Left ventricular rupture is one of the critical complications that can occur during cardiac surgeries, often during a mitral valve replacement. We report a case in which we encountered a left ventricular rupture during a mitral valve reconstruction after completing use of a cardiopulmonary bypass. A 58-year-old man was found to have a cardiac murmur during a health check-up, and visited a nearby hospital where he was given a diagnosis of severe mitral valve regurgitation due to a prolapsed mitral valve by an echocardiographic examination. Under a median sternotomy, a cardiopulmonary bypass was established, and we reconstructed chordae tendineae with Gore-Tex suture and placed an annuloplasty ring to repair the mitral valve. Weaning from the cardiopulmonary bypass was simple, but bleeding inside the pericardium increased during the following hemostasis and we found an oozing area in the left ventricular posterior wall, which was diagnosed as a left ventricular rupture. The patient was placed back on cardiopulmonary bypass, and we closed the ruptured area by tucking it with felt strips while the heart was beating and reinforced it with a fibrin sheet, PGA sheet, and fibrin glue. We then inserted IABP. The hemodynamic condition was stable afterwards and IABP was removed on the 7th day. The patient developed an atrial flutter on the 13th day, which was drug resistant, and we performed a radiofrequency ablation. The patient fully recovered and was discharged on the 44th postoperative day. Considering factors such as excess resection of papillary muscle, failure of mitral loop due to a resection of papillary muscle, excess resection of annulus tissue, excess traction of papillary muscle, damage to the left ventricular inner wall by suction tubes, or excess load on the left ventricle when removing a cardiopulmonary bypass as possible causes, we think very careful maneuvers are required and important even in a mitral valve reconstruction.

An 83-year-old woman who had an attack of fever, fatigue, and lumbar pain was hospitalized as an emergency. Detailed investigations revealed that she had urinary infection, infectious spondylitis, and bacteremia with Streptococcus pneumonia, for which she received antimicrobial therapy. After 12 days in hospital, enhanced computed tomography showed that the aortic arch had expanded, with fluid collection. Though there had been no imaging findings by computed tomography scan on admission. We thought this was an infected thoracic aortic aneurysm with Streptococcus pneumonia, and continued to administer the antibiotic drugs for infection control. After 14 days in hospital, she developed hoarseness and complained of severe back pain. Emergency computed tomography scan showed that the aortic arch had further expanded to 66 mm in size and that much more fluid had collected. We decided it was an impending rupture of the rapidly-expanding infected thoracic aortic aneurysm, and we then performed an emergency operation. The infected portion of the thoracic aorta was resected. The ascending, arch, and descending portions of the aorta were replaced with rifampicin-bonded synthetic graft, and then omental wrapping was performed. Antimicrobial administration was continued after surgery. The postoperative course was uneventful. The infection was successfully controlled. She was discharged without complications. No signs of recurrent infection have been observed for 1 year and 6 months after operation.

We produced a transgenic rodent malaria parasite (Plasmodium berghei) that contained the luciferase gene under a promoter region of elongation factor-1α. These transgenic (TG) parasites expressed luciferase in all stages of their life cycle, as previously reported. However, we were the first to succeed in observing sporozoites as a mass in mouse skin following their deposition by the probing of infective mosquitoes. Our transgenic parasites may have emitted stronger bioluminescence than previous TG parasites. The estimated number of injected sporozoites by mosquitoes was between 34 and 775 (median 80). Since luciferase activity diminished immediately after the death of the parasites, luciferase activity could be an indicator of the existence of live parasites. Our results indicated that sporozoites survived at the probed site for more than 42 hours. We also detected sporozoites in the liver within 15 min of the intravenous injection. Bioluminescence was not observed in the lung, kidney or spleen. We confirmed the observation that the liver was the first organ in which malaria parasites entered and increased in number.

A 53-year-old man was urgently hospitalized with chronic renal failure, congestive heart failure, pulmonary edema, and pneumonia. He received respiratory support and dialysis after hospitalization in the intensive care unit. Coronary arteriography revealed an old myocardial infarction and unstable angina (triple vessel disease). Surgery was planned. However, after dialysis under heparin administration, clot formation was noted in the dialyzer. Serological tests confirmed the presence of antibodies to heparin-platelet factor 4 complex ; accordingly, heparin-induced thrombocytopenia (HIT) was diagnosed. Coronary artery bypass surgery should preferably be performed early in the case of coronary artery disease. However, surgery during the acute phase of HIT when antibodies to heparin-platelet factor 4 complex (HIT antibodies) are present is associated with a very high risk of developing thromboembolism. There is no criterion regarding the optimal timing for surgery when HIT antibodies are present. Therefore, clinicians are often confused about this. In cases where the platelet count, D-dimer level, fibrinogen degradation product (FDP) level, and fibrinogen level improve, thrombin production due to HIT antibodies is thought to decrease. We considered that the improvement in these values suggests that the number of HIT antibodies decreases and thus HIT antibody activity would be reduced. We evaluated the platelet count, D-dimer level, FDP level, and fibrinogen level over time and accordingly determined the optimal timing for surgery. In the present case, argatroban administration was started after HIT developed, and the platelet counts increased gradually ; the D-dimer and FDP levels decreased, whereas there were no significant changes in the fibrinogen levels. Although HIT antibodies were still present, we performed off-pump coronary artery bypass grafting under the administration of argatroban when the platelet count, D-dimer, and FDP values improved. The patency of coronary bypass grafts was confirmed postoperatively ; the patient did not develop thromboembolism during the perioperative period and was discharged without complications. When HIT antibodies are present, an improvement in platelet count, D-dimer, and FDP values is thought to be useful in determining the optimal timing of surgery.

Weproduced a transgenic rodent malaria parasite (Plasmodium berghei) that contained the luciferase gene under apromoter region of elongation factor-1α. These transgenic (TG) parasites expressed luciferase inall stages of their life cycle, as previously reported. However, we were the firstto succeed in observing sporozoites as a mass in mouse skin following theirdeposition by the probing of infective mosquitoes. Our transgenic parasites mayhave emitted stronger bioluminescence than previous TG parasites. The estimatednumbers of injected sporozoites by mosquitoes were between 34 and 775 (median 80). Since luciferase activity diminished immediately after the death of theparasites, luciferase activity could be an indicator of the existence of liveparasites. Our results indicated that sporozoites survived at the probed sitefor more than 42 hours. We also detected sporozoites in the liver within 15 minof the intravenous injection. Apart from the liver, bioluminescence was notobserved in the lung, kidney, or spleen. We reconfirmed that the liver was thefirst organ for malaria parasites to enter and increase in number.

Advances in genetic medicine has rapidly been applied to clinical practice. However, many medical students have not studied biology or genetics in high school. There is little chance to think in Japan medical education about how to treat genetic information appropriately in the setting of clinical medicine. The timing and contents of a clinical genetics education program in medical school has hardly been discussed in Japan. This paper discusses the clinical genetics educationduring the medical-science and clinical-medicine stages at Nippon Medical School.
1) An exercise on information gathering and role-play (for 180 minutes) about color vision deficiency were performed during the second-year molecular genetics course.
2) A clinical genetics course (45 minutes 18 classes) in the fourth year was started in 2002 as a part of an integrated medical curriculum with courses classified by organ system.
3) This clinical genetics course included systematic lectures for knowledge acquisition, lectures by patient support groups, exercises in drawing pedigrees, role-play, and discussions of ethical issues. Students evaluated this course favorably.
4) Some topics in clinical genetics can be effectively presented at an early stage of medical education as part of an introduction to medicine. To maximize the educational effects and increase the possibility that students understand the importance of medical genetics, clinical genetics education in medical school will be performed after the student have grasped a basic understanding of diseases through lectures about clinical subjects.

It has been proposed that transgenic mosquitoes can be used as a “flying syringe” for infectious disease control. We succeeded in generating a transgenic (TG) mosquito, Anopheles stephensi, excreting and discharging DsRed in saliva. DsRed was deposited on the membrane where the TG mosquito probed with its proboscis. Repeated feeding by the TG mosquitoes induced anti-DeRed as well as anti-SG antibodies in mice. This indicates that the TG mosquitoes can immunize the animal. Moreover, in this report, we employed a pre-immunization method before exposing mice to the TG mosquitoes. We injected DsRed to mice to prepare memory B cells and exposed the mice to bites by the TG mosquitoes excreting DsRed. The mice produced a higher titer of antibody to DsRed, suggesting that the bites from TG mosquitoes act as a booster and that primary immunization with a vaccine protein and exposure to TG mosquitoes excreting the vaccine protein in the saliva produces a synergistic effect.

Anomalous origin of the coronary artery is rare. Various complications have been reported in patients with this anomaly undergoing heart valve surgery. We describe a case of aortic valve stenosis combined with an anomalous origin of the left coronary artery. An 84-year-old man with exertional dyspnea was referred for surgical treatment of severe aortic valve stenosis. Coronary angiography and computed tomography of the coronary artery revealed a coronary arterial anomaly : the left anterior descending coronary artery originated as a branch of the right coronary artery, and the left circumflex artery separately originated from the right coronary sinus and extended behind the aortic annulus. To prevent injury to the anomalous circumflex artery during surgery, the artery was separated from the fatty tissue around the aortic annulus and dissected free from the aortic wall before the performance of transverse aortotomy. The coronary artery exhibited a single orifice that was significantly enlarged. Whether antegrade infusion of the cardioplegic solution could be achieved was difficult to determine. To perform the retrograde infusion, the catheter tip was inserted directly into the coronary sinus from the epicardium because the orifice in the right atrium was lattice-like. Aortic valve replacement was successfully performed with supra-annular prosthesis insertion using a 19-mm Mosaic porcine valve (Medtronic, Minneapolis, MN, USA). The postoperative course was uneventful. When aortic valve replacement is performed for patients with an anomalous coronary artery, careful performance of operative procedures and postoperative observation are considered important for the prevention of specific perioperative complications, such as intraoperative coronary injury or postoperative myocardial ischemic events in patients with an anomalous left circumflex artery.

BACKGROUND/AIMS: Intestinal Behçet's disease (BD) is an immune-mediated inflammatory disorder. We followed up the patients and evaluated safety profile and effectiveness of adalimumab for the treatment of intestinal BD through 100 weeks rolled over from the 52 week clinical trial (NCT01243671). METHODS: Patients initiated adalimumab therapy at 160 mg at week 0, followed by 80 mg at week 2, followed by 40 mg every other week until the end of the study. Long-term safety and all adverse events (AEs) were examined. The efficacy was assessed on the basis of marked improvement (MI) and complete remission (CR) using a composite efficacy index, which combined global gastrointestinal symptoms and endoscopic assessments. RESULTS: Twenty patients were enrolled in this study; 15 patients received adalimumab treatment until study completion. The incidence of AEs through week 100 was 544.4 events/100 person-years, which was comparable to the incidence through week 52 (560.4 events/100 person-years). No unexpected trend was observed and adalimumab was well tolerated. At weeks 52 and 100, 60.0% and 40.0% of patients showed MI, respectively, and 20.0% and 15.0% of patients showed CR, respectively. CONCLUSIONS: This report demonstrates 2 years safety and effectiveness of adalimumab in intestinal BD patients. Patients with intestinal BD refractory to conventional treatment receiving up to 2 years of adalimumab treatment demonstrated safety outcomes consistent with the known profile of adalimumab, and the treatment led to sustained reduction of clinical and endoscopic disease activity.
Adalimumab* ; Biological Products ; Endoscopy ; Humans ; Incidence ; Ulcer

No abstract available.
Crohn Disease* ; Food, Formulated* ; Humans ; Infliximab*