[Maze procedure for atrial fibrillation associated with aortic valve disease in an elderly patient: report of a case].

The choice of a valve substitute in elderly patients remains controversial. Moreover, the combined use of the maze procedure in elderly patients raises further discussion. We report a case of bioprosthetic aortic valve replacement concomitant with the maze procedure in a 74-year-old man. With symptom of orthopnea and short of breath, he was diagnosed as aortic stenosis and regurgitation with atrial fibrillation. We performed the bioprosthesis aortic valve replacement and the maze procedure in this patient. He was extubated next day and discharged on the fifteenth day after the operation without any complications. Postoperatively he gained a sinus regular rhythm and A wave of transmitral flow was detected by Doppler echocardiography. Now, he enjoys his better quality of life without any drugs including warfarin. Although combined aortic valve replacement and maze procedure are more invasive for elderly patients, these procedures provides better quality of life after the operation.

Processing of tumor necrosis factor by the membrane-bound TNF-alpha-converting enzyme, but not its truncated soluble form.

Tumour necrosis factor (TNF)-alpha-converting enzyme (TACE) is a membrane protein belonging to the ADAM (a disintegrin and metalloproteinase) family that cleaves various membrane proteins, including the proform of TNF-alpha. In this study, we constructed expression vectors for the membrane-bound full-length TACE (mTACE) and its truncated soluble form (sTACE). When a human TNF-alpha expression vector was introduced into human 293 cells, processing of TNF-alpha to its mature form was enhanced by coexpressing mTACE, and this processing was inhibited by a metalloproteinase inhibitor. On the other hand, coexpression of sTACE had no effect on the processing of TNF-alpha, although the culture medium of sTACE-transfected cells could cleave a peptide containing the TNF-alpha cleavage site. Fas ligand (FasL)-transfected 293 cells released a considerable amount of soluble FasL, and coexpression of neither mTACE nor sTACE enhanced this shedding. Immunoprecipitation and Western blotting analysis with cells that were cotransfected with TACE and TNF-alpha indicated that both mTACE and sTACE could interact with the proform of TNF-alpha. In the same assay, neither mTACE nor sTACE interacted with FasL. The catalytic domain-lacking TACE mutant, which could also interact TNF-alpha, showed a dominant negative effect on not only TNF-alpha secretion but also FasL secretion. These results suggest that binding of the membrane-anchored but not the soluble form of TACE to TNF-alpha results in efficient ectodomain shedding, and that FasL secretase is a metalloproteinase similar, but not identical, to TACE.

Stabilization of human recombinant erythropoietin through interactions with the highly branched N-glycans.

Human erythropoietin (EPO) produced in Chinese hamster ovary cells (CHO-EPO) is a hydrophobic protein stabilized by the highly branched complex-type N-glycans. To characterize the stabilizing effect of the N-glycans, the properties of enzymatically N-glycan-modified CHO-EPO species were compared spectrophotometrically. CD and fluorescence spectra following the protein unfolding induced by guanidine hydrochloride or pH revealed that the inner regions including the galactose residues of the N-glycans stabilize the protein conformation. The decrease in the conformational stability caused by enzymatic trimming of the N-glycans was associated with the exposure of the hydrophobic protein surface areas accessible to 1-anilino-8-naphthalenesulfonic acid (ANS) binding. Further, the ANS binding and heat denaturation of Escherichia coli-expressed EPO (nonglycosylated EPO) were depressed in dilute solutions (1 mM or so) of free N-glycans of the complex type. These results, together with the finding that the N-glycans of CHO-EPO make little contact with the aromatic amino acid residues exposed on the protein surface, indicate that the inner regions including the galactose residues of the intramolecular N-glycans stabilize the protein conformation by clinging to the hydrophobic protein surface areas mainly made up of nonaromatic hydrocarbon groups.

Psychological effects of aromatherapy on chronic hemodialysis patients.

Effects of aromatherapy (odorless condition, lavender, and hiba oil) on mood and anxiety were investigated in 14 female patients who were being treated with chronic hemodialysis. A control period consisting of natural hospital smells was established before each test session, and then aromatic test conditions were systematically evaluated for odorless conditions as well as aromatic conditions containing lavender and hiba oil aromas. The effects of aromatherapy were measured using the Hamilton rating scale for depression (HAMD) and the Hamilton rating scale for anxiety (HAMA). Hiba oil aroma significantly decreased the mean scores of HAMD and HAMA, and lavender aroma significantly decreased the mean scores of HAMA. The mean scores of HAMD and HAMA in an odorless condition were not significantly different from those of the control conditions. These results indicate that in chronic hemodialysis patients hiba oil is an effective, non-invasive means for the treatment of depression and anxiety, and that lavender alleviates anxiety.

[A successful case of hybrid therapy for the left main trunk and triple coronary vessel lesions with acute myocardial infarction and cardiogenic shock].

A 86-year-patient who had acute myocardial infarction and critical cardiogenic shock was diagnosed to have the left main trunk (LMT) and triple vessel disease. Emergent coronary artery bypass grafting to the left anterior descending artery was performed using saphenous vein graft without cardiopulmonary bypass through median sternotomy. On the 41st postoperative day, catheter intervention was performed to the remaining lesions by stenting of LMT and percutaneous transluminal coronary angioplasty to the right coronary artery lesions. Tl scintigraphy showed remarkable reduction of myocardial ischemia. Hybrid therapy is the effective new strategy for critical cases which cannot be successfully and securely treated by medical or surgical approach alone.

Downregulation of Fas ligand by shedding.

Apoptosis-inducing Fas ligand (FasL) is a type II membrane protein, predominantly expressed in the activated T cells. FasL is cleaved by a putative metalloproteinase to produce a soluble form. Here, we blocked the shedding of human FasL by deleting its cleavage site. Although human Jurkat cells and mouse primary hepatocytes that express a low level of Fas were resistant to the soluble form of FasL, they were efficiently killed by membrane-bound FasL. Furthermore, soluble FasL inhibited cytotoxicity of the membrane-bound FasL. These results indicate that the membrane-bound form of FasL is the functional form and suggest that shedding of FasL is to prevent the killing of the healthy bystander cells by cytotoxic T cells.

Clinical significance of exercise-induced negative U-waves in patients with anterior myocardial infarction.

To elucidate the clinical significance of the exercise-induced negative U-wave (NU) in patients with anterior myocardial infarction, we compared the angiographic and scintigraphic findings in 15 patients with and 20 patients without NU, and obtained the following results: 1) On coronary angiography, all patients in the NU (+) group showed over 90% stenosis or total occlusion of the left anterior descending coronary artery (LAD). In the latter cases moderate to abundant collaterals were visualized on the anterior wall. In contrast, such a tendency was not observed in the NU (-) group. 2) Segments composed of viable myocardium (estimated by preservation of contraction at rest and T1-201 redistribution after exercise) numbered 30 of 45 segments (67%) in the NU (+) group, and 13 of 60 segments (22%) in the NU (-) group. Segments composed of lost myocardium (estimated by loss of contraction at rest and persistent defect in T1-201 uptake) numbered 7 of 45 segments (16%) in the NU (+) group, and 38 of 60 segments (63%) in the NU (-) group. 3) Exercise-induced NU was frequently observed on R-wave preserved leads with ST depression, but was also observed over abnormal Q waves, ST elevation and in isolation in some instances. 4) In 3 patients, preexisting exercise-induced NU was no longer observed and a transient stress-induced T1-201 defect disappeared after successful LAD revascularization. In conclusion, exercise-induced NU on precordial leads in patients with anterior myocardial infarction may be a sign suggesting the presence of jeopardized, but still salvageable, myocardium in the infarcted area.

Plasma vitamin E levels in uremic children and adolescents.

We studied plasma vitamin E levels in children/adolescents 3-19 years of age (10.9 +/- 4.5; mean +/- 1 SD) with chronic renal failure treated conservatively, on hemodialysis, on continuous ambulatory peritoneal dialysis and after renal transplantation. In all 4 groups of patients vitamin E levels (0.66-0.90 mg/dl) were within the normal range (0.76 +/- 0.19 mg/dl). The lowest levels of vitamin E (0.59 +/- 0.1 mg/dl) were found in nonuremic patients with a good functioning renal transplant. These data do not support the notion that uremia is accompanied by vitamin E malabsorption.

Rheumatic fever in a 2-year-old child.

A 2-year-old boy with rheumatic fever is described. The patient presented with fever, flitting polyarthritis and an elevated erythrocyte sedimentation rate. Treatment with aspirin was successful. Rheumatic fever in this age-group is very rare, but it is important to consider this diagnosis even in children under 3 years of age.

Heart rate at onset and termination of paroxysmal atrial fibrillation in apparently healthy subjects.

Eighteen paroxysms were documented on Holter electrocardiogram both at the onset and the termination of paroxysmal atrial fibrillation in 14 apparently healthy subjects. There were large inter- and intraindividual variations and no definite trend was observed in the time and duration of paroxysms. Heart rate at the onset of paroxysms was consistently higher than that at sinus rhythm immediately before atrial fibrillation started. There were 2 patterns in the sequence of heart rate during paroxysms. One was an almost constant heart rate during paroxysms, and the other was a trend toward a decrease in heart rate from the onset to the termination of paroxysms. The duration of paroxysms was within 2 hours in the former group and more than 2 hours in the latter group. There was a reverse correlation between heart rate at the termination of paroxysms and their duration.

Different recovery process of ST depression on postexercise electrocardiograms in women in standing and supine positions.

False-positive exercise test responses are frequently observed in women. To differentiate a false-positive from a true-positive test response, the effect of postures for recording a postexercise electrocardiogram to the recovery process of ST depression was investigated in 26 women with nonischemic ST depression and in 14 patients with typical angina pectoris. Exercise tests were performed twice, and the postexercise electrocardiogram was recorded while standing during the first test and in the supine position during the second test. In the false-positive test, maximal ST depression occurred immediately after exercise and showed a rapid recovery process in the early recovery phase. However, ST depression persisted without complete recovery, or increased in the late recovery phase as long as subjects were kept standing. In contrast, ST depression returned to the control level when subjects changed to the supine position after exercising. This discrepant pattern in the recovery process of ST depression by changing postures was not observed in the true-positive test results. Changing postures for recording postexercise electrocardiograms could be helpful in differentiating a false-positive response from a true ischemic response.