Search

Protein design is a useful method to create novel artificial proteins. A rational approach to design a heterodimeric protein using domain swapping for horse myoglobin (Mb) was developed. As confirmed by X-ray crystallographic analysis, a heterodimeric Mb with two different active sites was produced efficiently from two surface mutants of Mb, in which the charges of two amino acids involved in the dimer salt bridges were reversed in each mutant individually, with the active site of one mutant modified. This study shows that the method of constructing heterodimeric Mb with domain swapping is useful for designing artificial multiheme proteins., (© 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Transaortic septal myectomy, known as Morrow's procedure, is a standard treatment for hypertrophic obstructive cardiomyopathy (HOCM). The case is described of a 58-year-old male patient who suffered a repetition of syncope due to HOCM, in whom septal myectomy was performed. As resection of the hypertrophied septum using Morrow's procedure was considered insufficient by palpation to release mitral regurgitation (MR) and systolic anterior motion of the mitral valve, the surgical approach was changed such that the right ventricular outflow tract and ventricular septum was incised. The residual hypertrophied septum was successfully resected to the base of the anterior papillary muscle under direct vision. Postoperative echocardiography demonstrated a dramatic improvement in the MR and left ventricular outflow tract obstruction. The patient's postoperative course was good, with cibenzoline and calcium channel blocker therapy stopped and beta-blocker therapy reduced after surgery. If resection of the hypertrophied septum using Morrow's procedure is considered insufficient, a trans-septal approach represents an adequate option to treat HOCM.

NAD+-reducing [NiFe] hydrogenases catalyze the oxidoreduction of dihydrogen concomitant with the interconversion of NAD+ and NADH. Here, the isolation, purification and crystallization of the NAD+-reducing [NiFe] hydrogenase from Hydrogenophilus thermoluteolus TH-1 are reported. Crystals of the NAD+-reducing [NiFe] hydrogenase were obtained within one week from a solution containing polyethylene glycol using the sitting-drop vapour-diffusion method and micro-seeding. The crystal diffracted to 2.58 Å resolution and belonged to space group C2, with unit-cell parameters a=131.43, b=189.71, c=124.59 Å, β=109.42°. Assuming the presence of two NAD+-reducing [NiFe] hydrogenase molecules in the asymmetric unit, VM was calculated to be 2.2 Å3 Da(-1), which corresponds to a solvent content of 43%. Initial phases were determined by the single-wavelength anomalous dispersion method using the anomalous signal from the Fe atoms.

Objectives: Current guidelines recommended surgery for patients with severe degenerative mitral regurgitation (MR) when specific left ventricular (LV) dimensions or ejection fraction (EF) are reached, based on previous postoperative survival studies. The aim of this study was to evaluate the incidence and predictors of long-term postoperative LV dysfunction, and investigate the preoperative parameters necessary to maintain or recover long-term LV function in the era of mitral valve (MV) repair., Methods: We retrospectively reviewed 473 consecutive patients undergoing MV repair for severe degenerative MR for whom both preoperative and 3-year postoperative echocardiographic data were available in our institution. Preoperative and 3-year postoperative echocardiographic data and clinical outcomes were evaluated., Results: Receiver operating characteristic analysis identified preoperative LVEF 63% or less (area under curve [AUC], 0.725; P<.001) and LV end-systolic dimension (ESD) 39 mm or greater (AUC, 0.724; P<.001) as cut-off values for predicting LVEF less than 50% 3 years after surgery. On multivariate analysis, both preoperative LVEF and LVESD were not significant predictors of 3-year postoperative LV dysfunction among patients with preoperative LVEF greater than 63% and LVESD less 39 mm, whereas preoperative LVESD (odds ratio [OR], 2.22; P=.004), higher age (OR, 1.03; P=.04), and atrial fibrillation (OR, 2.68; P=.01) were independent predictors among patients with preoperative LVEF 63% or less or LVESD 39 mm or greater., Conclusions: Early MV repair with LVEF greater than 63% and LVESD less than 39 mm preserved long-term postoperative LV function well, and smaller preoperative LVESD was associated with long-term LV function recovery, even in patients with preoperative LV dysfunction., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

A 62-year-old man was admitted to a local hospital for cervical abscess. He was given an antibiotic, but his symptoms worsened. Computed tomographic cervical and chest scan 6 days after hospitalization revealed that left cervical abscess extended to the mediastinum. He was transferred to our hospital following a diagnosis of descending necrotizing mediastinitis. Cervical and left transthoracic drainage through a left cervical incision and a left antero-axillary thoracotomy were performed on hospital day 1. On hospital day 2, chest radiograph revealed enlargement of the superior mediastinal shadow. Mediastinoscopic drainage was performed for the abscess in the paratracheal space on hospital day 3. Two mediastinal drainage tubes were placed in the upper and middle mediastinal space using mediastioscopy. Postoperatively, he required additional right transthoracic drainage by chest tube for pleural effusion on hospital day 5. Then his clinical and radiological findings gradually improved, and he was discharged from hospital day 37.

Purpose: Pseudoaneurysms of the thoracic aorta after cardiovascular surgery are rare, but life-threatening complications. We herein describe the clinical outcomes of pseudoaneurysms of the thoracic aorta arising after cardiovascular surgery., Methods: We retrospectively reviewed 14 patients (mean age 64 years) who underwent reoperation for a pseudoaneurysm of the thoracic aorta between January 1997 and December 2010., Results: Pseudoaneurysms of the thoracic aorta were detected incidentally during routine follow-up in 11 asymptomatic patients, whereas symptoms or signs indicating an aortic pseudoaneurysm were present in three patients. The mean intervals between repeat and previous cardiovascular surgeries and the follow-up were 167 and 62 months, respectively. The aortic pseudoaneurysms were located in the proximal and distal suture lines in six patients, and at aortotomy sites in four. These locations accounted for about 70 % of all aortic pseudoaneurysms. None of the patients died in the hospital. Postoperative complications, such as a need for permanent pacemaker implantation or groin-related issues, occurred in five patients. However, no major postoperative complications, aorta-related events or a need for reoperation developed during the follow-up period., Conclusions: Regular follow-up, including imaging modalities and physical examinations, is mandatory to detect aortic pseudoaneurysms after cardiovascular surgery.

Background: Mitral valve repair is an established surgical procedure for treating severe organic mitral regurgitation. The mechanisms of mitral regurgitation due to infective endocarditis include rheumatic disease and congenital diseases such as a lack of leaflet tissue, and thus additional material is required to create a functional coaptation surface. We review our experience with 139 patients who underwent mitral valve repair with glutaraldehyde-treated autologous pericardium to treat organic mitral regurgitation between March 1992 and November 2011., Methods: Mitral valve disease mainly consisted of infective endocarditis in 51 patients (active, n = 32; healed, n = 19) and rheumatic disease in 47. This procedure was also applied to 12 patients who required reoperation after mitral valve repair for degenerative, congenital, or rheumatic mitral regurgitation. The mean follow-up was 4.5 ± 4.3 years (maximum 19.1)., Results: Actuarial survival at 10 years was 84% ± 5%. Eleven reoperations proceeded at a mean of 68 months after surgery. The causes of reoperation were rheumatic disease progression (n = 4), infection (n = 3), patch dehiscence (n = 2), progressive fibrosis of the remaining mitral valve tissue after infective endocarditis (n = 1), and patch tear (n = 1). Mitral valves were replaced in 8 patients and re-repaired in 3 patients. The autologous pericardium was not calcified at the time of reoperation. The rate of freedom from reoperation was 82% ± 7% at 10 years., Conclusions: Mitral valves that might otherwise require replacement can be durably and predictably repaired using glutaraldehyde-treated autologous pericardium., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We, herein, report the use of tricuspid leaflet augmentation with an autologous pericardial patch to treat a patient with severe tricuspid regurgitation (TR) that occurred after suture annuloplasty. The patient underwent mitral valve replacement for rheumatic mitral disease and tricuspid suture annuloplasty for moderate TR 23 years ago. She developed right-sided heart failure associated with severe TR. Leaflet augmentation with an autologous pericardial patch and ring annuloplasty were applied at redo surgery. Postoperative echocardiography showed trivial TR with significant improvement of the patient's symptoms. We have now performed this technique on three cases of severe recurrent TR that occurred after suture annuloplasty, and excellent early results were obtained in each case.

[NiFe] hydrogenase catalyzes reversible oxidation of molecular hydrogen. Its active site is constructed of a hetero dinuclear Ni-Fe complex, and the oxidation state of the Ni ion changes according to the redox state of the enzyme. We found that the Ni-A state (an inactive unready, oxidized state) of [NiFe] hydrogenase from Desulfovibrio vulgaris Miyazaki F (DvMF) is light sensitive and forms a new state (Ni-AL) with irradiation of visible light. The Fourier transform infrared (FT-IR) bands at 1956, 2084 and 2094 cm(-1) of the Ni-A state shifted to 1971, 2086 and 2098 cm(-1) in the Ni-AL state. The g-values of g(x)=2.30, g(y)=2.23 and g(z)=2.01 for the signals in the electron paramagnetic resonance (EPR) spectrum of the Ni-A state at room temperature varied for -0.009, +0.012 and +0.010, respectively, upon light irradiation. The light-induced Ni-AL state converted back immediately to the Ni-A state under dark condition at room temperature. These results show that the coordination structure of the Fe site of the Ni-A state of [NiFe] hydrogenase is perturbed significantly by light irradiation with relatively small coordination change at the Ni site., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: A higher operative mortality rate has been reported after redo valvular procedures than after the primary operation., Methods: Outcomes of 330 consecutive patients undergoing 433 redo valvular operations at our institute during a 20-year period (January 1990 to December 2010) were reviewed retrospectively. The mean follow-up was 6.4 years (range, 0.05 to 1.3 years). Logistic regression analysis was used to identify factors associated with hospital death., Results: The overall hospital mortality rate was 6.7% (29 of 433 procedures). Logistic regression analysis identified only advanced New York Heart Association (NYHA) class as an independent predictor of hospital death. Overall survival at 5, 10, and 15 years was 83.6%±2.2%, 70.7%±3.4%, and 61.5%±4.5%, respectively. The 5-, 10-, and 15-year survivals for the first redo vs more than second redo groups were 86.5%±2.4% vs 74.7%±5.5%, 71.8%±3.9% vs 66.8%±6.6%, and 60.2%±5.7% vs 63.1%±7.2%, respectively (log-rank P=0.505). The 5- and 10-year survivals for NYHA class I/II vs III/IV patients were 91.5%±2.1% vs 70.4%±4.5% and 77.8%±4.1% vs 58.5%±5.6%, respectively (log-rank p<0.005)., Conclusions: Redo valvular operation in NYHA class III/IV patients is associated with high hospital death and poor long-term survival. To achieve low hospital death and good long-term survival, redo operations, including more than third redo operations, should be performed in patients with lower NYHA class., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The bacterial translational GTPases release factor RF3 promotes translation termination by recycling RF1 or RF2. Here, we present the crystal structures of RF3 complexed with GDP and guanosine 3',5'-(bis)diphosphate (ppGpp) at resolutions of 1.8 and 3.0Å, respectively. ppGpp is involved in the so-called "stringent response" of bacteria. ppGpp binds at the same site as GDP, suggesting that GDP and ppGpp are two alternative physiologically relevant ligands of RF3. We also found that ppGpp decelerates the recycling of RF1 by RF3. These lines of evidence suggest that RF3 functions both as a cellular metabolic sensor and as a regulator., (Copyright © 2012 Federation of European Biochemical Societies. Published by Elsevier B.V. All rights reserved.)

Myoglobin (Mb) stores dioxygen in muscles, and is a fundamental model protein widely used in molecular design. The presence of dimeric Mb has been known for more than forty years, but its structural and oxygen binding properties remain unknown. From an X-ray crystallographic analysis at 1.05 Å resolution, we found that dimeric metMb exhibits a domain-swapped structure with two extended α-helices. Each new long α-helix is formed by the E and F helices and the EF-loop of the original monomer, and as a result the proximal and distal histidines of the heme originate from different protomers. The heme orientation in the dimer was in the normal mode as in the monomer, but regulated faster from the reverse to normal orientation. The dimer possessed the oxygen binding property, although it exhibited a slightly higher oxygen binding affinity (∼1.4 fold) compared to the monomer and showed no cooperativity for oxygen binding. The oxygen binding rate constant (k(on)) of the dimer ((14.0 ± 0.7) × 10(6) M(-1) s(-1)) was similar to that of the monomer, whereas the oxygen dissociation rate constant (k(off)) of the dimer (8 ± 1 s(-1)) was smaller than that of the monomer (12 ± 1 s(-1)). We attribute the similar k(on) values to their active site structures being similar, whereas the faster regulation of the heme orientation and the smaller k(off) in the dimer are presumably due to the slight change in the active site structure and/or more rigid structure compared to the monomer. These results show that domain swapping may be a new tool for protein engineering.

As a remarkable structural feature of hydrogenase active sites, [NiFe]-hydrogenases harbor one carbonyl and two cyano ligands, where HypE and HypF are involved in the biosynthesis of the nitrile group as a precursor of the cyano groups. HypF catalyzes S-carbamoylation of the C-terminal cysteine of HypE via three steps using carbamoylphosphate and ATP, producing two unstable intermediates: carbamate and carbamoyladenylate. Although the crystal structures of intact HypE homodimers and partial HypF have been reported, it remains unclear how the consecutive reactions occur without the loss of unstable intermediates during the proposed reaction scheme. Here we report the crystal structures of full-length HypF both alone and in complex with HypE at resolutions of 2.0 and 2.6 Å, respectively. Three catalytic sites of the structures of the HypF nucleotide- and phosphate-bound forms have been identified, with each site connected via channels inside the protein. This finding suggests that the first two consecutive reactions occur without the release of carbamate or carbamoyladenylate from the enzyme. The structure of HypF in complex with HypE revealed that HypF can associate with HypE without disturbing its homodimeric interaction and that the binding manner allows the C-terminal Cys-351 of HypE to access the S-carbamoylation active site in HypF, suggesting that the third step can also proceed without the release of carbamoyladenylate. A comparison of the structure of HypF with the recently reported structures of O-carbamoyltransferase revealed different reaction mechanisms for carbamoyladenylate synthesis and a similar reaction mechanism for carbamoyltransfer to produce the carbamoyl-HypE molecule.

A 77-year-old man successfully underwent aortic valve replacement with a bioprosthesis through a right thoracotomy. Right thoracotomy was utilized because the patient had previously undergone esophagectomy with reconstruction of a substernal gastric tube for esophageal cancer as well as total laryngectomy with tracheostoma formation for laryngeal cancer. Thus, even in a situation in which conventional median sternotomy was difficult, a good outcome for aortic valve replacement was achieved through an alternate approach. This case highlights the need to consider patient history when selecting a surgical approach., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 44-year-old woman was transferred to our institution because of blunt chest trauma. Transthoracic echocardiography revealed decompression of the right ventricle resulting from pericardial effusion. Her hemodynamic condition was worsening gradually, and the decision was made to take the patient to the operating room. After releasing a large amount of clotting blood within the pericardial cavity, catastrophic hemorrhage occurred. Under better visualization after the patient was placed on cardiopulmonary bypass, we identified a 5-cm longitudinal tear and a 2-cm tear in the right atrium (RA), a 2-mm tear in the right ventricle (RV), and a 5-mm tear in the right lower pulmonary vein (PV). Those tears were repaired successfully with 5-0 polypropylene sutures., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

BacD is an ATP-dependent dipeptide ligase responsible for the biosynthesis of L-alanyl-L-anticapsin, a precursor of an antibiotic produced by Bacillus spp. In contrast to the well-studied and phylogenetically related D-alanine: D-alanine ligase (Ddl), BacD synthesizes dipeptides using L-amino acids as substrates and has a low substrate specificity in vitro. The enzyme is of great interest because of its potential application in industrial protein engineering for the environmentally friendly biological production of useful peptide compounds, such as physiologically active peptides, artificial sweeteners and antibiotics, but the determinants of its substrate specificity and its catalytic mechanism have not yet been established due to a lack of structural information. In this study, we report the crystal structure of BacD in complex with ADP and an intermediate analog, phosphorylated phosphinate L-alanyl-L-phenylalanine, refined to 2.5-Å resolution. The complex structure reveals that ADP and two magnesium ions bind in a manner similar to that of Ddl. However, the dipeptide orientation is reversed, and, concomitantly, the entrance to the amino acid binding cavity differs in position. Enzymatic characterization of two mutants, Y265F and S185A, demonstrates that these conserved residues are not catalytic residues at least in the reaction where L-phenylalanine is used as a substrate. On the basis of the biochemical and the structural data, we propose a reaction scheme and a catalytic mechanism for BacD., (Copyright © 2012 The Protein Society.)

Objective: Repair of bileaflet prolapse has been considered to be technically demanding and challenging. To assess the reliability and durability of mitral valve repair for bileaflet prolapse, the present study compared the outcomes of mitral valve repair for bileaflet prolapse with those for posterior prolapse., Methods: From January 1991 to April 2010, 191 consecutive patients with bileaflet prolapse (group B) underwent mitral valve repair using a combination procedure of expanded polytetrafluoroethylene chordal reconstruction for anterior prolapse, resection suture technique with/without sliding technique for posterior prolapse, and ring annuloplasty. During the same period, 323 patients with posterior prolapse (group P) underwent standard mitral valve repair. Serial echocardiograms were obtained at discharge and 1, 3, 5, and 10 years postoperatively., Results: The mean age in group B (54 ± 15 years) was significantly younger than that in group P (61 ± 12 years). Survival, including hospital death at 10 years, was superior in group B (group B, 90% ± 3%; group P, 83% ± 3%; P = .046). At 10 years, no significant differences were found between the groups in terms of freedom from recurrent mitral regurgitation of more than mild (group B, 89% ± 3%; group P, 90% ± 2%), freedom from reoperation (group B, 97% ± 2%; group P, 97% ± 1%), and event-free survival (group B, 79% ± 5%; group P, 83% ± 3%)., Conclusions: The reproducibility and reliability of mitral valve repair for bileaflet prolapse compares favorably with that of posterior leaflet prolapse. Early surgery might be recommended for patients with severe mitral regurgitation owing to bileaflet prolapse., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Atopic dermatitis is a skin condition often complicated by colonization with Staphylococcus aureus, which increases the risk of infective endocarditis, skin cellulitis and osteomyelitis. Positive cultures for Staphylococcus aureus are obtained from 70% to 80% of wounds in patients with mediastinitis. Thus sternotomy carries increased risk of mediastinitis in patients with atopic dermatitis. We retrospectively reviewed 25 patients with atopic dermatitis who underwent cardiac surgery via a median sternotomy or thoracotomy from January 1997 to September 2010 at our institution. Postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus was found in 3 patients who had a median sternotomy. They were ultimately discharged in good condition. No mediastinitis occurred in patients undergoing thoracotomy. Mediastinitis may occur due to direct exposure of the bone marrow to methicillin-resistant Staphylococcus aureus in patients with atopic dermatitis whose skin is colonized with such bacteria. Thoracotomy may be a better surgical approach in patients with atopic dermatitis who require thoracic surgery.

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background and Aim of the Study: It remains controversial whether early mitral valve (MV) repair should be performed for severe degenerative mitral regurgitation (MR) without symptoms, left ventricular (LV) dilatation or dysfunction, atrial fibrillation (AF) or pulmonary artery hypertension (PH), even at experienced surgical centers. The study aim was to reconsider the optimal timing of intervention for asymptomatic patients with severe degenerative MR at experienced surgical centers., Methods: Clinical outcomes were reviewed retrospectively for 298 consecutive asymptomatic patients (mean age 57 +/- 12 years) who underwent MV surgery for degenerative MR. The patients were allocated to two groups based on the following comorbid conditions: LVEF < or = 60%, LV end-systolic dimension 40 mm, AF, and PH. Group A comprised 122 patients with none of these conditions, while group B comprised 176 patients with any one of the conditions. The clinical outcomes were compared between the two groups at a mean of 7.0 +/- 4.5 years after surgery., Results: MV repair had been attempted in all patients, with a success rate of 100%. At 10 years, survival among group B patients was poorer than in group A (93% and 81%, respectively; p = 0.02), and there was a lower freedom from valve-related events (89% and 71%, respectively; p < 0.01). The independent predictors of valve-related events were preoperative AF (hazard ratio 3.34; p < 0.001) and age > 60 years (hazard ratio 2.50; p < 0.01)., Conclusion: Early MV repair is a reasonable option in asymptomatic patients, while preoperative AF may be a more appropriate predictor of an adverse outcome than LV function, as is currently recommended.

A 71-year-old patient with systemic lupus erythematosus, scleroderma and secondary antiphospholipid syndrome underwent coronary artery bypass grafting using cardiopulmonary bypass for angina pectoris. Postoperatively, new onset of thrombotic complications including neurological deficits was not recognized. She was discharged without any complications.

Membrane-bound respiratory [NiFe]-hydrogenase (MBH), a H(2)-uptake enzyme found in the periplasmic space of bacteria, catalyses the oxidation of dihydrogen: H(2) → 2H(+) + 2e(-) (ref. 1). In contrast to the well-studied O(2)-sensitive [NiFe]-hydrogenases (referred to as the standard enzymes), MBH has an O(2)-tolerant H(2) oxidation activity; however, the mechanism of O(2) tolerance is unclear. Here we report the crystal structures of Hydrogenovibrio marinus MBH in three different redox conditions at resolutions between 1.18 and 1.32 Å. We find that the proximal iron-sulphur (Fe-S) cluster of MBH has a [4Fe-3S] structure coordinated by six cysteine residues--in contrast to the [4Fe-4S] cubane structure coordinated by four cysteine residues found in the proximal Fe-S cluster of the standard enzymes--and that an amide nitrogen of the polypeptide backbone is deprotonated and additionally coordinates the cluster when chemically oxidized, thus stabilizing the superoxidized state of the cluster. The structure of MBH is very similar to that of the O(2)-sensitive standard enzymes except for the proximal Fe-S cluster. Our results give a reasonable explanation why the O(2) tolerance of MBH is attributable to the unique proximal Fe-S cluster; we propose that the cluster is not only a component of the electron transfer for the catalytic cycle, but that it also donates two electrons and one proton crucial for the appropriate reduction of O(2) in preventing the formation of an unready, inactive state of the enzyme.

Membrane-bound respiratory [NiFe] hydrogenase is an H2-uptake enzyme found in the periplasmic space of bacteria that plays a crucial role in energy-conservation processes. The heterodimeric unit of the enzyme from Hydrogenovibrio marinus was purified to homogeneity using chromatographic procedures. Crystals were grown using the sitting-drop vapour-diffusion method at room temperature. Preliminary crystallographic analysis revealed that the crystals belonged to space group P2(1), with unit-cell parameters a=75.72, b=116.59, c=113.40 Å, β=91.3°, indicating that two heterodimers were present in the asymmetric unit.

Coiled-coil DIX1 (Ccd1) is a positive regulator that activates the canonical Wnt signalling pathway by inhibiting the degradation of the key signal transducer β-catenin. The C-terminal DIX domain of Ccd1 plays an important role in the regulation of signal transduction through homo-oligomerization and protein complex formation with other DIX domain-containing proteins, i.e. axin and dishevelled proteins. Here, the expression, purification, crystallization and X-ray data collection of the Ccd1 DIX domain are reported. The crystals of the Ccd1 DIX domain belonged to space group P2(1)2(1)2(1), with unit-cell parameters a=72.9, b=75.7, c=125.6 Å. An X-ray diffraction data set was collected at 3.0 Å resolution.

Chylous ascites is a rare complication, and the treatment, which includes conservative and surgical strategies, is controversial. We describe two cases of chylous ascites that occurred after abdominal aortic aneurysm surgery. The first patient died of underlying diseases despite conservative treatment, while in the second patient, chylous ascites resolved with conservative treatment. In this article, we will discuss the management of chylous ascites, which vascular surgeons may face as a complication after abdominal aortic aneurysm surgery.

Purpose: To preliminarily examine whether solubility of water-soluble polyvinyl alcohol (PVA) microspheres in blood plasma changes in proportion to their degrees of saponification. The study also examined their feasibility as a temporary embolic agents in the pig renal artery., Materials and Methods: Three types of PVA microspheres with the degrees of saponification of 97 mol% (S97), 98 mol% (S98), and 99 mol% (S99) were prepared. Seven kidneys in seven miniature pigs were embolized and divided into three groups so there would be at least two kidneys for each type of PVA. One animal in each group was euthanized immediately after angiography at 3 hours after embolization and the other one at 7 days after. In addition, one animal embolized with S99 microspheres was euthanized at 21 days after embolization., Results: With S97 microspheres, the vascular network had recovered to the preembolic state by 3 hours after embolization. With S98 microspheres, blood flow in the third-order branch had been restored in the same period. With S99 microspheres, the second- and lower order branches remained occluded until 21 days. Histopathologic specimens harvested at 3 hours revealed only a trace of PVA for S97 microspheres. With S98 microspheres, the vascular lumen was still found to be filled with PVA gel. With S99 microspheres, swollen microspheres densely filled the vascular lumen even on day 21., Conclusions: Dissolution process in vitro and the duration of arterial occlusion in vivo were possibly related to the degree of saponification of PVA. This result may support feasibility of PVA microspheres as a temporary embolic agent., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

An 88-year-old man was transfered to our hospital due to loss of consciousness. Intravenous dopamine was initiated for a shock status and endotracheal intubation was performed. Computed tomography with contrast medium showed Stanford type A acute aortic dissection complicating cardiac tamponade. Because cardiac drainage was not effective, we performed an emergent operation. Intrapericardial cavity was filled with clotted blood. Prosthetic graft replacement of ascending aorta was performed successfully under deep hypothermic circulatory arrest. His clinical course was uneventful and he was discharged on foot without any neurologic deficits.

An asymptomatic 49-year-old woman was admitted for the purpose of surgery for aortic pseudoaneurysm. She had Marfan syndrome and had undergone an emergent Bentall procedure 10 years previously. About six months previously, she could palpate distended bilateral external jugular veins, which became distended only in a supine position and without any other symptoms. Enhanced computed tomography revealed an aortic pseudoaneurysm originating from a previous distal anastomosis site. During induction of general anesthesia in a supine position, bilateral external jugular venous distention was remarkable. Immediately after a successful operation, distention completely resolved. The present case emphasizes the importance of physical examination leading to a diagnosis of asymptomatic life-threatening diseases in patients with a history of previous aortic surgery.

Dissimilatory sulfite reductase (Dsr) plays an important role in sulfate respiration in many sulfate-reducing bacteria. Dsr from Desulfovibrio vulgaris Miyazaki F has been purified and crystallized at 277 K using the sitting-drop vapour-diffusion method with PEG 3350 and potassium thiocyanate as precipitants. A data set was collected to 3.7 Å resolution from a single crystal at 100 K using synchrotron radiation. The Dsr crystal belonged to space group P4(1)2(1)2, with unit-cell parameters a = b = 163.26, c = 435.32 Å. The crystal structure of Dsr was determined by the molecular-replacement method based on the three-dimensional structure of Dsr from D. vulgaris Hildenborough. The crystal contained three α(2)β(2)γ(2) units per asymmetric unit, with a Matthews coefficient (V(M)) of 2.35 Å(3) Da(-1); the solvent content was estimated to be 47.7%.

N-terminal truncation of the Escherichia coli ethanolamine ammonia-lyase beta-subunit does not affect the catalytic properties of the enzyme (Akita, K., Hieda, N., Baba, N., Kawaguchi, S., Sakamoto, H., Nakanishi, Y., Yamanishi, M., Mori, K., and Toraya, T. (2010) J. Biochem. 147, 83-93). The binary complex of the truncated enzyme with cyanocobalamin and the ternary complex with cyanocobalamin or adeninylpentylcobalamin and substrates were crystallized, and their x-ray structures were analyzed. The enzyme exists as a trimer of the (alphabeta)(2) dimer. The active site is in the (beta/alpha)(8) barrel of the alpha-subunit; the beta-subunit covers the lower part of the cobalamin that is bound in the interface of the alpha- and beta-subunits. The structure complexed with adeninylpentylcobalamin revealed the presence of an adenine ring-binding pocket in the enzyme that accommodates the adenine moiety through a hydrogen bond network. The substrate is bound by six hydrogen bonds with active-site residues. Argalpha(160) contributes to substrate binding most likely by hydrogen bonding with the O1 atom. The modeling study implies that marked angular strains and tensile forces induced by tight enzyme-coenzyme interactions are responsible for breaking the coenzyme Co-C bond. The coenzyme adenosyl radical in the productive conformation was modeled by superimposing its adenine ring on the adenine ring-binding site followed by ribosyl rotation around the N-glycosidic bond. A major structural change upon substrate binding was not observed with this particular enzyme. Glualpha(287), one of the substrate-binding residues, has a direct contact with the ribose group of the modeled adenosylcobalamin, which may contribute to the substrate-induced additional labilization of the Co-C bond.

Ethanolamine ammonia-lyase (EAL) catalyzes the adenosylcobalamin-dependent conversion of ethanolamine to acetaldehyde and ammonia. The wild-type enzyme shows a very low solubility. N-terminal truncation of the Escherichia coli EAL beta-subunit dramatically increases the solubility of the enzyme without altering its catalytic properties. Two deletion mutants of the enzyme [EAL(betaDelta4-30) and EAL(betaDelta4-43)] have been overexpressed, purified and crystallized using the sitting-drop vapour-diffusion method. Crystals of EAL(betaDelta4-30) and EAL(betaDelta4-43) diffracted to approximately 8.0 and 2.1 A resolution, respectively.

A 76-year-old woman with a history of percutaneous transvenous mitral commissurotomy and repeated hospital admissions due to heart failure was referred for an operation for severe mitral valve stenosis. She presented with hypertension, hyperlipidemia and cerebral infarction with stenosis of right internal carotid artery, retinopathy, neuropathy and nephropathy caused by long-term uncontrolled diabetes mellitus, hemoglobin A1c of 9.4%, and New York Heart Association (NYHA) functional classification of 3/4. Echocardiography revealed severe mitral valve stenosis with mitral valve area of 0.6 cm2, moderate tricuspid valve regurgitation, and dilatation of the left atrium. Taking into consideration the NYHA functional classification and severe mitral valve stenosis, an immediate surgical intervention designed to prevent mediastinitis was performed. The approach was via the right 4th thoracotomy, as conventional sternotomy would raise the risk of mediastinitis. Postoperative antibiotics were administered intravenously for 2 days, and signs of infection were not recognized.In patients with long-term uncontrolled diabetes mellitus, mid-line sternotomy can easily cause mediastinitis. The choice of operative approach plays an important role in preventing this complication. In this report, the importance of the conventional right thoracotomy for prevention for mediastinitis is reviewed.

NADH:rubredoxin oxidoreductase (NROR), an O(2)-inducible protein, is a versatile electron donor for scavengers of O(2) and reactive oxygen species (ROS) in Clostridium acetobutylicum. Recombinant NROR was overexpressed in Escherichia coli and purified to homogeneity; it was subsequently crystallized using the sitting-drop vapour-diffusion method at 293 K. Preliminary crystallographic analysis revealed that the crystals belonged to space group P4(1)22 or P4(3)22, with unit-cell parameters a = b = 98.6, c = 88.3 A, and diffracted to 2.1 A resolution. Assuming that the crystals contained one molecule per asymmetric unit, the Matthews coefficient was calculated to be 2.7 A(3) Da(-1) and the solvent content to be 54.1%.

The purpose of this study is to evaluate the clinical efficacy of transcatheter embolization for pseudoaneurysms of peripheral arteries with n-butyl cyanoacrylate (NBCA). From November 2000 to February 2008, 17 patients with 18 pseudoaneurysms were treated by transcatheter embolization at our affiliated hospitals. The locations of the pseudoaneurysms were right hepatic artery (n=3), renal artery (n=5), splenic artery (n=2), gastroduodenal artery (n=2), common hepatic artery (n=1), pancreatic arcade (n=1), external iliac artery (n=1), internal iliac artery (n=1), internal thoracic artery (n=1), and left gastric artery (n=1). We assessed technical success rate, embolization methods, and clinical course in this study. The technical success rate was 94.4% (17/18 cases). Embolization methods were isolation (n=17) and packing (n=1). Only NBCA was used in 14 cases, both coils and NBCA were used in four cases. Six patients were in shock prior to the procedure, but all patients recovered immediately after embolization procedure including transfusion. None of the patients died of procedure-related factors or had notable postoperative complications, but three patients died within a week of the procedure because of deterioration of the underlying disease. In conclusion, transcatheter embolization of pseudoaneurysms with NBCA is a safe and effective technique for treatment.

We report herein a case of a patient with high-flow priapism for whom a gelatin sponge was used as a temporary occlusive agent in arterial embolization, resulting in favorable outcome. The American Urological Association guideline on the management of priapism recommends using temporary occlusive agents. We reviewed all reports published after the introduction of this guideline to compare temporary and permanent occlusive agents in terms of symptom improvement and onset of erectile dysfunction. The rate of symptom improvement differed significantly between temporary and permanent embolizing materials, but no significant difference was apparent in the rate of erectile function improvement.

Class II release factor 3 (RF3) from the sulfate-reducing bacterium Desulfovibrio vulgaris Miyazaki F, which promotes rapid dissociation of a class I release factor, has been overexpressed, purified and crystallized in complex with GDP at 293 K using the sitting-drop vapour-diffusion method. A data set was collected to 1.8 A resolution from a single crystal at 100 K using synchrotron radiation. The crystal belongs to space group P1, with unit-cell parameters a = 47.39, b = 82.80, c = 148.29 A, alpha = 104.21, beta = 89.78, gamma = 89.63 degrees . The asymmetric unit contains four molecules of the RF3-GDP complex. The Matthews coefficient was calculated to be 2.3 A(3) Da(-1) and the solvent content was estimated to be 46.6%.

Purpose: To evaluate relationships between biochemical markers of bone turnover, bone mineral density, and new compression fractures following vertebroplasty., Methods: Initially, we enrolled 30 consecutive patients with vertebral compression fractures caused by osteoporosis. Twenty-three of the 30 patients visited our hospital for follow-up examinations for more than 4 weeks after vertebroplasty. The patients were divided into two groups: patients with new fractures (group F) and patients with no new fractures (group N). We analyzed differences in the following parameters between these two groups: serum bone alkaline phosphatase, urinary crosslinked N-telopeptide of type I collagen, urinary deoxypyridinoline, and bone mineral density. Next, the patients were divided into another two groups: patients with higher risk (group H: urinary crosslinked N-telopeptide of type I collagen >54.3 nmol BCE/mmol Cr or urinary deoxypyridinoline >7.6 nmol/mmol Cr, and serum bone alkaline phosphatase <29.0 U/l) and patients with lower risk (group L). We analyzed the difference in the rate of new fractures between these two groups., Results: We identified 9 new fractures in 7 patients. There were no significant differences between groups F and N. We identified 5 new fractures in 3 of the 4 patients in group H, and 4 new fractures in 4 of the 19 patients in group L. There was a significant difference in the rate of new fractures between groups H and L., Conclusions: A combination of high levels of bone resorption markers and normal levels of bone formation markers may be associated with increased risk of new recurrent fractures after percutaneous vertebroplasty.

Objective: The objective of this study was to prospectively investigate relationships between cement distribution patterns and the occurrence rates of new compression fractures after percutaneous vertebroplasty., Subjects and Methods: Percutaneous vertebroplasty was performed for osteoporotic compression fractures in 76 consecutive patients. Patients were divided into two groups according to the cement filling pattern shown on radiography and CT: cleft pattern group (group C, n = 34), compact and solid cement filling pattern in vertebrae; and trabecular pattern group (group T, n = 42), sponge-like filling pattern. A visual analog scale (VAS) was used to assess pain severity, and anterior and lateral radiographs of the thoracic and lumbar vertebrae were obtained 1-3 days and 1, 4, 10, 22, and 34 months after percutaneous vertebroplasty. Differences in treatment efficacy and the occurrence rates of new compression fractures were examined and compared for both groups using the Mann-Whitney U test and chi-square test., Results: A significant difference was seen between groups with respect to the volume of cement injected per vertebra (mean volume: group C, 4.5 mL; group T, 3.7 mL; p = 0.01). VAS improvement did not differ significantly between group C (4.6) and group T (4.5). The mean follow-up period was 19.5 months, during which new compression fractures were significantly more frequent in group C (17 of 34 [50%]) than in group T (11 of 42 [26.2%]; p = 0.03)., Conclusion: Although cement distribution patterns do not significantly affect initial clinical response, a higher incidence of new compression fractures is seen in patients with treated vertebrae exhibiting a cleft pattern.

The hydrogenase maturation protein HypE serves an essential function in the biosynthesis of the nitrile group, which is subsequently coordinated to Fe as CN(-) ligands in [Ni-Fe] hydrogenase. Here, we present the crystal structures of HypE from Desulfovibrio vulgaris Hildenborough in the presence and in the absence of ATP at a resolution of 2.0 A and 2.6 A, respectively. Comparison of the apo structure with the ATP-bound structure reveals that binding ATP causes an induced-fit movement of the N-terminal portion, but does not entail an overall structural change. The residue Cys341 at the C terminus, whose thiol group is supposed to be carbamoylated before the nitrile group synthesis, is completely buried within the protein and is located in the vicinity of the gamma-phosphate group of the bound ATP. This suggests that the catalytic reaction occurs in this configuration but that a conformational change is required for the carbamoylation of Cys341. A glutamate residue is found close to the thiol group as well, which is suggestive of deprotonation of the carbamoyl group at the beginning of the reactions.

Axin is a negative regulator of the canonical Wnt signalling pathway that mediates the phosphorylation of beta-catenin by glycogen synthase kinase 3beta. The DIX domain of rat axin, which is important for its homooligomerization and interactions with other regulators in the Wnt pathway, was purified and crystallized by the sitting-drop vapour-diffusion technique using polyethylene glycol 6000 and lithium sulfate as crystallization agents. Crystals belong to space group P6(1) or P6(5), with unit-cell parameters a = b = 91.49, c = 84.92 A. An X-ray diffraction data set has been collected to a nominal resolution of 2.9 A.

Purpose: To compare primary patency rates of cutting balloon percutaneous transluminal angioplasty (PTA) (hereafter, cutting PTA) and conventional balloon PTA (hereafter, conventional PTA) in the treatment of different types of hemodialysis access stenosis., Materials and Methods: The institutional review board approved this study. Written informed consent was obtained for the prospective component of this study and waived for the retrospective component. Patients in whom treatment with cutting PTA alone or conventional PTA alone was clinically successful formed the two study groups. Primary patency for the lesion was defined as uninterrupted patency of the treated site after balloon PTA. A site was no longer considered patent when the patient underwent treatment for hemodialysis access failure due to restenosis of the treated site. Primary patency rates for lesions were calculated with the Kaplan-Meier method according to the type of stenosis. We compared the two groups by using the log-rank test to determine statistical significance., Results: In the cutting PTA group, 62 patients with 77 stenoses (32 men, 30 women; mean age, 65.5 years +/- 10.1 [standard deviation]) achieved clinical success. In the conventional PTA group, 52 patients with 68 stenoses (23 men, 29 women; mean age, 61.9 years +/- 10.2) achieved clinical success. In patients with autogenous venous stenosis, no significant difference in the primary patency rate was noted between groups (P = .369). In patients with graft-to-vein anastomotic stenosis, the primary patency rate was significantly higher for cutting PTA than for conventional PTA (P = .39). In patients with intragraft stenosis, no significant difference in the primary patency rate was noted between groups (P = .379). In patients with in-stent restenosis, no significant difference in the primary patency rate was noted between groups (P = .923)., Conclusion: Primary patency rates are significantly higher for cutting PTA in the treatment of graft-to-vein anastomotic stenosis; however, no significant differences in primary patency rates exist between these PTAs in the treatment of autogenous venous stenosis, intragraft stenosis, or in-stent restenosis.

The case is reported of a 65-year-old male who required reoperation for early failure of a Freestyle stentless valve aortic root bioprosthesis implanted using the full root technique. The bioprosthesis had been implanted to treat annuloaortic ectasia associated with severe aortic regurgitation (AR). At 18 months postoperatively, a new diastolic murmur developed, though without complaint by the patient. Transthoracic echocardiography demonstrated severe AR with aneurysmal dilatation of the non-coronary porcine sinus of Valsalva. Pseudoaneurysm formation, associated with perforation of the non-coronary sinus of Valsalva of the bioprosthesis, was observed at surgery. On inspection, the pseudoaneurysm had pushed the commissures inward, and had created severe aortic valve regurgitation. No infection or calcification was detected on the Freestyle valve, and the aortic root was successfully reconstructed using a composite graft.

The HspBP1 homolog Fes1p was recently identified as a nucleotide exchange factor (NEF) of Ssa1p, a canonical Hsp70 molecular chaperone in the cytosol of Saccharomyces cerevisiae. Besides the Ssa-type Hsp70s, the yeast cytosol contains three additional classes of Hsp70, termed Ssb, Sse and Ssz. Here, we show that Fes1p also functions as NEF for the ribosome-bound Ssb Hsp70s. Sequence analysis indicated that residues important for interaction with Fes1p are highly conserved in Ssa1p and Ssb1p, but not in Sse1p and Ssz1p. Indeed, Fes1p interacts with Ssa1p and Ssb1p with similar affinity, but does not form a complex with Sse1p. Functional analysis showed that Fes1p accelerates the release of the nucleotide analog MABA-ADP from Ssb1p by a factor of 35. In contrast to the interaction between mammalian HspBP1 and Hsp70, however, addition of ATP only moderately decreases the affinity of Fes1p for Ssb1p. Point mutations in Fes1p abolishing complex formation with Ssa1p also prevent the interaction with Ssb1p. The ATPase activity of Ssb1p is stimulated by the ribosome-associated complex of Zuotin and Ssz1p (RAC). Interestingly, Fes1p inhibits the stimulation of Ssb1p ATPase by RAC, suggesting a complex regulatory role of Fes1p in modulating the function of Ssb Hsp70s in co-translational protein folding.

Purpose: To investigate the pain-alleviating effects of radiofrequency ablation (RFA) on metastatic bone tumors in relation to tumor size, combined therapy, and percent tumor necrosis rate following RFA., Methods: Subjects comprised 24 patients with 28 painful metastatic bone tumors. A 17G internally cooled electrode was inserted into the tumor for CT guidance and ablation was performed. Bone cement was injected following RFA for 4 tumors involving a weight-bearing bone, while 5 tumors were treated using combined RFA and external irradiation. Percent necrosis rate of the tumor was measured using contrast-enhanced computed tomography 1 week after RFA., Results: Improvement in the visual analog scale (VAS) score was 4.6 +/- 2.2 for large tumors (> 5 cm, n = 12), 3.7 +/- 1.8 for medium-sized tumors (3.1-5.0 cm, n = 11), and 3.5 +/- 1.7 for small tumors (< or = 3 cm, n = 4), with no significant differences noted among tumor sizes. Improvement in the VAS score was 3.5 +/- 1.3 for the 4 tumors in the RFA + bone cement group, 3.2 +/- 1.9 for the 5 tumors in the RFA + radiation therapy group, and 4.8 +/- 2.2 for the 18 tumors in the RFA group. No significant differences were identified between groups. The improvement in the VAS score was 3.8 +/- 2.3, 4.0 +/- 1.9, and 4.7 +/- 2.6 in patients with tumor necrosis rates of 0-49%, 50-74%, and 75-100%, respectively. No significant association was observed among these three groups., Conclusion: Percutaneous RFA therapy was effective in relieving pain due to metastatic bone tumors. No relationships appear to exist between initial response and tumor size, combined therapy, and percent tumor necrosis.

Purpose: To investigate the risk factors and relative risk of new compression fractures following vertebroplasty., Methods: Initially, we enrolled 104 consecutive patients with vertebral compression fractures caused by osteoporosis. A total of 83 of the 104 patients visited our hospital for follow-up examinations for more than 4 weeks after vertebroplasty. Logistic regression analysis of the data obtained from these 83 patients was used to determine relative risks of recurrent compression fractures, using 13 different factors., Results: We identified 59 new fractures in 30 of the 83 patients: 41 new fractures in vertebrae adjacent to treated vertebrae; and 18 new fractures in vertebrae not adjacent to treated vertebrae. New fractures occurred in vertebrae adjacent to treated vertebrae significantly more frequently than in vertebrae not adjacent to treated vertebrae. Only cement leakage into the disk was a significant predictor of new vertebral body fracture after vertebroplasty (odds ratio = 4.633). None of the following covariates were associated with increased risk of new fracture: age, gender, bone mineral density, the number of vertebroplasty procedures, the number of vertebrae treated per procedure, the cumulative number of vertebrae treated, the presence of a single untreated vertebra between treated vertebrae, the presence of multiple untreated vertebrae between treated vertebrae, the amount of bone cement injected per procedure, the cumulative amount of bone cement injected, cement leakage into the soft tissue around the vertebra, and cement leakage into the vein.

Hsp70 molecular chaperones function in protein folding in a manner dependent on regulation by co-chaperones. Hsp40s increase the low intrinsic ATPase activity of Hsp70, and nucleotide exchange factors (NEFs) remove ADP after ATP hydrolysis, enabling a new Hsp70 interaction cycle with non-native protein substrate. Here, we show that members of the Hsp70-related Hsp110 family cooperate with Hsp70 in protein folding in the eukaryotic cytosol. Mammalian Hsp110 and the yeast homologues Sse1p/2p catalyze efficient nucleotide exchange on Hsp70 and its orthologue in Saccharomyces cerevisiae, Ssa1p, respectively. Moreover, Sse1p has the same effect on Ssb1p, a ribosome-associated isoform of Hsp70 in yeast. Mutational analysis revealed that the N-terminal ATPase domain and the ultimate C-terminus of Sse1p are required for nucleotide exchange activity. The Hsp110 homologues significantly increase the rate and yield of Hsp70-mediated re-folding of thermally denatured firefly luciferase in vitro. Similarly, deletion of SSE1 causes a firefly luciferase folding defect in yeast cells under heat stress in vivo. Our data indicate that Hsp110 proteins are important components of the eukaryotic Hsp70 machinery of protein folding.

Purpose: To prospectively investigate the relationship between initial clinical response and bone marrow edema pattern on preprocedural magnetic resonance (MR) images in vertebral bodies selected for percutaneous vertebroplasty (PVP)., Materials and Methods: Institutional review board approval and written informed consent were obtained. PVP was performed for osteoporotic compression fractures in 80 consecutive patients (mean age, 72.4 years; range, 44-85 years; 67 women and 14 men; 157 vertebrae). Patients were divided into three groups according to the proportion of the vertebra in which the bone marrow edema pattern was observed on sagittal MR images: group 1, 50% or more of the vertebra; group 2, less than 50%; group 3, no edema pattern observed. By using Wilcoxon rank sum test, Fisher exact test, and Wilcoxon signed rank test, groups were examined for differences in treatment efficacy, which was defined as the difference between preprocedural and postprocedural pain as assessed by means of visual analog scale (VAS) score at 1-3 days after PVP., Results: Forty-four patients were assigned to group 1, 14 to group 2, and 22 to group 3. No significant difference was seen between the groups with respect to age, sex, number of treated vertebrae, or preprocedural VAS score. In group 1, VAS score decreased from 7.5 before the procedure to 2.9 after (improvement of 4.6). In group 2, the score decreased from 6.8 to 3.1 (improvement of 3.7). In group 3, the score decreased from 7.0 to 4.3 (improvement of 2.7). Improvement was significantly greater in group 1 than in group 3 (P < .005)., Conclusion: PVP resulted in significantly greater clinical improvement in patients with an extensive bone marrow edema pattern than in those without this pattern. (c) RSNA, 2006.

Spontaneous regression of hepatocellular carcinoma (HCC) is a rare phenomenon. We present herein the case of a patient with hepatocellular carcinoma with multiple lung metastases in whom malignancy spontaneously regressed after taking Pheliinus linteus Mycelium. A 79-year-old man consulted our hospital complaining of epigastric discomfort. Abdominal MRI and CT revealed a 3 cm diameter tumor in the liver, and chest CT showed numerous nodular lesions. The levels of alpha-fetoprotein (AFP) and protein induced by vitamin K deficiency or antagonist-II (PIVKA-II) were very high. We diagnosed HCC with multiple lung metastases, and no therapy was performed. Independently he took exact from Phellinus linteus Mycelium for one month, and 6 months later the tumors appeared to be in complete regression. The mechanism underlying this intriguing phenomenon remains unknown.