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Introduction The shortage of cadaver organs has led to expansion of living donor kidney transplantations with, 30% increase among ABO-incompatible cases in Japan and the use of marginal extended donors. Herein we have reported the outcome after an ABO-incompatible kidney transplantation from an aged living-related donor who suffered from mild diabetes mellitus and hypertension. Case Report A 48-year-old man underwent ABO-incompatible kidney transplantation from his 76-year-old father, using anti-CD20 antibody induction, followed by cyclosporine (CsA), mycophenolate mofetil (MMF), and prednisolone. After the operation, MMF was switched to high-dose mizoribine (MZ). He was discharged from the hospital on postoperative day (POD) 28 with a serum creatinine (sCr) of 1.47 mg/dL. On POD 34 when the sCr was 8.14 mg/dL, his urine examination showed uric acid crystals with serum uric acid of 24.6 mg/dL. Biopsy findings showed no evidence of acute rejection but mild tubulointerstitial injury. Hemodialysis performed twice to reduce uric acid was accompanied by hydration. CsA/MZ was switched to tacrolims/MMF; benzbromarone, to febuxostat to treat hyperuric acidemia. On POD 58, sCr reduced to 1.75 mg/dL he was discharged. On POD 416, graft function was stable with sCr of 1.70 mg/dL. Conclusion Common side effect of MZ is hyperuricemia which presumably caused acute renal failure of this aged marginal donor kidney.

An 81-year-old female found to have an aneurysm in the distal aortic arch was successfully treated with arch translocation method. Under selective cerebral perfusion, a stent graft bound to a nephrostomy balloon catheter with a chainstitch was inserted from the ascending aorta into the descending aorta and its proximal end was sutured together with the distal aortic stump. Then a 4-branched Dacron graft replaced the ascending aorta reconstructing cephalobracheal branches individually. Each proximal end of cephalobracheal branches was ligated. The patient had no neurological deficit except for recurrence nerve palsy that had already existed before the operation. Postoperative angiography revealed complete thrombocclusion of the aneurysm.

A tuberculous aneurysm is rare and fatal because it may lead to a rupture due to the forming of a pseudoaneurysm. A lesion is especially uncommon in the ascending aorta. We report an unusual case of tuberculous pseudoaneurysm of the ascending aorta which developed 7 months after the onset of multiple intracranial tuberculoma in a 59-year-old man. He was treated for multiple intracranial tuberculomas in another hospital because of headache and left homonymous hemianopia. The temporal intracranial tuberculomas were reduced after antituberculous drug administration. However, they enlarged again shortly thereafter. At that time, a pseudoaneurysm of the ascending aorta was found, so he was introduced to our department. Intensive antituberculous drugs were administered perioperatively and postoperatively. The intracranial tuberculoma was reduced preoperatively. After that, the ascending aorta was successfully replaced with a Dacron graft. A hole was noted in the back of the ascending aorta. Three years after the operation, no symptoms of recurrence have been recognized. A tuberculous pseudoaneurysm of the ascending aorta may easily cause systemic tuberculosis or rupture, therefore it should be treated as early as possible.

The purpose of this study was to verify the difference between carrying a load on the sacrum (LOS) and on the lumbar vertebrae (LOL) in oxygen uptake, muscle activities, heart rate, cadence, and subjective response. Nine males (26.7 +/- 3.1 years old), each carrying a 7.5 kg carrier frame and a 40 kg load, walked on a treadmill at a speed of 50 m/min. EMGs were recorded from the trapezius, rectus abdominis, erector spinae, vastus lateralis, rectus femoris, vastus medialis, biceps femoris long head, tibial anterior, soleus, medial head of gastrocnemius, and the lateral head of gastrocnemius. For each subject the integrated EMG (IEMG) was normalized by dividing the IEMG in the LOL and LOS by the IEMG in a no-load condition (NL) for each investigated muscle. The following was significantly higher in LOL than in LOS: oxygen uptake; IEMG of the tibial anterior, soleus, and medial head of gastrocnemius; cadence; and rated perceived exertion. However, IEMG of the erector spinae was significantly lower in LOL than in LOS. These results suggest that seita-fitting in LOS causes a decrease of leg muscle activities, which causes oxygen uptake to decrease beyond the increase of the erector spinae activity.

The purpose of this study was to evaluate characteristics and outcomes of octogenarians undergoing cardiovascular surgery with cardiopulmonary bypass in a Japanese population. Thirty-one consecutive patients over 80 years of age underwent coronary artery bypass grafting 19 (61%), combined coronary artery bypass grafting and ventricular septal perforation closure 1 (3%), valve replacement 3 (10%), and prosthetic graft replacement 8 (26%). The early mortality rate was 16.1%. Survival estimates were 74% after 1 year, 74% after 3 year, and 64% after 5 years. Emergency and urgent cases involved 16 (51.6%), and 2 patients (6.5%), respectively. Multivariate analyses revealed that predictors of early mortality was preoperative left ventricular ejection fraction. Predictors of hospital death (within 3 months after surgery) were preoperative renal dysfunction, intraaortic balloon pumping, and age. Predictors of late mortality were chronic lung disease and age. Twenty-one patients expected to have died before surgery were living at home, and 9 (40.9%) patients were completely autonomous. Multivariate analyses revealed diabetes mellitus and a small number of bypass grafts were predictive risk factors for postoperative autonomy. Thus, cardiovascular surgery can be performed in octogenarians under 85 years of age with a favorable long-term outcome, when appropriately applied in selective octogenarians without significant comorbidity. If patients are over 85 years of age or have significant comorbidity, clinical treatment recommendations should be individually tailored while evaluating the risk of having or not having surgery and their life expectancy. QOL of survivors was almost satisfactory and significantly improved compared with a preoperative state.

A 27-year-old male who had been diagnosed with Ebstein's anomaly was admitted with uncontrollable congestive heart failure. The echocardiogram revealed severe tricuspid valve incompetence and the electrocardiogram showed atrial fibrillation. He underwent Hetzer's repair procedure for tricuspid valve incompetence and Minzioni's right atrial isolation technique to restore sinus rhythm. His congestive heart failure quickly disappeared and sinus rhythm was restored after operation. He was discharged 3 weeks postoperatively and remains well 22 months after his operation. Hetzer's technique for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid anulus by using the most mobile leaflet for valve closure without plication of the atrialized chamber. We conclude that Hetzer's procedure is an effective operation for Ebstein's anomaly.

An infected pseudoaneurysm of the ascending aorta after heart surgery is a fatal disease due to its rapid progress, worsening of the systemic condition and a tendency of recurrence. We report a 53-year-old man with this condition who presented with fever and an aortic regurgitation due to compression of the ascending aortic root 2 months after mitral valve replacement for infective endocarditis. We performed an aneurysmectomy with a cardiopulmonary bypass using groin cannulation and moderate systemic hypothermia. A pseudoaneurysm developed 5 mm proximally of the previous aortotomy. There was no dehiscence of the former aortic suture line. After debridement of the ascending aorta involving the previous aortotomy and pseudoaneurysm, we elected to directly close the aortic defect using Teflon felt strips to avoid a prosthetic graft. The aortic valve had no infective endocarditis and other abnormality. Postoperatively, there was no aortic regurgitation, and the cause of the previous aortic regurgitation was believed to be due to a compression of the aortic root from outside. The postoperative course has been good.

True aneurysms of the intrathoracic segment of the subclavian artery are extremely rare. Atherosclerosis is the most common etiology. The surgical approach and timing of repair remain controversial. We successfully treated a patient with a large proximal subclavian artery aneurysm which was secondary to atherosclerosis. The patient was asymptomatic for 30 years as the aneurysm enlarged. Three-dimensional computed tomography provided the most useful information regarding anatomy of the cervical vasculature. The patient underwent closure of the inlet port of the aneurysm and repair using a 6-mm Dacron bypass graft (Gelsoft , VASCTEK, Scotland) via a minimally invasive surgical approach.

The spontaneous dissection of a peripheral artery not involving the aorta is rare and usually does not arise from a true aneurysm. This is the first report of a spontaneous external iliac artery dissection originating in a true aneurysm.

The purpose of the study was to evaluate the potential of dynamic Gd-DTPA-enhanced MR imaging in assessing of the function of transplanted kidneys. Dynamic MR imaging was performed using the GRASS pulse sequence in 21 subjects (56 examinations), and in each examination 30 images were obtained after a bolus injection of Gd-DTPA. Imaging findings including signal increase and/or signal drop in cortex, signal drop in medulla, and signal drop in calyces were utilized for the evaluation of renal function. Renal function was also evaluated using the following parameters: Ta, time between the initial observation of signal increase in cortex and signal drop in medulla. Tb, time between the initial observation of signal drop in medulla and in calyces; Tc, Ta + Tb, and Max. C/M, maximum ratio of signal intensity between cortex and medulla among 30 images. In the group of patients with normal graft function (Ccror = 60ml/min), all imaging findings were observed. In the group of patients with mild graft dysfunction (30ml/minor = Ccr60ml/min), all imaging findings but signal drop in cortex were observed. The time parameters of Ta, Tb, and Tc were significantly larger, and Max. C/M was significantly smaller than those observed in the group with normal graft function. In the group of patients with severe graft dysfunction (Ccr30ml/min), almost none of the findings were observed. The investigation in patients in the postoperative state revealed a close correlation of the imaging findings and the values of parameters with changes in graft function over time. The results indicated the usefulness of the method in semiquantitative evaluation of graft function, including that of patients in postoperative state. This study suggests that dynamic Gd-DTPA-enhanced MR imaging could be a valuable method for the management of transplanted kidneys.

It is known that bicuspid aortic valve with dilatation of the ascending aorta is one of risk factors of the aortic dissection. A case of acute aortic dissection (DeBakey type-II) associated with bicuspid aortic valve who underwent successfully operation 8 hours after onset is reported. This patient went into cardiogenic shock because of cardiac tamponade and aortic valve regurgitation immediately after onset. Aortic valve and the ascending aorta were replaced using composite graft (#23 SJM prosthetic aortic valve and 26 mm woven Dacron vascular graft) combined with coronary artery reconstruction by Cabrol's technique. Aortic valve showed bicuspid and histological examination revealed cystic medionecrosis and loss of elastic fiber. Postoperative course was uneventful and this patients is doing well 3 years after the operation.

Fifty-seven patients of type A aortic dissection were underwent operations from Jan. 1985 to Nov. 1994. The number of patients who underwent graft replacement of the aorta and received aortogram after the operation was twenty-nine. To investigate factors affecting the occurrence of anastomotic leakage after graft replacement of the aorta, the aortograms of the 29 patients were examined retrospectively. The aortograms revealed leakage at the distal anastomotic site on 11 of the 29 patients. Eight factors: the kind of graft, Marfan's syndrome, the use of felt at the anastomotic site, the clamping method, distal anastomotic site, acute or chronic, the state of the aortic wall at the anastomotic site and the blood pressure control after operation, were examined relating to the occurrence of anastomotic leakage. The results showed 3 factors; acute or chronic, the state of the aortic wall and the blood pressure control, affected the occurrence of anastomotic leakage. In short, the anastomotic leakage easily occurred in patients who underwent in the acute stage and whose blood pressure was uncontrolled after the operation. Therefore, strict control of the blood pressure after the operation is the most effective for preventing anastomotic leakage.

Papillary fibroelastoma is one of the most common benign primary cardiac tumor after myxoma. However, it is rare to originate from Eustachian valve. A 44-year-old woman was pointed out the right atrial tumor during admission for vasospastic angina. On two-dimensional echocardiogram, the tumor was found in the right atrium, and easily moved to the right ventricle. At operation, the tumor originated from Eustachian valve, and was resected together with the valve by means of extracorporeal circulation. The size of tumor was 57 mm in length, and the histological diagnosis was papillary fibroleastoma. The post-operative course was uneventful.

Aortic regurgitation due to traumatic rupture of the aortic valve with dove-coo murmur is rare. A 71-year-old man was admitted for cardiac failure due to aortic regurgitation with dove-coo murmur, 4 years after the traffic accident. The aortic valve replacement was performed and his postoperative course was good. The aortic valve was tricuspid valve with the tear in the left side of right coronary cusp, and the size of the tear was 7 mm. The aortic valve was not recognized the findings of inflammatory or rheumatic change in the pathological study.

We clinically compared a heparin-bonded Carmeda MAXIMA membrane oxygenator to a nonheparin-bonded MAXIMA in 20 patients undergoing coronary artery bypass grafting or valve replacement. Reductions of fibrinogen, factor XII, and high molecular weight kininogen were greater in the MAXIMA group. Serum C3a and free hemoglobin were lower in the Carmeda group. The level of C4a, though remarkably lower than that of C3a, was higher in the Carmeda group then in the MAXIMA group. Both oxygenators performed well in terms of blood gas exchange. We conclude that the heparin-bonded Carmeda oxygenator offers superior biocompatibility during cardiopulmonary bypass.

A 55-year-old male was diagnosed as acute type A aortic dissection caused by retrograde propagation from a tear in the descending aorta. A replacement of the descending aorta was performed with a prosthetic graft (VASCUTEK). Sixteen days after the operation, the patient required an emergency operation due to a rupture in the ascending aorta. Transesophageal echo and contrast enhanced CT indicated the point of entry to be at the proximal anastomotic portion of the prosthetic graft and the prosthetic graft (30 mm in diameter) to be dilated to 45 mm. Intimal tear at anastomotic portion owing to graft dilation was suspected as the main factor causing rupture of the ascending aorta.

Aortoesophageal fistula due to ruptured thoracic aortic aneurysm is uncommon, and exhibits extremely high mortality. We experienced two cases of such lesion. The first case showed aneurysm in the aortic arch closed with Dacron patch but leaving the esophageal defect. The patient died of an infection of the patch graft after oral feeding. The second case was demonstrated infected aneurysm of the descending aorta. The patient was rescued by primary operation, replacement of the aorta by an artificial graft and resection of the esophagus, and the secondary operation, reconstruction of the esophagus. We recommend resection of aneurysm and the esophagus as well in the aspect of lower post-operative infection in the graft and of the better prognosis of the lesion.

We performed surgical treatment for partial endocardial cushion defect in 3 patients over fifty year old. Case 1 was a 55-year-old-male with TR of grade II. Case 2 was a 59-year-old-female with TR and MR, and was repaired mitral cleft by a mattress suture. She needed infusion of dopamine (over 5 micrograms/kg/min) for 6 days and therapy of mediastinitis postoperatively. Case 3 was 56-year-old-male without atrioventricular valve regurgitation. Preoperative left ventricular volume was small in all patients, therefore perioperative circulatory control, mainly water balance, and respiratory control were importance. All patients survived, and both decreasing of CTR and improvement of NYHA classification were recognized in all three patients. In conclusion the operation for ECD in even elder patients was effective, but intensive care needed perioperatively.

Simple aortic valve replacement was performed in a 59-year-old man whose ascending aorta was moderately dilated (45 mm) because he had no characteristics of Marfan's syndrome or other connective tissue diseases. However, about 20 months later, reoperation needed to be performed for aortic dissection of DeBakey type I. The pathological findings of the aortic wall obtained at the initial operation revealed cystic medial necrosis. The occurrence of aortic dissection after aortic valve replacement is uncommon but not rare, especially in patients with cystic medial necrosis and/or dilated aortic root. Therefore, in these patients, wrapping or replacement of the ascending aorta may be required at the same time of aortic valve replacement.

Gait patterns of 440 young Japanese women walking along a sidewalk were observed in September. Walking speed, step length and cadence were significantly greater in single walking than in group walking. Time of day, walking direction and clothes did not influence the walking patterns. Step length in heeled shoes was shorter than that in sneakers and flat shoes.

To study the hemodialysis period following cadaveric renal transplantation, we reviewed 18 consecutive cadaver donor kidney pairs of which one kidney was transplanted at Shiga University of Medical Science (SUMS) while the contralateral kidney was transplanted at Kyoto Prefectural Medical University (KPMU) between January 1983 and September 1988. Of these 18 pairs, graft function was satisfactory and the recipient was free from hemodialysis in 13 pairs. However, the postoperative hemodialysis periods were different between the two centers. To clarify the factors causing this difference, recipient factors, such as age, HLA matching, total ischemic time of the graft (TIT), immunosuppression, onset of diuresis and postoperative complications were studied. There were no significant differences in age, HLA matching, or immunosuppression. TIT of cases at SUMS was significantly longer than that of cases at KPMU. The postoperative hemodialysis period at SUMS was 25.8 days and that at KPMU was 17.8 days, however, the difference was not statistically significant. The results of this study indicate that TIT seems to be a major factor relating to delayed graft function in cadaveric renal transplantation.

Thymus humoral factor seems to have an ability of differentiating the precursor T cells (PTC) into cells bearing T-cell (thymus-dependent lymphocyte) characteristics. Human fetal thymic extract (hFTE) was examined for in vitro effect on the concanavalin A (Con A) responsiveness of peripheral blood lymphocytes in 28 patients with uterine cervical cancer and 9 healthy volunteers. The result was expressed as percentage increase of Con A response of the hFTE-treated group to that of the nontreated group. The effect of hFTE was found to be pronounced in patients in Stages 0 and I, in spite of the small difference in T-cell count in unit volume of peripheral blood. Meanwhile, the effect of hFTE was no longer observed in patients with advanced cancer (Stages III and IV). The present study has suggested that some of PTC, which are prevented from differentiating into mature T cells in vivo due to presumably depressed thymic hormone production, accumulates in peripheral blood of patients with early cancer. And it was also suggested that decrease of both PTC and T-cell count in patients with advanced cancer is due to general immunodeficiency.

Since Kistner in 1959 took up the gestagen therapy for endometrial hyperplasia and endometrial carcinoma with a view to inhibiting cellular proliferation, many clinical reports on that therapy have been published. It has been clarified by cell-biological studies that progesterone inhibit the DNA synthesis of endometrial cells followed by the discontinuance of cell division. At dichophase , prior to the onset of the S-stage in cell division cycle, under conjugation of progesterone with a certain specific type of protein (hormone receptor) the cells are induced toward the development of secretory function, i.e. toward differentiation, resulting in no synthesis of DNA. On the basis of the consideration mentioned above, when hormone treatment will be applied to endometrial carcinoma it is required that those cancer cells have the gene activated by administered hormone or have specific type of protein produced by hormone dependent gene in cytoplasm. When cancer cells have still retained the traits of the normal epithelial cells of endometrium, they were believed still possess the character to show the specific reaction to progesterone. However, not all the cancer cells can be considered to have a uniform character (the degree of differentiation), so gestagen therapy cannot be interpreted to be able completely to bring about the fundamental cure of endometrial carcinoma.

Sixteen patients who underwent surgery and postoperative chemotherapy for carcinoma of the ovary were studied. Eleven survived more than 18 months without evidence of recurrence, and 5 died more than 5 months after surgery. Serial determinations were made preoperatively and postoperatively of the immunosuppressive effect of the serums of these patients on the response of normal lymphocytes to phytohemagglutinin stimulation. These determinations were plotted for each patient; the shapes of the curves for patients who survived are markedly different from those of patients who died. The prognostic value of these findings is discussed.

The effects of an anabolic steroid on the immune activity and clinical condition of patients with cancer of the uterine cervix were studied. The effects of the steroid on tumor growth were also studied in animals. The results obtained demonstrated that the anabolic steroid (1) enhanced the activity of macrophages and cell-mediated immune activity, (2) reduced the incidence of post-operative infection, (3) reduced pose-operative loss of weight of patients due to the intrinsic anabolic activity of the steroid, and (4) did not exert any influence on tumor growth. Judging from these results, administration of the anabolic steroid would appear to be effective for the improvement of the general condition of cancer patients following surgery or in terminal cases.

Monocytes have been thought to play an important role in the immune surveillance system of cancer patients since monocytes were shown to participate as accessory cells in the induction of T-cell proliferation to PHA by Potter et al. in 1977. We had already reported the depression of monocyte function with the progress of cancer after PHA response of mononuclear cells obtained by centrifugation of Ficoll-Hypaque and lymphocytes obtained by depletion of monocytes ingesting Silica from mononuclear cells was compared in cancer patients. In that study, however, monocyte function was considered not to be indicated truly because responding cells were different at each examination. Therefore, in this study responding cells were graded as T-cells obtained from healthy volunteers and monocytes were added to the T-cells. Monocyte function in this study was as follows: PHA response to T-cells and monocytes over PHA response to T-cells. In this study, monocytes were allogenic to T-cells. At first, the influence of monocytes to allogenic T-cells was studied but it was found to be negligible. The ratio of monocytes and T-cells was 1:1. The concentration of PHA was 20 micrograms/ml. Finally, the monocyte function of patients with cervical cancer was studied. It was increased at the stage of CIS and then gradually decreased. At the advanced stage, it was significantly decreased to comparison with that of healthy volunteers.

The status of autoimmune diseases and viral infections is known to change during and after pregnancy. Cell-mediated immunity (CMI) in pregnant women is thought to be involved. Recently, macrophages and monocytes (M phi) were reported to play an important role in CMI. Therefore, this study was designed to examine the effect of peripheral blood M phi on CMI in pregnant women. First, the ratio of M phi to lymphocytes and the absolute number of M phi were calculated during pregnancy. They increased during the 2nd and 3rd trimesters. Next, the effect of M phi on CMI in pregnant women was studied in terms of the ability of M phi to obtain access to T cells. This decreased slightly during the 1st trimester, increased significantly during the 3rd trimester (p less than 0.01) and returned to normal after delivery. It was found that serum from pregnant women in the 3rd trimester was able to enhance the accessory ability of M phi. Of the various hormones which show the wide fluctuations in concentration in the serum during pregnancy, estrogen increased the accessory ability by 41%, while cortisol decreased it by 40%. In conclusion, M phi were found to influence the CMI in pregnant women and pregnant serum, and especially the hormones such as estrogen and cortisol included in it, were also found to relate to M phi function.

Four cases of pneumocystis carinii pneumonia occurred among 38 renal transplant recipients. Diagnosis was confirmed by cyst concentration technique in 2 cases. The other 2 cases were clinically, from the rapid improvement of fever, pulmonary infiltrates and hypoxia following a therapeutic trial of high dose sulfamethoxazole-trimethoprim. All patients responded to treatment with high dose sulfamethoxazole-trimethoprim. Three patients survived pneumocystis carinii pneumonia, but i died due to aspergillosis. One patients showed serological evidence of concomitant cytomegalovirus infection.

Cell-mediated immune response was measured in 23 patients with ovarian cystadenocarcinoma, 38 patients with benign ovarian tumor, and 44 healthy volunteers. The method used two indexes: the lymphocyte response per unit volume of peripheral blood to phytohemagglutinin (PHA) and the immunosuppressive effect of serum on the response of normal lymphocytes to PHA stimulation. The lymphocyte response per 50 microliter peripheral blood did not differ significantly between patients with ovarian cancer and healthy volunteers. The serum effect, in contrast, differed significantly between malignant and benign ovarian tumors, and was found to increase significantly even when the cancer masses were as small as about 5 x 5 x 5 cm in size, ie, in FIGO Stage I. It is our belief that the measurement of the serum effect in patients with any ovarian tumor enables the early detection of ovarian cancer.