Search

A 83-year-old man underwent thyroplasty with arytenoid adduction for right recurrent laryngeal nerve palsy 1 year ago. He had been suffering from hemosputum and cough for last 2 months, and was referred to our hospital for medical examination. Laryngoscopy and neck computed tomography showed subglottic nodule. No evidence of malignancy was noted by a transbronchial biopsy of subglottic nodule. Since subglottic nodule grew rapidly during 2 months observation period, subglottic nodule resection was performed by bronchoscope. Histopathologic examination revealed that the tumor was suture granuloma with no evidence of malignancy. Cervical abscess as a complication of subglottic suture granuloma resection was occurred, because of suture material for arytenoid adduction and the injury of mucous membrane for removing the granuloma with the fenestration of thyroid cartilage for thyroplasty.

Because the liver is the primary target organ for chemicals and pharmaceuticals, evaluation of these substances' liver toxicity is of critical importance. New evaluation methods without animal testing (i.e., in vitro and/or in silico) are eagerly anticipated, both for animal welfare and for decreasing cost. Also, the importance of mechanistic interpretation of the output derived from non-animal testing has been increasing. Accordingly, we investigated the potential for evaluating liver toxicity by applying the adverse outcome pathway (AOP) concept using gene set enrichment analysis (GSEA) from gene expression (GEx) data. A case study targeting hepatocellular fatty degeneration (HFD) is reported and discussed. We first identified the events detectable in an in vitro system by comparing the GEx data from the rat primary hepatocyte (in vitro) and rat liver (in vivo) treated with a chemical with the ability to induce HFD as one of the phenotypes in a 28-day repeated-dose toxicity test. Then, the scores based on GSEA were calculated after establishing the gene sets for each event leading to HFD. As a result, the mechanistic information leading to HFD was obtained from the score calculated based on the GSEA and the usefulness of the transcriptome-driven evaluation using AOP was demonstrated.

A 76-year-old man, diagnosed with chronic myeloid leukemia in 2010, had been on nilotinib for 7 years. He presented with right hemiparesis in September 2017. He had no history of hypertension, diabetes, hyperlipidemia, heart disease, or smoking. Brain MRI revealed a border-zone infarction of the left cerebral hemisphere and a rapidly progressing severe left internal carotid artery (ICA) stenosis. He was initiated on clopidogrel and bosutinib instead of nilotinib. He presented with right hemiparesis once again in December 2017. Brain MRI revealed the border-zone infarction of the left cerebral hemisphere and a more progressed, severe bilateral ICA stenosis. A carotid ultrasound demonstrated iso-intense and concentrically narrowed ICA on both sides. Carotid artery stenting of the left ICA was performed in February 2018, and clopidogrel was replaced by cilostazol to provide a drug-induced rush. Carotid artery stenting of the right ICA was performed in June 2018 and cervical angiogram demonstrated that there were no residual artery stenoses in the bilateral stent. In recent years, several case reports suggest that tyrosine kinase inhibitors (TKIs) are associated with progressive artery stenosis and cause cerebral infarction. Brain imaging tests should be conducted to evaluate arterial stenosis progression for patients with a history of taking TKI when an arterial vascular event occurs.

A70 -year-old man with a diagnosis of panperitonitis caused by colon perforation due to invasion of gallbladder cancer was transferred to our hospital. The next day, an emergency operation was performed. During laparotomy, the ascending colon was perforated; therefore, ileocecal resection was performed. Six hours after the operation, the stoma became ischemic with marked abdominal distention. The intra-abdominal pressure increased to 28 mmHg, and the patient was diagnosed as having abdominal compartment syndrome(ACS). He immediately underwent decompressive laparotomy at bedside. Multiple organ failure was avoided and he recovered, but he died of advanced gallbladder cancer 4 months after the surgery. This case suggests that immediate surgical decompressive laparotomy for ACS can prevent multiple organ failure.

A 44-year-old woman was referred to our hospital with pleural effusion and unknown fever. Mycobacterium tuberculosis was not detected by culture of pleural effusion and sputum and gastric fluid. Pleural fluid was serous and exudative, and cytological examination showed no malignant cells. Computed tomography revealed a little pleural thickening of the right middle lobe and massive pleural effusion. As acute pleurisy was suspected based on the findings of imaging studies, thoracoscopy was performed under general anesthesia. Many yellowish-white, small nodules were seen on the parietal pleura, and white small nodule were seen on the visceral pleura of the right middle lobe. Mycobacterium tuberculosis was not detected by culture and polymerase chain reaction for Mycobacterium tuberculosis( TB-PCR) of parietal pleura and pleural effusion, but was detected by only culture and TB-PCR of visceral pleura, yielding a diagnosis of tuberculous pleurisy. Her symptoms improved and the right pleural effusion decreased with isoniazid (INH), rifampicin (RFP), ethambutol (EB) and pyrazinamide(PZA) treatment.

The 42-year-old woman who had been taking 300 mg phenytoin and 2,000 mg levetiracetam daily took 28.6 g of phenytoin and was transferred to our critical care center. The blood phenytoin concentration was 67.9 μg/mL on admission and decreased to 53.4 μg/mL on hospital day 2. Tonic seizures occurred several times on hospital day 2; thus, we resumed levetiracetam via a nasogastric tube. Thereafter, no further seizures were observed. We thought the seizure to have been caused by temporary withdrawal of levetiracetam because it did not occur on the day when the blood phenytoin concentration peaked and stopped altogether after resumption of levetiracetam. We considered that to treat the convulsion attack resulting from an overdose of the other antiepileptic drug with a different action mechanism, it was necessary to promptly restart the administration of the antiepileptic drug, which the patient was usually administered.

Aortic pseudoaneurysm is a late complication after cardiac surgery. The patient was a 63-year-old female who had undergone aortic valve replacement 3 years before. She complained of syncope and underwent pacemaker implantation for complete atrioventricular block. Aortic root pseudoaneurysms were accidentally detected by computed tomography, and 1 of them was 50 mm in size. She underwent aortic root replacement with a modified Bentall technique. Although there was no definite infection or inflammation, careful follow-up was considered to be mandatory.

A 61-year-old female, who had undergone the surgical treatment of acute type A aortic dissection with a ringed intraluminal graft 26 years before, presented with breathlessness. Computed tomography (CT) showed peri-prosthetic leakage and enlargement (45×50 mm in diameter), enlargement of the aortic root (42 mm in diameter), and aneurysm of the ascending aorta and the aortic arch (55 mm in diameter) with chronic type A aortic dissection. Echocardiography showed severe aortic regurgitation. She successfully underwent aortic root replacement( Bentall procedure) and total arch replacement.

A 39-year-old premenopausal nulliparous woman presented with severe pain in her right breast, bleeding and pus-like discharge, and a deep ulcer approximately 18 cm in diameter.Contralateral breast metastasis, bilateral axillary lymph node metastases, and multiple lung and bone metastases were detected on computed tomography.Five years previously she had undergone surgery for ovarian cancer and had prematurely discontinued adjuvant chemotherapy because of side effects. Following the administration of pain control, the patient received trastuzumab(Tr)plus vinorelbine(VNR)for her breast cancer as first-line therapy to avoid hair loss.The ulcer on her right chest wall underwent complete epithelialization and the patient's performance status improved from 3 to 0.The pus-like discharge, pain, bleeding, and odor from the breast resolved completely, and 5 months later, her quality of life had improved.The lung metastases also resolved completely.No adverse affects, including hematotoxicity and hair loss, were seen until treatment failure 12.5 months later. Second-line and third-line treatments were performed, but brain metastases developed, and the patient's overall condition deteriorated because of the development of ileus of unknown etiology.She died 21 months later.The patient received all therapies on an outpatient basis. Combination therapy using Tr and VNR is superior in safety and tolerability, and has been considered an option for first-line treatment of metastatic, locally advanced HER2-positive breast cancer.

The past decade of researches have revealed mutations of known or putative glycosyltransferases in several types of muscular dystrophy, including Fukuyama-type congenital muscular dystrophy. In these disorders, the function of α-dystroglycan is severely decreased, therefore they are called α-dystroglycanopathy. Recently, putative glycosyltransferase Large was shown to restore the defective function of α-dystroglycan, thus, it is an intriguing idea to apply this effect to the therapy of α-dystroglycanopathy. In the present study, we sought to test this possibility. Using several cultured cell lines, we confirmed that the overexpression of Large results in hyperglycosylation and marked enhancement of the function of α-dystroglycan. For this effect, the whole luminal domain of Large was shown to be necessary using several deletion constructs. We further generated transgenic mice overexpressing Large ubiquitously. In each tissue of the mice, the glycosylation of α-dystroglycan and its laminin binding activity was remarkably increased. Moreover, the morphological analyses on each tissue stained by H-E revealed no significant abnormality in the transgenic mice, suggesting no serious side effects by the overexpression of Large. Taken together, these results indicate that the restoration of the function of α-dystroglycan by Large should be an important molecular target to develop therapeutic strategies for α-dystroglycanopathy.

Tracheo-innominate artery fistula (TIF) is one of the highly lethal complications after the tracheostomy. We report a case of successful surgical treatment of TIF 4-year after the tracheostomy due to subacute sclerosing panencephalitis. Once the bleeding was controlled by the position and the high pressure of the tracheostomy tube cuff, but was not able to be controlled 24-hour after the hospitalization. At surgery, innominate artery was clamped simply at its origin under a median sternotomy. The each side orifice of the fistula was closed directly. The thymus was interposed between the innominate artery and the trachea to prevent the infection and the re-adhesion. After surgery, the cerebral infarction due to the procedure was not detected by the brain computed tomography (CT) and also the stenosis of the innominate artery was not detected by the chest enhanced CT.

Various treatments for hepatic metastasis of gastric cancer have been attempted, but problems remain with respect to long-term effectiveness and recurrence. Case reports have indicated the tumor regression effect of polysaccharide K(PSK)combined with chemotherapy, and meta-analysis has shown that PSK combined with chemotherapy improves the prognosis compared to chemotherapy alone. However, marked improvement of disease following PSK administration is rarely reported. We report a case of hepatic metastasis of gastric cancer in which low-dose UFT and PSK therapy resulted in regression of metastatic hepatic lesions and improvement of tumor markers. A 78-year-old man had synchronous hepatic metastasis of gastric cancer. Gastrectomy and microwave coagulation therapy using Microtase were conducted, followed by postoperative adjuvant chemotherapy with UFT 300 mg/day. Recurrences of metastatic hepatic lesion and new hepatic lesion were observed 6 months after surgery. Addition of PSK to UFT chemotherapy was selected as the treatment for recurrences, resulting in disappearance of the hepatic lesions and normalization of tumor markers. The patient is alive without recurrence at this writing, 38 months after surgery.

A 68-year-old man was referred to our hospital because of eosinophilia in peripheral blood and pancreatic tumor on abdominal US. He was accustomed to eating the raw flesh of wild boar and keeping wild boar, and under medical treatment for Diabetes. Pancreatic tumor was diagnosed to the pancreatic ductal cancer by the imaging examination and endoscopic transpapillary brushing cytology for pancreatic duct. The diagnosis of hepatic eosinophilic granuloma was done by aspiration biopsy for hepatic multiple small nodules. Because of the strong positive finding for nematose in the assay of multi dot-ELISA for parasite, hepatic eosinophilic granuloma caused by visceral larva migrans was accidentally complicated by pancreatic cancer, and operation for the pancreatic cancer was done. To bear this disease in mind and to research his life history, is important to diagnose hepatic multiple nodules with eosinophilia.

Congenital muscular dystrophy (CMD) refers to a heterogeneous group of muscular dystrophies with onset during the neonatal period. Among them, some types of CMD are characterized by the association of brain malformations and ocular abnormalities. Biochemical analyses revealed altered glycosylation and decreased laminin-binding activity of alpha-dystroglycan in these disorders, therefore they are correctively called alpha-dystroglycanopathy. Recently, mutations in the genes encoding demonstrated or putative glycosyltransferases have been identified in alpha-dystroglycanopathy. Fukuyama-type CMD and MDC1C are caused by mutations in the fukutin and fukutin-related protein (FKRP) genes, respectively. Mutations in the protein O-mannose beta-1, 2-N-acetylglucosaminyltransferase (POMGnT-1) and protein O-mannosyltransferase 1 and 2 (POMT1 and POMT2) genes cause muscle-eye-brain disease and Walker-Warburg syndrome, respectively. In addition, mutations in Large gene results in MDC1D. Furthermore, recent genotype-phenotype correlation analyses have revealed that the spectrum of phenotypes caused by mutations in these genes is much wider than originally assumed. In this review, we focus on the molecular pathomechanism and diverging clinical phenotypes of alpha-dystroglycanopathy.

Background: Assessment of deterioration of regional wall motion by echocardiography is not only subjective but also features difficulties with interobserver agreement. Progress in digital communication technology has made it possible to send video images from a distant location via the Internet., Objectives: The possibility of evaluating left ventricular wall motion using video images sent via the Internet to distant institutions was evaluated., Methods: Twenty-two subjects were randomly selected. Four sets of video images (parasternal long-axis view, parasternal short-axis view, apical four-chamber view, and apical two-chamber view) were taken for one cardiac cycle. The images were sent via the Internet to two institutions (observer C in facility A and observers D and E in facility B) for evaluation. Great care was taken to prevent disclosure of patient information to these observers. Parasternal long-axis images were divided into four segments, and the parasternal short-axis view, apical four-chamber view, and apical two-chamber view were divided into six segments. One of the following assessments, normokinesis, hypokinesis, akinesis, or dyskinesis, was assigned to each segment. The interobserver rates of agreement in judgments between observers C and D, observers C and E, and intraobserver agreement rate (for observer D) were calculated., Results: The rate of interobserver agreement was 85.7% (394/460 segments; Kappa = 0.65) between observers C and D, 76.7% (353/460 segments; Kappa = 0.39) between observers D and E, and 76.3% (351/460 segments; Kappa = 0.36)between observers C and E, and intraobserver agreement was 94.3% (434/460; Kappa = 0.86). Segments of difference judgments between observers C and D were normokinesis-hypokinesis; 62.1%, hypokinesis-akinesis; 33.3%, akinesis-dyskinesis; 3.0%, and normokinesis-akinesis; 1.5%., Conclusions: Wall motion can be evaluated at remote institutions via the Internet.

Although various therapies have been tried to improve advanced nonresectable pancreatic cancer, a sufficient consensus has not yet been obtained about the treatment. We have performed arterial infusion chemotherapy for pancreatic cancer in order to maintain QOL. The response rate was 17.3%, the mean survival time 282.1+/-204.7 days, median survival time 243.0+/-84.7 days, and many patients were continuously treated on an outpatient basis. It is thus expected that survival time and maintenance of QOL can be extended by self-sustaining arterial infusion chemotherapy.

Systemic lupus erythematosus (SLE) is often associated with various opportunistic infections, particularly during treatment with corticosteroids or immunosuppressants. We studied the clinical characteristics of 15 patients with SLE who underwent diagnostic bronchoalveolar lavage (BAL) and compared 6 patients with confirmed Pneumocystis pneumonia (PcP+), with 9 patients without Pneumocystis pneumonia (PcP-). The serum concentrations of beta-D-glucan and KL-6 were significantly higher in PcP+ than in PcP- patients, whereas serum LDH was similar in both groups. The serum concentrations of complement, a marker of SLE activity, and of IgG did not predict the presence of PcP. In all patients, the overall cell and lymphocyte counts were increased in the BAL fluid, without any significant difference between the PcP+ and PcP- groups. Ground-glass opacities on chest computed tomography, and oxygenation impairment (PaO2/FiO2<200Torr) were more common in PcP+ than PcP- patients. We concluded that, in patients with SLE, serum beta-D-glucan and KL-6 might be useful in the diagnosis of PcP, particularly when severe hypoxemia precludes BAL.

Many studies have shown that treatment with calcium channel blockers (CCB) decreases cardiovascular mortality and morbidity in elderly hypertensive patients. Many CCBs are now commercially available in Japan. CCBs recently developed have long lasting hypotensive effect and improve patient's compliance. CCB is one of the first line drugs for elderly hypertensive according to the recent international guidelines. Guidelines of Japanese Society of Hypertension (JSH2004) also recommend CCB as a first line drug in elderly hypertensive patients. We summarize the results of the studies using CCB in elderly hypertensive patients and the therapeutic strategy using CCB in elderly hypertensive patients.

Considerable evidence of the usefulness of antihypertensive therapy in elderly hypertensive patients has been shown by the clinical intervention studies in western countries, using diuretics, beta-blockers, Ca antagonist, angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Only two intervention studies on elderly hypertensive patients, which are NICS-EH and JATE, have been reported in Japan. Several Japanese intervention studies, such as JATOS, COPE, CASE-J, HOMED-BP and VALISH which conducted recently will provide us with new evidence in elderly hypertensive patients. We summarize the content of intervention studies on elderly hypertensive patients in western countries and Japan.

The arachidonic cascade involves three types of metabolic pathways; cyclo-oxygenase, lipoxygenase(LO), and cytochrome P450. The products of LO pathway participate in the pathogenesis of variety of disease such as allergic diseases and hypertension. In particular, 12-hydroxyeicosatetraenoic acid(12-HETE); product of 12-LO pathway, is concerned in the development of hypertension induced by angiotensin-II. In fact, several investigators have reported that 12-HETE has a critical role in hypertension and LO inhibitors have antihypertensive effects in experimental animals. And so, we can expect organ-protective effects of LO inhibitors as well as antihypertensive effects. Besides 12-LO, several investigators mentioned that 5- and 15-LO also have influences to cardiovascular systems. Therefore, we can expect further elucidation of the mechanism of 12-LO's participation in the organ damage and the clinical roles of 12-LO inhibitors to prevent from organ failure in future.

The number of patients undergoing combined aortic valve replacement (AVR) for aortic stenosis (AS) and coronary artery bypass grafting (CABG) has been increasing. In CABG, the internal thoracic artery (ITA) is the preferred conduit for its long-term patency. Although Doppler studies on ITA have been widely used, flow characteristics of the vessel in patients with AS have not been reported. To evaluate blood flow pattern of the ITA in AS, duplex scanning was performed in 10 patients before and after AVR. Peak systolic velocity was measured, and blood flow was calculated from mean velocity and cross-sectional area. The mean diameters of the vessels were approximately 1.8 mm on both sides. AVR caused an increase in systolic velocities from 61.2 cm/sec to 85.5 cm/sec in right ITA and from 58.4 cm/sec to 84.7 cm/sec in left ITA. The flow volumes increased from 32.2 ml/min to 46.7 ml/min in right and increased from 31.6 ml/min to 46.3 ml/min in left after AVR. In simultaneous AVR for AS and CABG, suitability of the ITA should be assessed before its use, and concomitant AVR may be quite important to provide adequate flow of the ITA as a conduit.

The flow reactivity of a left internal thoracic artery graft (LITAG) in response to atrial pacing was evaluated in 14 patients who underwent coronary artery bypass grafting (CABG) with LITAG to left anterior descending artery (LAD). Systolic peak velocity and diastolic peak velocity were recorded using a duplex scanner of 7.5 MHz, and flow volumes in each phase and flow ratio were calculated. The external temporary atrial pacing was used to increase heart rates 25 and 50%. Diastolic peak velocity and flow volume increased predominantly on both pacing rates. In contrast, systolic peak velocity decreased when heart rate was raised 50%, and there was no significant difference between the pacing modes in systolic flow volumes. As a result, flow ratio increased predominantly on both pacing rates. Based on the present studies, there may be some advantages with atrial pacing to increase the LITAG flow in response to the myocardial oxygen demand.

We report a 52-year-old right-handed man with cerebral infarction of the right anterior cerebral artery area. The MRI findings showed cerebral infarction in the trunk of the right corpus callosum, although some part of the posterior half of the trunk was spared. Some part of right precuneal gyrus, cingulate gyrus were also involved. The clinical feature of this case is characterized by following two points. First, although callosal apraxia is usually accompanied by agraphia, he showed apraxia with the left hand, but showed no agraphia. Secondary, he showed speech dysfluency mainly characterized by initial syllable repetitions. The nature of this speech dysfluency was determined as acquired stuttering. This case suggests that the pathway for praxis locates distinct portion from that for writing on corpus callosum. We analyzed callosal lesions of previous studies reporting callosal apraxia without agraphia, then compared to that of this case. And we also reviewed acquired stuttering report caused by callosal lesions. Consequently, we suggest that apraxia and stuttering were caused by damage of the trunk of the corpus callosum. While writing was preserved by the intact fibers in the posterior half of the trunk.

Diabetes mellitus may be an independent risk factor for disturbance of cardiac function, but the detailed mechanism remains unclear. In the present study, histological examinations were carried out on 25 hearts from diabetes model rats as well as myocardial biopsy materials from patients with diabetes (n = 25). The mean diameter of the cardiac myocytes in humans was 12.2 +/- 0.5 microns in the control group of patients without diabetes mellitus or hypertension (n = 6), 13.7 +/- 0.8 microns in the hypertension group (n = 3), 9.0 +/- 1.7 microns in the diabetes group (n = 8), and 11.9 +/- 2.0 microns in the diabetes with hypertension group (n = 8). The cardiac myocytes of diabetic patients appeared to be atrophic. Comparison of the size of myocytes in the control rats vs streptozotocin-induced diabetes model rats (n = 7, each) was 5.4 +/- 0.2 vs 5.2 +/- 0.3 microns at 2 weeks; 5.9 +/- 0.1 vs 4.9 +/- 0.9 microns at 12 weeks, and 5.7 +/- 0.1 vs 4.0 +/- 0.2 microns at 24 weeks, respectively, and gradually decreased in streptozotocin rats with aging. Immuno-histochemistry with phaloidin was used to assess F-actin in the cardiac myocytes. The relative cross-sectional area of F-actin in the cardiac myocytes of streptozotocin rats was compared to that in non-streptozotocin rat myocytes. F-actin fluorescence in streptozotocin rats was 89.9 +/- 3.9% at 2 weeks, 77.9 +/- 6.4% at 12 weeks, and 56.8 +/- 5.7% at 24 weeks, indicating a decrease in F-actin. These results suggest that the smaller myocytes observed in patients with diabetes and streptozotocin rats are related to the decrease in F-actin in myocytes.

Only three cases of the combination of bicuspid aortic valve and ruptured aneurysm of the sinus of Valsalva, associated with previously repaired coarctation of aorta, have been reported. A twenty-year-old man with a sudden onset of CHF due to ruptured aneurysm of the sinus of Valsalva underwent intracardiac repair by direct closure of the sinus Valsalva in combination with patch closure of a subarterial VSD. Although, no AR was detected preoperatively, massive regurgitation occurred after the repair due to subsequent failure of aortic valve coaptation in the present of the bicuspid aortic valve, which was not diagnosed preoperatively. Aortic valve replacement with SJM 25 mm was successfully performed.

Three years after myocardial infarction, a 60-year-old man had congestive heart failure caused by left ventricular aneurysm with mitral regurgitation. He underwent the following concomitant operations: (1) patch reconstruction for a left ventricular aneurysm and (2) mitral plasty for a torn chordate and mitral regurgitation by using valvuloplasty, a shortening chordae and a prosthetic ring. A postoperative examination indicated that his cardiac function had markedly improved.

ACE inhibitor is known to have a therapeutic efficacy in renal diseases by reducing proteinuria and maintaining renal function. However, the relationship between ACE gene polymorphism and renal disease has not been fully elucidated. In this study, a 287 base pair(bp) I/D polymorphism of the ACE gene was examined with polymerase chain reaction(PCR) in 100 healthy subjects, 34 patients with chronic glomerulonephritis(CGN), 29 with chronic renal failure(CRF) and 25 with diabetes mellitus(DM) with(13) and without(12) nephropathy. We also measured serum ACE activity of these patients. ACE genotype and derived allele frequencies in each disease group did not differ significantly from those in healthy subjects. In all disease groups, values of serum ACE activity were higher in genotype DD than in genotype II. These findings suggest no significant association between I/D polymorphism of the ACE gene and renal disease. Further studies are needed to clarify these findings, considering renal function and type of renal disease.

A 63-year-old woman was admitted to our intensive care unit suffering from severe chest pain and shock. Emergency CT scan demonstrated an acute type A aortic dissection with non-opacified false lumen and cardiac tamponade. The aortography showed ulcer like projection at the ascending aorta. An emergency operation was performed to replace the ascending aorta with a woven double-velour Dacron graft of 30 mm in diameter. It seems that an acute type A aortic dissection with non-opacified false lumen has good prognosis. The presence of other complications, however, suggests that surgical treatment should be decided upon at an early stage.

A 30-year-old man, who had undergone Hardy's operation and the direct closure of an atrial septal defect for Ebstein's anomaly at age 9, was reoperated on by Carpentier's procedure for a long-standing tricuspid regurgitation. He required IABP support to wean from the cardiopulmonary bypass for the acute heart failure. Nonetheless, his postoperative course was uneventful. Echocardiography, nine months after the operation, showed a decrease in moderate residual regurgitation and an increase in the right ventricular inflow velocity, which were considered signs of an improvement in the right ventricular function and, furthermore, it showed an increase in the left ventricular volume and a marked improvement in the left ventricular ejection fraction. We consider that tricuspid regurgitation for many years result in a dysfunction in the right ventricle and, because of a decrease in the filling volume, in the left ventricle. For this reason, we should positively perform an operation without leaving tricuspid regurgitation as it is.

We report a patient with a relapsing form of acute ataxic polyradiculoneuritis. The patient developed marked sensory ataxia with mild limb weakness following a respiratory tract infection. Five similar relapses occurred over 18 years. The symptoms reached their maximum in 2 weeks, followed by subsequent gradual improvement over 1-2 months. Sural nerve biopsy showed mild loss of large myelinated fibers.

To study the mechanism of action of BCG against transitional cell carcinoma of the bladder from the immunological standpoint, we observed time-course changes in the serum and urine levels of tumor necrosis factor (TNF-alpha) and interleukin-2 (IL-2) before and after an intravesical BCG instillation in 16 patients with superficialis transitional cell carcinoma. Serum TNF-alpha concentrations were roughly constant and lower than normal though there was a slight difference between the values before and after BCG instillation or between the test and control values. TNF alpha secretion in urine was increased irrespective of the time for sampling specimens as compared with the control values sampling, remained unaffected by BCG instillations and was increased in many patients even before BCG instillation, probably due to presence of vesical inflammation. No significant changes were detected regarding serum or urine IL-2 before and after BCG instillation and between the test and control values. Thus, the present study failed to demonstrate the involvement of a direct action of TNF-alpha, activation of immunological cells by IL-2 or its direct action as an anti-tumor effect of intravesical instillation of BCG.

A 49-year-old woman with Lutembacher syndrome, atrial septal defect (ASD), mitral stenosis (MS), tricuspid regurgitation and cardiac cachexia underwent a mitral valve replacement with a 27 mm CarboMedics valve, patch closure of ASD and tricuspid annuloplasty to 29 mm by DeVega's method. The pressure volume loop (PV loop) was measured, both preoperatively and postoperatively (immediately and two months after the operation) by a Miller catheter and echocardiogram. The left ventricular stroke work (LVSW), left ventricular end diastolic volume (LVEDV) and left ventricular end diastolic pressure (LVEDP) markedly increased immediately after the operation. LVSW and LVEDV further increased, whereas LVEDP decreased with improvements in diastolic compliance two months after the operation. It was likely that those change of LV function was a sum of simple ASD and MS both of which have similar but less significant characters than Lutembacher syndrome.

We report results of a study on the relation between the clinical findings 2 years after initiation of the therapy and the long-term prognosis of seizure control, and discuss the possibility of predicting the prognosis in the early stage of therapy. The subjects consisted of 141 patients, observed for 10 to 20 years at Hirosaki University Hospital. Regarding the epilepsy type, the prognosis of temporal lobe epilepsy was unfavorable. In temporal lobe epilepsy, only 21% were in remission (seizure-free for 3 years or more) at the time of the study. Also, the presence of organic brain lesions or neuropsychiatric complications at the early stage of treatment was associated with unfavorable prognosis. We are particularly interested in the possibility of predicting the long-term prognosis from the result of early response to anti-epileptic drug therapy. We found a significant correlation between the early excellent response to drug treatment and the good long-term prognosis. Using discriminant analysis (quantification theory II), we tried to find which factors would influence more to the long-term prognosis. As the result, an importance was found in the following order: (1) epilepsy type, (2) presence or absence of neuropsychiatric complications, (3) age at onset, (4) early response to treatment, (5) presence or absence of organic brain lesions and (6) the interval between the onset and the initiation of drug treatment. Correct identification rate by discriminant analysis was 73%.

We report an autopsied case of Parkinson's disease manifesting Shy-Drager syndrome. At the age of 63 years, the patient noticed an onset of progressive orthostatic dizziness, which was followed by constipation, dysuria, and sexual impotence. When he was 66 years old, syncopal attack for a few minutes, tremor in the bilateral hands, and memory disturbance developed. On admission, his blood pressure was 142/72 mmHg in supine position, which fell to 58/42 mmHg on standing with appropriate increase of heart rate. Neurological examination revealed hallucination, memory disturbance, masked face, muscular rigidity, bradykinesia, mild postural tremor, and autonomic dysfunction including severe orthostatic hypotension, hypohydrosis, constipation, dysuria, and sexual impotence. Electroencephalogram showed diffuse slowing. Brain CT demonstrated absence of severe atrophy of the cerebellum, and brain stem. Pharmacological study revealed denervation hypersensitivity to the intravenously administrated noradrenaline. A diagnosis of Shy-Drager syndrome was made, and he was treated with anti parkinsonian drugs. However, no improvement was observed in his clinical symptoms. Seven months later, he died of pneumonia. Neuropathological examination revealed marked neuronal cell loss and gliosis in the substantia nigra and locus ceruleus. Lewy bodies were seen in those pigmented nuclei, dorsal vagal nucleus, hypothalamus and nucleus basalis of Meynert. No abnormality was found in the intermediolateral nucleus of the spinal cord. This is the first report on a Japanese patient who presented clinically Shy-Drager syndrome and pathologically typical Parkinson's disease. In this patient, from the pharmacological and pathological findings, sympathetic ganglia were supposed to be the responsible lesion for orthostatic hypotension.

Side effects and serious complications of intravesical bacillus Calmette-Guérin (BCG) therapy were reviewed in 120 patients with transitional cell carcinoma of the urinary bladder from October, 1983 to June, 1989 at Hirosaki University Hospital. As local side effects, 102 patients (85.0%) had bladder irritability with frequency and/or micturition pain, and 46 patients (38.3%) had hematopyuria. As systemic side effects, fever in 43 patients (35.8%), elevation of serum GOT, GPT in 9 patients (7.5%), and malaise in 3 patients (2.5%) were seen. Serious complications were observed in 7 patients. 4 patients had a severely contracted bladder with decreased compliance less than 50 ml, 2 patients had persistent arthritis and one patient had interstitial pneumonia. In all 4 patients with a contracted bladder partial cystectomy was performed before or after intravesical BCG therapy, and three of them received more than ten times instillation of BCG. It was suggested that contracted bladder most likely occurred after frequent BCG instillations in addition to decreased bladder compliance. Contracted bladder was irreversible in 2 patients. Histopathologically, there was marked fibrosis in the muscular layer of the bladder without tuberculous inflammatory changes. It might depend on the severity of fibrosis in the muscular layer whether contracted bladder was reversible or not. Persistent arthritis was nonspecific inflammation with negative culture results for mycobacteria in the joint fluid in 2 patients. In one patient with interstitial pneumonia, fiberoptic bronchoscopy with transbronchial lung biopsy demonstrated marked fibrosis of alveolar septums and increased lymphocyte count without tuberculous inflammatory changes. The pathogenesis of this complications is considered to be a hypersensitivity reaction to BCG.

An autopsy case of glioblastoma of the cerebellum associated with an intracerebellar hemorrhage and showing CSF seedings is reported. A 26 year-old male was admitted to our hospital with a 10-day history of headache, nausea and vertigo. On admission, disturbance of consciousness (10-20 by JCS), irregular respiration and central fixation of both eyes suggesting increased intracranial pressure and early stage of central herniation were recognized clinically. The cerebellar signs of dysmetria and nystagmus were also observed. CT scan and angiography revealed an avascular large mass in the right cerebellar hemisphere, obstructive hydrocephalus and upward transtentorial herniation. On MRI study, the mass was demonstrated to be a subacute hematoma with a small tumor in its margin. Total removal of the tumor and aspiration of the hematoma were performed. Histological examination revealed a highly cellular and pleomorphic astrocytic tumor with scattered small necrosis and glomeruloid capillary endothelial proliferation, typical of glioblastoma multiforme. During postoperative radiochemotherapy (focal irradiation to the posterior fossa), the tumor showed rapid regrowth and a second look operation was performed. He was readmitted 3 weeks after radiochemotherapy with complaints of severe headache, nausea and lumbago. He then suddenly became dyspnea, tetraplegic and bradycardic. Neuroradiological investigation revealed multiple masses in the suprasellar region, medulla oblongata and the cervical spinal cord, but no recurrence in the cerebellum. Malignant cells were noted on CSF cytology. During chemotherapy for CSF tumor dissemination, his condition deteriorated rapidly and he died 7 months after the onset of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

It is well known that some fetal antigens are expressed in malignant tumor cells. Likewise, brain tumors, especially histologically malignant cases, may have any antigenic relationships with fetal brain. So, we investigated the relationship by immunohistochemical technique, utilizing a polyclonal antibody to mouse fetal stage-specific polypeptide "GP68". We prepared GP68 from homogenate of head part of embryos at the 14th day of gestation mice by RCA-1 agarose column chromatography. And immunized it to Japanese white rabbits and the titer was measured by enzyme-linked immunosorbent assay. We analyzed operatively resected brain tumors and autopsy brain tissues. Frozen tissues were fixed in cold acetone and immunostained with anti-GP68 serum according to biotin-streptavidin peroxidase method. Remained tissues were homogenized in Laemmli's sample buffer and electrophoresed. The proteins were transferred to nitrocellulose membrane and immunostained with anti-GP68. Normal brain tissues were not positively stained, except for capillary endothelium which showed a weak staining. On the other hand, brain tumors of neuroectodermal origin were positively stained in varying degrees, and other tumors were negative. It is especially noteworthy that, in astrocytoma cases, there exists a definite correlation between the intensity of stain and the degree of histological malignancy. Immunoblot studies demonstrated a very weak band at 68 KD in normal brain and meningioma. In contrast, very strong band at the same position was seen in malignant astrocytomas. These results suggested that in brain tumors, especially those of neuroectodermal origin, GP68 antigen is expressed and the degree of expression is related to their histological malignancy. So this fetal antigen may be useful for evaluation of biological malignancy of gliomas.(ABSTRACT TRUNCATED AT 250 WORDS)

The alveolar bone of edentulous ridge is resorbed after the teeth extraction and the subsequent denture insertion. For the periodontal structure, the stress transmitted along the longitudinal axis is favorable, but the horizontal stress is destructive. Under the overdenture application which the retained teeth have the reduced clinical crown, it is possible to prevent the alveolar bone resorption and to improve the involved teeth. However it is difficult for the inclined teeth to get the successful results. In a case, having a few remained teeth contained the embedded root stump and the overdenture being applicated, we obtained the suggestion as follows. 1. Also the embedded root stump is useful to prevent the alveolar bone resorption. 2. The top and direction of longitudinal axes of the inclined abutment teeth can be determined by means of surveying the least teeth movement when the stress was applied to the teeth by the fingers with dental pincette. 3. Also to the inclined abutment teeth, it is possible to transmit the stress along the longitudinal axes, when the overdenture has the contact with the short dome coping at the top and in the inferior area to the longitudinal axes inclined, and is relieved in the superior area to its axes.

Using the islet perifusion preparation and the isolated rat pancreas in situ perfusion preparation, the effects of disopyramide (Diso) on insulin secretion were studied. In an isolated pancreatic islet perifusion experiment, Diso (300 micrograms/ml) produced a significant increase in the immunoreactive insulin (IRI) level in the perfusate. The Diso-induced IRI rise was not affected by pretreatment with various autonomic blocking agents, such as propranolol, phentolamine or atropine. In an isolated rat pancreas in situ perfusion experiment, the IRI level in the perfusate increased significantly after the administration of Diso (300 micrograms/0.1 ml) under the perfusion of Krebs-Ringer bicarbonate buffer solution containing 0.3% glucose (0.3% glucose buffer), but not under the perfusion of Krebs-Ringer bicarbonate buffer solution containing 0.1% glucose (0.1% glucose buffer). The Diso-induced IRI rise was not affected by pretreatment with the autonomic blocking agents. Diso suppressed the IRI rise which was induced by additional glucose application (25%, 0.2 ml) under the perfusion of 0.1% glucose buffer, but not under the perfusion of 0.3% glucose buffer. Furthermore, Diso also suppressed the hypersecretion of insulin induced by increasing the glucose concentration from 0.1% to 0.3% in the perfusion fluid. The suppressing action of Diso on glucose-stimulated insulin secretion was partially recovered after pretreatment with propranolol or phentolamine. These findings show that Diso has both stimulatory and inhibitory effects on insulin secretion processes, and that the inhibitory action of Diso is suppressed by high glucose solution.

The purpose of this study was to investigate the etiology and characteristics of the ectopic eruption of first permanent molars. The subjects were 35 cases (27 maxilla and 8 mandible) with ectopically erupted permanent first molars, which were recognized in 24 out-patients (10 boys and 14 girls) visiting Tohoku University, Dental Hospital. The materials used for the analysis were dental casts, X-ray lateral cephalograms and panoramic radiographs, and both materials of the ectopic and normal groups were compared. The results were as follows: 1) There were no significant differences statistically between the mesio-distal crown diameters of the maxillary permanent first molar, central and lateral incisor, and all deciduous teeth in ectopic group and their mean values in Ono's and Otsubo's studies. 2) There were no significant differences as compared to all parts of the size of the dental arch in ectopic sides with those in the normal sides of same individuals at IIA and IIC of Hellman's developmental stage in dentition. 3) When the sizes of the dental arch in the ectopic group were compared with those of the normal group, the former were smaller at the distance between the mid-point and the canine mesial surface (Fig. 1-4), the ridge of the posterior region of the basal arch and most distal point of the primary second molar (Fig. 1-6) at the Hellman's dental age IIA, while the canine distance to the midline (Fig. 1-1), the dental arch perimeter from mid-point to the distal surface of primary second molar (Fig. 1-4+5), and the distance between the canine and primary second molar, div. X (Fig. 1-7) at Hellman's dental age of IIC were significantly smaller than the latter. 4) Regarding the comparison of the value of the changes in dental arch size between the ectopic group and the normal group from Hellman's dental age of IIA to IIC, the distance between the canine and primary second molar, div. X (Fig. 1-7) decreased markedly and the distance between the ridge of the posterior region of the basal arch and the most distal point of the primary second molar (Fig. 1-6) increased. 5) Results of the analysis of X-ray lateral cephalograms showed that the angle of eruption of first molars in the ectopic group was significantly smaller compared with normal group. 6) According to the cluster analysis on the calcification of tooth germ using panoramic radiographs, similarity among all of the samples was lacking in the ectopic group, especially congenital missing of the second molars and second premolars in the ectopic side and the delayed calcification of the ectopically erupted teeth were found in maxilla.