxin.

Development of apoptosis and changes in lymphocyte subsets were examined mainly by flow cytometer in thymus, mesenteric lymph nodes and Peyer's patches of mice up to 24 hours after oral inoculation with T-2 toxin (10 mg/kg). T-2 toxin attacked Peyer's patches first, then mesenteric lymph nodes, and finally thymus in relation to the course of enteric absorption of orally inoculated T-2 toxin. The degree of lymphocyte apoptosis was prominent in the thymus, moderate in the Peyer's patches, and somewhat mild in the mesenteric lymph nodes, suggesting the difference in lymphocyte population susceptible to T-2 toxin. As to the changes in lymphocyte subsets, CD4+ CD8+ T cells were most sensitive to T-2 toxin, and CD4+ CD8- T cells were more severely depressed than CD4- CD8+ T cells in the thymus. In the mesenteric lymph nodes, CD3+ cells was more clearly affected than CD19+ cells, and the numbers of CD4+ and CD8+ cells were similarly decreased. In the Peyer's patches, the numbers of CD3+, CD 19+, CD4+ and CD8+ cells were unexceptionally decreased. In addition, among IgM+, IgG+ and IgA+ B cells, the number of IA+ B cells which are more important in the mucosal immunity was most severely affected.

Treatment of deep infection following thoracic aorta graft replacement without graft removal.

Deep infection following thoracic aortic replacement constitutes an extremely serious and life-threatening complication, and its treatment remains a challenge to surgeons. We report our experience involving five patients in whom deep infection occurred around the graft. Four of the five patients were treated by emergency surgery and one was treated by elective surgery. Surgical procedures performed including hemiarch replacement in one case, total arch replacement in one case, suspension of aortic valve and ascending aorta replacement in one case, Bentall procedure in one case, and descending aorta re-replacement in one case. Methicillin-resistant Staphylococcus aureus was detected in four patients, methicillin-resistant Staphylococcus epidermidis in one, and Aspergillus in one patient from purulent discharge at the operative site. Reoperative debridement and irrigation drainage were carried out at an early phase of infection. Intermittent irrigation following the reoperation was performed in all cases. In addition, muscle flap filling or omental translocation was carried out in three patients. Although the reported principle of treatment for arterial graft infection is extraanatomical bypass or rereplacement after removal of the infected graft, such procedures may be technically difficult and have a high risk at the thoracic level. Local anti-septic irrigation, administration of antibiotics, and vascular-rich tissue filling are useful procedures, and it appears that it is not always necessary to remove prosthetic grafts.

Apoptosis in mouse fetuses from dams exposed to T-2 toxin at different days of gestation.

T-2 toxin (2 mg/kg b.w.) was orally inoculated to pregnant mice at gestational day (GD) 8.5, 9.5, 10.5, 11.5, 12.5, 13.5, 14.5, 15.5 and GD 16.5, respectively, and the fetuses were examined 24 hours later. The number and region of pyknotic or karyorrhectic cells varied according to inoculation date. In the GD 13.5-subgroup, a moderate to high number of pyknotic or karyorrhectic neuronal cells were observed in the central nervous system, peri-ventricular zone to subventricular zone, and pyknosis or karyorrhexis were also observed in a small number of chondroblasts and chondrocytes. In the GD 16.5-subgroup, a moderate to high number of pyknotic or karyorrhectic cells were observed in the thymus and renal subcapsular parenchyma. The nuclei of these pyknotic or karyorrhectic cells were strongly stained by the terminal deoxy nucleotidyl transferase (TdT)-mediated dUTP-digoxigenin nick end labeling method widely used for the in situ detection of apoptotic nuclei. In addition, a few fetuses from dams which were given T-2 toxin at GD 13.5 or GD 14.5 and killed at GD 17.5 showed skeletal abnormalities such as wavy ribs and short scapula. From the present findings and the well known fact that T-2 toxin readily crosses the rat placenta, it seems that T-2 toxin-induced apoptosis in the developing mouse fetuses might be a direct effect of T-2 toxin on fetuses.

Apoptotic cell death and cell proliferative activity in the rat fetal central nervous system from dams administered with ethylnitrosourea (ENU).

Ethylnitrosourea (ENU), a well known DNA alkylating agent, induces anomalies in the central nervous system (CNS), craniofacial tissues and male reproductive organs, and the enhancement of apoptosis is found in these tissues immediately after the administration of ENU (Katayama et al., 2000a). In this study, pregnant rats were treated with 60mg/kg of ENU at day 13 of gestation, and kinetics of apoptotic cells, mitotic cells and bromodeoxyuridine (BrdU)-positive cells in the fetal CNS were examined from 3 to 48 hours after the treatment (HAT). From 3 HAT, a significant increase in the number of apoptotic cells and a significant decrease in the number of mitotic cells were detected in the fetal CNS, and BrdU-positive cells significantly decreased in accordance with the increase in the number of apoptotic cells. The present results strongly suggest that both excess cell death by apoptosis and cell growth arrest indicated by decreased number of mitotic cells and BrdU-positive cells may have a close relation to the later occurrence of microencephaly following ENU-administration, and that ENU affects mainly S-phase cells and causes apoptosis.

Teratologic studies on rat perinates and offspring from dams treated with ethylnitrosourea (ENU).

Ethylnitrosourea (ENU), a well known DNA alkylating agent, induces anomalies in the central nervous system (CNS), craniofacial tissues, limbs and male reproductive organs. Recently we clarified that excess cell death caused by apoptosis occurred in these organs and tissues of rat fetuses from dams treated with ENU at day 13 of gestation (GD13). In this study, we examined fetuses at GD21 and offspring at 10 weeks of age after ENU administration to pregnant rats at GD13 in order to clarify the relationship between ENU-induced apoptosis in the fetal tissues and teratogenicity of ENU. Severe intrauterine growth retardation was observed in the ENU group, and the body weight of the offspring in the ENU group was significantly lower than that of the control group throughout the experiment. In addition, a high incidence of microencephaly, ectrodactyly and curved caudal vertebrae was observed in the offspring from dams treated with ENU at GD13. Judging from the results of our previous and present studies, it was strongly suggested that ENU-induced apoptosis in rat fetal tissues may play an important role in the induction of anomalies in the corresponding tissues.

Ethylnitrosourea (ENU)-induced apoptosis in the rat fetal tissues.

Ethylnitrosourea (ENU), a well known DNA alkylating agent, induces anomalies in the central nervous system (CNS), craniofacial tissues and male reproductive organs. In this study, pregnant rats were treated with 60 mg/kg ENU at day 13 of gestation, and their fetuses were examined from 1 to 48 hours after treatment (HAT) to find a clue for clarifying the mechanisms of the ENU fetotoxicity and teratogenicity. From 3 to 12 HAT, the moderate to marked increase in the number of pyknotic cells was detected in the fetal CNS, craniofacial mesenchymal tissues, gonads and so on. These pyknotic cells had nuclei positively stained by the TUNEL method, which is widely used for the detection of apoptotic nuclei, and they also showed electron microscopic characteristics identical to those of apoptotic cells. The present results strongly suggest that excess cell death by apoptosis in the fetal CNS, craniofacial tissues and gonads may have a close relation to the later occurrence of anomalies reported in these tissues following ENU-administration.

Interposition of hydroxyapatite ceramic stents alternative to delayed sternal closure.

Ascending and hemiarch replacement surgery for an acute Stanford type A dissection in association with a previous type B dissecting aneurysm was performed on a 58-year-old female patient. However, sternal closure could not be performed after surgery due to hemodynamic deterioration. Even four weeks after the operation, sternal closure was impossible due to advanced adhesion around the mediastinum caused by mediastinitis. Therefore, hydroxyapatite ceramic spacers, which have osteogenesis and ossification characteristics, were interposed between the split sternum as stents to avoid further surgery.

Apoptosis in the developing mouse embryos from T-2 toxin-inoculated dams.

T-2 toxin (3 mg/kg b.w.) was orally inoculated to pregnant mice at 11 days of gestation to examine the effect of T-2 toxin on the developing embryos. At 24 hours after T-2 toxin-inoculation, moderate pyknosis or karyorrhexis was generally observed in some layers of the central nervous system, caudal sclerotomic segment, caudal region of the tongue to pharyngeal- to laryngeal-mesenchyma, trachea and facial mesenchyma. These pyknotic or karyorrhectic nuclei were strongly stained by the modified TUNEL method widely used for the in situ detection of apoptotic nuclei and also showed ultrastructural changes characteristic for apoptosis. This is the first report of mycotoxin-induced apoptosis in embryos.

An effective device to keep the sternum open.

Delayed sternal closure following cardiothoracic surgery facilitates the treatment of heart failure and arrhythmias caused by sternal closure, and also allows access to treat uncontrollable bleeding. The present study examines the use of stents made from disposable syringes for keeping the sternum open. The syringes demonstrated good strength, as well as resistance to tapping during pulmonary physical therapy and stability against body movement necessary to prevent the formation of decubitus ulcers. Thus, the proposed stent provides an inexpensive, easy, and effective method for keeping the sternum open.

[A case of an expanding congenital left ventricular aneurysm].

Congenital ventricular aneurysm is rare. There have been only 17 case reports in Japan. Only 9 of them were treated surgically. In this paper, we report a case with a congenital left ventricular aneurysm successfully treated by surgery. A 42-year-old female was admitted to our hospital with chest pain and ECG abnormalities. Left ventriculography revealed aneurysmal formation of the left ventricle with normal coronary arteries. Surgical resection was performed because repeated echocardiography had showed its enlargement. Surgical treatment for congenital ventricular aneurysm seems to be indicated to those with worsening symptoms, volume enlargement or thrombus formation.

Surgery for hepatocellular carcinoma with tumor thrombus in the right atrium.

Three cases of tumor thrombus that originated from a hepatocellular carcinoma in the liver and extended into the right atrium are described. All patients had received both resection of the tumor thrombus and lobectomy of the liver either simultaneously or independently within a short interval. Surgical order and extracorporeal circulation system were varied depending on the thrombus extension. Two of the patients died within 4 months of surgery due to different reasons and the other is doing well at 24 months after surgery.

Unexpected extraction of a ventricular septal defect patch without an interventricular shunt.

We report the case of a mediastinocutaneous fistula, 13 years after the total correction of tetralogy of Fallot. During a fistula curettage operation, we unexpectedly extracted a ventricular septal defect patch. An interventricular shunt was not detected after the operation. The patient is well 3 years after the last operation.

[Experience of predeposit autologous blood transfusion and medication of recombinant human erythropoietin in pediatric open heart surgery].

To avoid using the homologous blood, 11 children between the age of 5 and 15 years donated autologous blood of 10 ml/kg of body weight (upper limit 400 ml) once a week for two weeks prior to elective open heart surgery. Five of 11 children received erythropoietin (100 U/kg of body weight) intravenously three times a week for two weeks. Only one patient experienced a mild donor reaction but no adverse effects occurred in erythropoietin therapy. In all the patients cardiac operations were able to be completed without homologous blood transfusion. Patients treated with erythropoietin were not anemic despite of preoperative donation although without erythropoietin therapy patients were mildly anemic. Our experience documents safety and effectiveness of predeposit autologous blood transfusion and erythropoietin therapy in pediatrics.