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Movements of the human biological system have adapted to the physical environment under the 1-g gravitational force on Earth. However, the effects of microgravity in space on the underlying functional neuromuscular control behaviors remain poorly understood. Here, we aimed to elucidate the effects of prolonged exposure to a microgravity environment on the functional coordination of multiple muscle activities. The activities of 16 lower limb muscles of 5 astronauts who stayed in space for at least 3 mo were recorded while they maintained multidirectional postural control during bipedal standing. The coordinated activation patterns of groups of muscles, i.e., muscle synergies, were estimated from the muscle activation datasets using a factorization algorithm. The experiments were repeated a total of five times for each astronaut, once before and four times after spaceflight. The compositions of muscle synergies were altered, with a constant number of synergies, after long-term exposure to microgravity, and the extent of the changes was correlated with the increased velocity of postural sway. Furthermore, the muscle synergies extracted 3 mo after the return were similar in their activation profile but not in their muscle composition compared with those extracted in the preflight condition. These results suggest that the modularity in the neuromuscular system became reorganized to adapt to the microgravity environment and then possibly reoptimized to the new sensorimotor environment after the astronauts were reexposed to a gravitational force. It is expected that muscle synergies can be used as physiological markers of the status of astronauts with gravity-dependent change.

Background Whether pulmonary hemodynamic parameters and functional capacity are associated with quality of life in patients with chronic thromboembolic pulmonary hypertension remains unknown. This study aimed to evaluate disease‐specific quality of life using the emPHasis‐10 questionnaire and assess its determinants in patients with chronic thromboembolic pulmonary hypertension with normalized pulmonary hemodynamics. Methods and Results This cross‐sectional study included 187 health status assessments of 143 patients with chronic thromboembolic pulmonary hypertension (median age, 68 [58–75] years; men/women, 51/136; use of home oxygen therapy, 51 patients [27%]) after balloon pulmonary angioplasty with normalized mean pulmonary artery pressure P P =0.003) but not with hemodynamic parameters. Multiple regression analysis revealed that a higher emPHasis‐10 score was associated with lower 6‐minute walk distance (β=−0.475 [95% CI, −0.631 to −0.319], P Conclusions Health‐related quality of life was associated with exercise capacity and the use of home oxygen therapy, but not with hemodynamic parameters, in patients with chronic thromboembolic pulmonary hypertension and normalized hemodynamics after balloon pulmonary angioplasty. Improvements in exercise capacity may lead to further improvements in quality of life.

BackgroundThe International Classification of Functioning, Disability, and Health (ICF) Generic-30 (Rehabilitation) Set is a tool used to assess the functioning of a clinical population in rehabilitation. The ICF Generic-30 consists of nine ICF categories from the component “body functions” and 21 from the component “activities and participation”. This study aimed to develop a rating reference guide for the nine body function categories of the ICF Generic-30 Set using a predefined, structured process and to examine the interrater reliability of the ratings using the rating reference guide.MethodsThe development of the first version of the rating reference guide involved the following steps: (1) a trial of rating patients by several raters; (2) cognitive interviews with each rater to analyze the thought process involved in each rating; (3) the drafting of the rating reference guide by a multidisciplinary panel; and (4) a review by ICF specialists to confirm consistency with the ICF. Subsequently, we conducted a first field test to gain insight into the use of the guide in practice. The reference guide was modified based on the raters’ feedback in the field test, and an inter-rater reliability test was conducted thereafter. Interrater agreement was evaluated using weighted kappa statistics with linear weights.ResultsThe first version of the rating reference guide was successfully developed and tested. The weighted kappa coefficient in the field testing ranged from 0.25 to 0.92. The interrater reliability testing of the rating reference guide modified based on the field test results yielded an improved weighted kappa coefficient ranging from 0.53 to 0.78. Relative improvements in the weighted kappa coefficients were observed in seven out of the nine categories. Consequently, seven out of nine categories were found to have a weighted kappa coefficient of 0.61 or higher.ConclusionsIn this study, we developed and modified a rating reference guide for the body function categories of the ICF Generic-30 Set. The interrater reliability test using the final version of the rating reference guide showed moderate to substantial interrater agreement, which encouraged the use of the ICF in rehabilitation practice.

Orthoses and insoles are among the primary treatments and prevention methods of refractory plantar ulcers in patients with Hansen&rsquo, s disease. While dynamic plantar pressure and tactile sensory disturbance are the critical pathological factors, few studies have investigated whether a relationship exists between these two factors. In this study, dynamic pressure measured using F-scan system and tactile sensory threshold evaluated with monofilament testing were determined for 12 areas of 20 feet in patients with chronic Hansen&rsquo, s disease. The correlation between these two factors was calculated for each foot, for each clinical category of the foot (0&ndash, IV) and across all feet. A significant correlation was found between dynamic pressure and tactile sensation in Category II feet (n = 8, p = 0.016, r2 = 0.246, Spearman&rsquo, s rank test). In contrast, no significant correlation was detected for the entire foot or within the subgroups for the remainder of the clinical categories. However, the clinical manifestation of lesion areas showed high variability: (1) pressure concentrated, sensation lost, (2) margin of pressure concentration, sensation lost, (3) pressure concentrated, sensation severely disturbed but not lost, and (4) tip of the toe. These results may indicate that, even though there was a weak relationship between dynamic pressure and tactile sensation, it is important to assess both, in addition to the basics of orthotic treatment in patients with Hansen&rsquo, s disease presenting with refractory plantar ulceration.

Background Despite improved survival for patients with chronic thromboembolic pulmonary hypertension (CTEPH) due to progressive medical and interventional treatment, impaired exercise capacity remains common due to poorly understood mechanisms. We aimed to clarify the exercise capacity of CTEPH patients with near-normal pulmonary hemodynamics and evaluate its determinants among the hemodynamic, peripheral (e.g., oxygen use by the peripheral tissues), and muscular (e.g., skeletal muscle strength) factors. Methods Three hundred and twenty-nine patients with CTEPH (mean age, 63 ± 12 years; men/women, 73/256) with a near-normal mean pulmonary artery pressure (≤30 mm Hg) at rest were enrolled. We assessed exercise capacity by peak oxygen consumption (peak VO2) using cardiopulmonary exercise testing with a right heart catheter. We also measured the 6-minute walk distance (6MWD) and quadriceps muscle strength. Results The mean pulmonary artery pressure was 19 ± 4 mmHg and mean cardiac output was 4.8 ± 1.5 L/min at rest. The mean 6MWD was 444 ± 101 m, while the mean peak VO2 was 14.4 ± 3.9 mL/min/kg. A multivariate model that predicted 6MWD included quadriceps strength (β = 0.45, p Conclusions The 6MWD performance may be significantly influenced by peripheral oxygen use and muscular factors, while peak VO2 is influenced by hemodynamic and peripheral factors in CTEPH patients with near-normal hemodynamics.

Prognostication of quadriceps contusion is based on the patient's active knee flexion after the injury. Unlike ultrasonography, clinical grading does not define the extent of soft tissue injury and may provide inaccurate time for return to play. The purposes of this report are to describe the ultrasound findings of the different clinical grading of quadriceps contusion and document the return to play of each case. Seven patients were evaluated in this series. Results showed discrepancies in the disability time between clinical grading and ultrasound findings. Clinical grading did not consistently estimate the return to play as described in previously published literature. Contusions with hyperechoic lesions had earlier return to play compared to patients with hypoechoic findings. Contusions with hypoechoic lesions might require aggressive monitoring and therapy to decrease disability time and avoid complications such as myositis ossificans.

BackgroundThe World Health Organization developed the International Classification of Functioning, Disability, and Health (ICF) in 2001 and has been in the process of implementing it in clinics since then. Current international efforts to implement ICF in rehabilitation clinics include the implementation of ICF Core Sets and the development of simple, intuitive descriptions for the ICF Generic-30 Set (also called Rehabilitation Set). The present study was designed to operationalize these ICF tools for clinical practice in Japan. This work included 1) the development of the Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set, 2) the development of a rating reference guide for Activity and Participation categories, and 3) the examination of the interrater reliability of rating Activity and Participation categories.MethodsThe Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set was developed following the process employed to develop the Chinese and Italian versions.For further operationalization of this ICF Set in practice, a rating reference guide was developed. The development of the rating reference guide involved the following steps: 1) a trial of rating patients by several raters, 2) cognitive interviewing of the raters to analyse the thinking process involved in rating, 3) drafting of the rating reference guide, and 4) review by ICF specialists to confirm consistency with the original ICF concepts.After the rating reference guide was developed, interrater reliability of the rating with the reference guide was determined. Interrater reliability was examined using weighted kappa statistics with linear weight.ResultsThrough the pre-defined process, the Japanese version of the simple, intuitive descriptions for 30 categories of the ICF Generic-30 Set and the rating reference guides for 21 Activity and Participation categories were successfully developed. The weighted kappa statistics ranged from 0.61 to 0.85, showing substantial to excellent agreement of the ratings between raters.ConclusionsThe present study demonstrates that ICF categories can be translated into clinical practice. Collaboration between clinicians and researchers would further enhance the implementation of the ICF in Japan.

To date, no gold standard imaging method has been used to assess calcaneofibular ligament (CFL) injuries. Ultrasound (US) has become increasingly important in the assessment of ligaments around the ankle. However, very few reports in the literature have focused on detecting CFL injuries. The objective of this study was to determine the effectiveness of ultrasound in detecting CFL injuries in comparison with magnetic resonance imaging (MRI). A retrospective study was conducted in 21 patients with chronic lateral ankle injury, 10 males and 11 females with a mean age of 27.6 ± 14.5 years (range 14–68 years). High-frequency US and three-dimensional (3D) MRI of the affected ankle were performed. Evaluations of the CFL were performed by two orthopedic surgeons experienced in US, while the MRI findings were interpreted by two musculoskeletal radiologists. The US findings were then compared with the MRI findings. US detected CFL injury in 9/21 patients, and these findings were confirmed by the MRI findings. However, one patient with a normal CFL on US was evaluated as laxity on MRI. In this study, US sensitivity and specificity in detecting CFL injuries was 90% (9/10) and 100% (10/10), respectively, with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 91.7% in comparison with MRI. With the proper technique and knowledge of the ankle anatomy, high-frequency US proved to be an effective imaging modality in the diagnosis of CFL lesions in chronic lateral ankle injuries. US had a high sensitivity and specificity in the evaluation of the CFL when MRI findings were regarded as the reference standard.

Background: The functional independence measure (FIM) is a standard tool to provide a detailed evaluation of ADL of patients with disabilities. This study aimed to show the differences in FIM scores as an outcome predictor between patients with anterior circulation (AC) and posterior circulation (PC) strokes. Methods: Consecutive patients with acute ischemic stroke hospitalized within 7 days after onset were investigated. Baseline NIHSS scores, 1st-FIM (< 72 h after ­admission to stroke unit), 2nd-FIM (< 72 h before discharge), and modified Rankin Scale (mRS) scores were collected. Logistic regression analyses were used to identify predictors of a favorable outcome (mRS 0–2) at 3-month after stroke. Results: Three hundred eighty-five patients (median age, 78 years; male, 59%; median length of stroke unit stay, 20 days) were included. The median baseline NIHSS, 1st- and 2nd-FIM scores were 4 (interquartile range 2–9), 65 (33–91), and 98 (54–122) respectively. Baseline NIHSS (3 vs. 4, p = 0.01) and mRS score at 3-month (1 vs. 2, p = 0.01) were lower, and 1st-FIM (75 vs. 64, p < 0.01) and 2nd-FIM (113 vs. 95, p = 0.01) were higher in 82 patients with PC than 303 patients with AC strokes. On multivariate logistic regression analysis, 2nd-FIM score was an independent predictor of favorable outcomes in both PC (OR 1.18, 95% CI 1.04–1.48, p < 0.01) and AC (OR 1.12, 95% CI 1.06–1.20, p < 0.01) strokes. The optimal cutoff scores of 2nd-FIM for predicting favorable outcome were 104 for PC (sensitivity 0.82, specificity 0.88) and 93 for AC (0.88–0.90) strokes. Conclusions: The differences in outcome predictability by FIM score between AC and PC strokes should be considered, although FIM scores at discharge from stroke unit were useful to predict a favorable outcome.

The International Space Station (ISS) is a huge manned construct located approximately 400 km above the earth and is inhabited by astronauts performing space experiments. Because the station is within a closed microgravity environment, the astronauts are subject to consistent stress. This study analyzed the temporal changes in the skin fungal microbiota of 10 astronauts using pyrosequencing and quantitative PCR assay before, during, and after their stay in the ISS. Lipophilic skin fungi, Malassezia predominated most samples regardless of the collection period, body site (cheek or chest), or subject. During their stay in the ISS, the level of Malassezia colonization changed by 7.6- ± 7.5-fold (mean ± standard deviation) and 9.5- ± 24.2-fold in cheek and chest samples, respectively. At the species level, M. restricta, M. globosa, and M. sympodialis were more abundant. In the chest samples, the ratio of M. restricta to all Malassezia species increased, whereas it did not change considerably in cheek samples. Fungal diversity was reduced, and the ratio of Malassezia to all fungal colonization increased during the astronauts' stay at the ISS. The ascomycetous yeast Cyberlindnera jadinii was detected in abundance in the in-flight sample of 5 of the 10 astronauts. The microorganism may have incidentally adhered to the skin during the preflight period and persisted on the skin thereafter. This observation suggests the ability of a specific or uncommon microorganism to proliferate in a closed environment. Our study is the first to reveal temporal changes in the skin fungal microbiota of ISS astronauts. These findings will provide information useful for maintaining the health of astronauts staying in the space environment for long periods and for preventing infection due to the human skin microbiota.

著者人数: 12名, Accepted: 2015-05-12, 資料番号: SA1150187000

Performing aerobics and resistance exercise at exactly the same time has not been available although combining both types of exercise in one training program has been attempted. The hybrid training system (HTS) is a resistance exercise that combines voluntary concentric muscle contractions with electrically stimulated eccentric muscle contractions. We devised an exercise technique using HTS on a cycle ergometer (HCE). Growth hormone (GH) and lactate are indicators of adequate training intensity. Interleukin-6 (IL-6) reflects enhancing lipid metabolism. The purpose of this study was to show that HCE provides sufficient exercise to stimulate the secretion of GH, lactate and IL-6. We compared an HCE test with cycle ergometer alone (CE). Ten healthy male subjects performed HCE and CE tests for 30 minutes each. The workload of both tests was set the same at 40% of each subject's peak oxygen uptake. For HCE, 2-minute HTS and 1-minute rest intervals were repeated. GH, lactate, and IL-6 were evaluated before and immediately after exercise, and at 15, 30 and 60 minutes. GH and lactate increased immediately after HCE. Moreover, the degree of the increases in GH after HCE (0 and 15 minutes) was higher than that after CE. IL-6 increased after HCE at 30 min, and the rate of change was higher than for CE. These results showed that HCE was more efficient in stimulating acute increases in GH, lactate and IL-6 than CE at the same workload. We may be able to combine electrically stimulated resistance exercise with aerobic exercise using HCE.

The human intestinal microbiota (HIM) settles from birth and continues to change phenotype by some factors (e.g. host’s diet) throughout life. However, the effect of extreme life environment on human HIM composition is not well known. To understand HIM fluctuation under extreme life environment in humans, fecal samples were collected from six Japanese men on a long Antarctic expedition. They explored Antarctica for 3 months and collected their fecal samples at once-monthly intervals. Using terminal restriction fragment length polymorphism (T-RFLP) and real time polymerase chain reaction (PCR) analysis, the composition of HIM in six subjects was investigated. Three subjects presented restoration of HIM after the expedition compared versus before and during the expedition. Two thirds samples collected during the expedition belonged to the same cluster in dendrogram. However, all through the expedition, T-RFLP patterns showed interindividual variability. Especially, Bifidobacterium spp. showed a tendency to decrease during and restore after the expedition. A reduction of Bifidobacterium spp. was observed in five subjects the first 1 month of the expedition. Bacteroides thetaiotaomicron, which is thought to proliferate during emotional stress, significantly decreased in one subject, indicating that other factors in addition to emotional stress may affect the composition of HIM in this study. These findings could be helpful to understand the effect of extreme life environment on HIM., 資料番号: PA1510088000

Introduction: Weeding or snow shovelling is indispensable for life in farm villages of northern countries. Clarifying the relationships between the degrees of these activities after total hip replacement (THR) and the clinical results of THR may enable us to predict the results of THR for high-level activity patients. The relationships between work activities after THR and the results were investigated. Methods: The subjects were 95 post-THR patients, who consulted 6 hospitals in August 2012. First, the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) and a questionnaire on postoperative activity were administered. Then, the Japanese Orthopaedic Association hip score (JOA score) was evaluated. Results: The subjects’ average age was 68 years. The average period after surgery was 4 years and 5 months. Weeding and snow shovelling were performed after THR in 44.2% and 40.0% of cases, respectively. The rate of farming after surgery (25.6%) was greater than that of swimming (21.1%). Both the JOA score and JHEQ were higher in those who played sports after THR than in those who did not (p = 0.003, p = 0.0046). The JOA score of those who performed work activities after THR was higher than that of those who did not (p = 0.0295). Conclusions: Nearly half of patients performed weeding or snow shovelling after THR, and about 1/4 of the patients engaged in farming after THR. The clinical results in cases doing sports and work activities after THR were better than those of cases not doing such activities. Therefore, these activities may be positively recommended.

Ultrasonography (US) is a safe and noninvasive imaging modality that is gaining popularity in different medical and surgical fields. Its introduction in musculoskeletal and sports medicine has taken this advanced subspecialty to a higher level. It has the advantage over other imaging techniques with regards to ease of use, availability, comfort and cost. Not to mention, in terms of safety profile, patients are not exposed to radiations, like in x-rays, and it can be performed on patients with metal or pacemaker implants, which are contraindicated in MRI. Standard diagnostic sonography doesn't have any known harmful effects on humans. In this article we will discuss the role of ultrasound in sports medicine, highlighting the diagnostic and interventional indications, uses and limitations.

Adaptation to the space environment can sometimes pose physiological problems to International Space Station (ISS) astronauts after their return to earth. Therefore, it is important to develop healthcare technologies for astronauts. In this study, we examined the feasibility of using hair follicles, a readily obtained sample, to assess gene expression changes in response to spaceflight adaptation. In order to investigate the gene expression changes in human hair follicles during spaceflight, hair follicles of 10 astronauts were analyzed by microarray and real time qPCR analyses. We found that spaceflight alters human hair follicle gene expression. The degree of changes in gene expression was found to vary among individuals. In some astronauts, genes related to hair growth such as FGF18, ANGPTL7 and COMP were upregulated during flight, suggesting that spaceflight inhibits cell proliferation in hair follicles.

We report a 47-year-old man with acute leukemia who survived a severe case of necrotizing fasciitis caused by Clostridium perfringens involving his right upper extremity. On day 5 after stem cell transplantation, progressive local tissue necrosis led to septicemia and disseminated intravascular coagulation. Early diagnosis and prompt initiation of appropriate therapy, including surgical debridement and broad-spectrum antibiotics, were crucial. A recombinant thrombomodulin might have not only resolved the coagulation problem but also prevented multiple organ failure associated with the systemic inflammatory response.

BackgroundMusculoskeletal atrophy is one of the major problems of extended periods of exposure to weightlessness such as on the International Space Station (ISS). We developed the Hybrid Training System (HTS) to maintain an astronaut's musculoskeletal system using an electrically stimulated antagonist to resist the volitional contraction of the agonist instead of gravity. The present study assessed the system's orbital operation capability and utility, as well as its preventative effect on an astronaut's musculoskeletal atrophy.MethodsHTS was attached to the non-dominant arm of an astronaut staying on the ISS, and his dominant arm without HTS was established as the control (CTR). 10 sets of 10 reciprocal elbow curls were one training session, and 12 total sessions of training (3 times per week for 4 weeks) were performed. Pre and post flight ground based evaluations were performed by Biodex (muscle performance), MRI (muscle volume), and DXA (BMD, lean [muscle] mass, fat mass). Pre and post training inflight evaluations were performed by a hand held dynamometer (muscle force) and a measuring tape (upper arm circumference).ResultsThe experiment was completed on schedule, and HTS functioned well without problems. Isokinetic elbow extension torque (Nm) changed -19.4% in HTS, and -21.7% in CTR. Isokinetic elbow flexion torque changed -23.7% in HTS, and there was no change in CTR. Total Work (Joule) of elbow extension changed -8.3% in HTS, and +0.3% in CTR. For elbow flexion it changed -23.3% in HTS and -32.6% in CTR. Average Power (Watts) of elbow extension changed +22.1% in HTS and -8.0% in CTR. For elbow flexion it changed -6.5% in HTS and -4.8% in CTR. Triceps muscle volume according to MRI changed +11.7% and that of biceps was +2.1% using HTS, however -0.1% and -0.4% respectively for CTR. BMD changed +4.6% in the HTS arm and -1.2% for CTR. Lean (muscle) mass of the arm changed only +10.6% in HTS. Fat mass changed -12.6% in HTS and -6.4% in CTR.ConclusionsThese results showed the orbital operation capability and utility, and the preventive effect of HTS for an astronaut's musculoskeletal atrophy. The initial flight data together with the ground data obtained so far will be utilized in the future planning of human space exploration.

Objectives: To evaluate the predictive value of growth patterns in patients undergoing sorafenib treatment for metastatic clear cell renal cell carcinomas (CCRCCs). Methods: Forty-eight patients were analyzed, each of whom underwent nephrectomy and received sorafenib treatment for metastatic CCRCC. Progression-free survival (PFS) was predicted using pathologic parameters, including pathologic stage, Fuhrman nuclear grade (FNG), the presence of a sarcomatoid component, lymphovascular invasion, tumor necrosis, and growth pattern. Results: Three (6%) patients showed partial response, 20 (42%) patients showed stable disease, and 25 (52%) patients showed progressive disease. Univariate analyses demonstrated that FNG, the presence of a sarcomatoid component, tumor necrosis, and growth pattern were significantly associated with PFS. In the multivariate analysis, growth pattern was the only parameter that was significantly and independently predictive of PFS. Conclusions: As a novel histologic prognostic parameter, growth pattern may be useful for predicting response to sorafenib treatment.

To develop a short version of the motor Functional Independence Measure (FIM) for use in long-term care settings.For model construction, the participants were 398 community-dwelling persons with disability (mean age 79.3 years (SD 10.3)) who were receiving visiting nurse services. For cross-validation, 169 patients with stroke (mean age 78.0 years (SD 11.2)) in the chronic phase and 187 patients with stroke (mean age 63.4 years (SD 12.7)) in the recovery phase.Model construction and cross-validation study.The second power of correlation coefficient (R2) was used for agreement analysis between the short and the full version. Cross-validation of the models was estimated with the intraclass correlation coefficient (ICC).Five to 7 motor FIM items were selected for the models based on Rasch calibration and consideration of internal consistency. Total motor FIM was estimated with the 6-item and 7-item models with regression analysis, which yielded high correlations with the original 13-item motor FIM score (R20.95). Regression formulas derived from the models could estimate total motor FIM scores accurately in the 2 cross-validation samples (ICC0.98).The short version of the motor FIM developed is a useful measure of functional status, not only in long-term care but in the recovery phase rehabilitation settings.

Although electromyography and electrodiagnosis (EMG-EDX) is one of the most fundamental skills in rehabilitation medicine, the number of residency programs that can provide comprehensive postgraduate EMG-EDX training is still limited in Japan. Under these circumstances, we started a 2-day primer course in EMG-EDX at Keio University Hospital in 1998. To review our 7-year experience with the course, we analyzed the number and specialty of the participants, their appraisal of the lectures and practical sessions, and the score distribution of the final examination. The number of participants totaled 288 during the past 7 years, and the mean number for each year was 41. The distribution by specialty for the whole period was 64.0% for rehabilitation medicine, 25.4% for orthopedic surgery, 5.1% for neurology, 1.0% for pediatrics, 0.5% for gerontology and 4.1% for physical therapists and occupational therapists. The difficulty levels of the lectures were judged as appropriate by 81 to 95.5% of the participants, and the presentation was judged as good by 34 to 67% of them. For the practice sessions, the difficulty levels were judged as appropriate by 88% of the participants, and the quality of the supervisors was judged as good by 64% of them. The mean score for the final examination was 56.0 (SD 15.2, median 60). In conclusion, our course has played an important role to promote EMG-EDX in our country by providing compact introductory exposure to EMG-EDX for beginners. A follow-up system for the course graduates is planned to support their EMG-EDX practice.

Objectives. To review our clinical results to confirm the long-term efficacy of the operative technique of endopyeloureterotomy using the transpelvic extraureteral approach that we developed. Methods. We treated 123 patients with ureteropelvic junction obstruction or upper ureteral stenosis by percutaneous endopyeloureterotomy using the transpelvic extraureteral approach between 1988 and 1999. All were followed up for at least 1 year (mean 58 months). Sixty-eight patients were male and 55 female between the ages of 3 and 78 years (mean 36). We evaluated the efficacy of our procedure preoperatively and then regularly every 6 to 12 months postoperatively using excretory urography and technetium-99m DTPA renography. Results. Our results showed that 115 (90.6%) of 127 procedures relieved the obstruction without any severe complications. In the 107 cases of ureteropelvic junction obstruction, we alleviated the stricture in 96 (90%). In the 20 cases of upper ureteral stenosis, our procedure alleviated the stricture in 19 (95%). In the 47 cases of a stenotic segment of 2 cm or more in length, 43 of our procedures led to a significant improvement (91.5%). Long-term follow-up of the 123 patients revealed late recurrence in 5 patients, despite the initial success. Conclusions. Percutaneous endopyeloureterotomy using the transpelvic extraureteral approach should be considered the first choice of treatment for ureteropelvic junction obstruction and upper third ureteral stenosis, even if the stenotic segment is 2 or more cm long.

Background Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial. Case presentation A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications. Conclusion In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.

Background Alagille syndrome is a multisystem disorder, which is characterized by hypoplasia of the intrahepatic bile ducts, malformations of the cardiovascular system, eyes, and vertebral column, and abnormal facies. Several of the characteristics of Alagille syndrome may result in an especially high risk of fracture. The majority of patients suffer from chronic cholestasis, which can have a variety of adverse effects on bone metabolism. In Alagille syndrome, fractures primarily occur in the lower limb long bones in the absence of significant trauma. Case presentation A 9-year-old Japanese girl with Alagille syndrome was admitted to our institution with marked hyperbilirubinemia and a pathological fracture of the femur. She had been diagnosed with biliary atresia at the age of 1 month and treated with surgical bile duct reconstruction, vitamins D and K, and ursodeoxycholic acid. However, her liver dysfunction and hyperbilirubinemia worsened. The pathological fracture of the femur was treated with low-intensity pulsed ultrasound stimulation (LIPUS) and an Ilizarov ring fixator. Seventy-four days after surgery, the patient had anatomically and functionally recovered. There was no leg-length discrepancy and no angular malalignment of the lower extremities as measured clinically and radiographically. The range of motion of the hip, knee, and ankle of the patient’s operative leg matched the range of motion in the nonoperative leg. Conclusion To the best of our knowledge, there are no reports on use of the Ilizarov frame and LIPUS in diaphyseal femoral fractures in Alagille syndrome. This case report provides evidence that this procedure is successful for managing such diaphyseal fractures in Alagille syndrome.

Rapidly destructive coxarthrosis (RDC) is known to affect elderly women, but its etiology is unknown. This is the first report to our knowledge, based on a search of the English literature, that reveals the entire process of hip destruction from the onset to the terminal stage of RDC, in an 80-year-old woman. Radiographic evaluation showed subchondral insufficiency fracture of the femoral head at an early stage of this disease. An MRI examination within a month of the onset of hip pain showed the entire femoral head with low intensity on T1-weighted images and high intensity on T2-weighted images, and a small low-intensity band at the subchondral area of the lateral weight-bearing portion of the head. These findings are consistent with subchondral insufficiency fracture and associated bone marrow edema. The lesion developed into a deep and large erosion at the superolateral portion of the femoral head, the process being observed on both roentgenograms and MRI. These findings were confirmed during total hip arthroplasty. This case suggests that subchondral insufficiency fracture of the femoral head may be a preceding sign of destruction of the femoral head.

We studied the range of shoulder motion of patients who underwent vertical as compared with horizontal capsulotomies during open Bankart repair for recurrent anterior dislocations of the shoulder. A vertical capsulotomy was used in 10 shoulders and a horizontal capsulotomy was used in 14 shoulders. Except for the method of capsulotomy, the surgical procedure and postoperative rehabilitation were the same. The range of motion was measured at 1.5, 2, 3, 4, 5, 6, 9, and 12 months after the surgery, and at the final follow-up (average, 49 months for the vertical and 26 months for the horizontal group). No dislocations recurred, and the anterior apprehension test was negative in all of the patients in both groups. External rotation in abduction was greater in the horizontal group than in the vertical group; the differences were significantly greater at 9 months and 12 months after surgery and at the final follow-up. External rotation in adduction, flexion, and internal rotation were not significantly different between the groups. We conclude that Bankart repair through a horizontal capsulotomy preserves a better range of external rotation in abduction than does a vertical approach.

A 71-year-old Japanese female Nagasaki-atomic-bomb survivor was admitted for evaluation of a mediastinal mass. She was infected with human T-cell leukemia virus type I. Histological examination of the biopsy specimen, obtained thoracoscopically from the mass, revealed amyloid lymphadenopathy confirmed by Congo-red staining and electron-microscopic examination. Amyloid deposits and the serum monoclonal peak consisted of immunoglobulin λ light chains. No atypical cells were detected in bone marrow. The case was diagnosed as an unusual amyloidosis affecting the mediastinal lymph node. No other sites were found to be affected by amyloidosis, although systemic involvement could not be conclusively ruled out.(Internal Medicine 39: 839-842, 2000)

Objectives. To evaluate the efficacy of laparoscopic radical nephrectomy for patients with small renal cell carcinoma by comparing the clinical results of patients treated laparoscopically with those of patients treated with traditional open radical nephrectomy. Methods. Of 100 patients with localized, small (less than 5 cm in diameter) renal cell carcinoma treated by the same surgical team between 1992 and 1998, 60 patients underwent laparoscopic radical nephrectomy and 40 underwent open radical nephrectomy. Of the 60 laparoscopically treated patients, the first 11 and the most recent 34 patients were operated on transperitoneally and the other 15 retroperitoneally. Results. The mean operative time of the laparoscopically treated patients was longer than that of the open nephrectomy patients (5.2 versus 3.3 hours, P < 0.001). The mean blood loss of the laparoscopically treated patients was less than that of the open nephrectomy patients (255 versus 512 mL, P < 0.001). One laparoscopically treated patient needed conversion to open surgery. The time to full convalescence of the laparoscopically treated patients was shorter than that of the open nephrectomy patients (23 versus 57 days, P < 0.001). Two of the 59 laparoscopically treated patients and 1 of the 40 open nephrectomy patients had metastatic disease. The former 2 are alive with stable disease and the latter died of progressive disease 11 months after surgery. The 5-year disease-free rate was 95.5% in laparoscopy patients and 97.5% in open nephrectomy patients (P = NS). Conclusions. Laparoscopic radical nephrectomy is a less invasive alternative to open surgery for patients with localized small renal cell carcinoma.

Both muscarinic and nicotinic acetylcholine (ACh) receptors are known to be present on the surface of lymphocytes. We have shown that variable amounts of ACh are detectable in the blood of various mammals including humans, and a major portion of blood ACh is localized in circulating mononuclear leukocytes in humans. In order to investigate which types of blood cell are the source of ACh in human blood, expression of mRNA for choline acetyltransferase (ChAT, EC 2.3.1.6), which catalyzes ACh synthesis, was analyzed using human leukemic cell lines as models of lymphocytes and the reverse transcription-polymerase chain reaction (RT-PCR) method. We observed that mRNA for the same ChAT as that in the nervous system is expressed constitutively in all the T-cell lines tested, but not in B-, pre-lymphoma or monocytic cell lines. Furthermore, only T-cell lines showed high ACh-synthesizing activities and intracellular ACh contents. These results suggest that the major portion of ACh in the circulating blood originates from T-lymphocytes.

Two cases are presented in which membranocystic lesions were observed in the cartilaginous tissue of surgical specimens. In both cases, the histological and ultrastructural features were reviewed, and S-100 protein distribution was examined immunohistochemically in one case. In both cases, the membranocystic lesions were observed to be adjacent to ballooned chondrocytes. In one case, several chondrocytes showed partially membranocystic lesions in their cytoplasm. The chondrocytes and nuclei in membranocystic lesions were stained positively for S-100 protein. It is suggested that the membranocystic lesions in the cartilaginous tissue were associated with the degeneration of the chondrocytes.

We followed patients who were stone-free after extracorporeal shock wave lithotripsy (ESWL) to investigate the factors that contributed to recurrent calculi.For longer than 5 years 903 patients without residual fragments 3 months after ESWL were enrolled in this study. Plain abdominal films and/or excretory urograms were evaluated every 6 months for recurrent stones on the side of ESWL. Patients who presented with colic pain or other complaints and who were suspected of having recurrent stones were also examined. Stone recurrence rates were calculated with the Kaplan-Meier method. We assessed the influence of patient age; size, location, composition and configuration of the original stones, and pyuria after ESWL on stone recurrence.Mean followup was 25 months and stones recurred in 183 of 903 renal units (20.3%). Kaplan-Meier recurrence rates were 6.7, 28.0 and 41.8% after 1, 3 and 5 years, respectively. There was a significant correlation between stone recurrence and multiple stones on one hand, and pyuria after ESWL on the other hand. Stones recurred most frequently in the lower calix. Recurrent stones were passed without intervention in 33 cases, while ESWL was repeated in 53.These data demonstrate the importance of long-term followup and the search for an effective prophylactic therapy to prevent recurrence.

Sixteen patients (23 feet) who underwent split posterior tibial tendon transfers were evaluated. The patients were seen on a followup basis for a minimum of 1 year postoperatively. The causes were spastic cerebral palsy in 13 feet, spastic-athetoid cerebral palsy in 3 feet, hydrocephalus in 3 feet, and other diseases in 4 feet. The indication for surgery was varus deformity during the stance phase of gait and increased varus deformity during the swing phase of gait because of spasticity of the posterior tibial muscle. Heel cord lengthening was done on 17 feet. Preoperative and postoperative gaits were evaluated while the patients were walking. Axial radiographs of the calcaneus and the tibia were taken of all patients while they were weightbearing. There were 15 excellent, 6 good, and 2 poor results. The poor ratings were assigned to patients who had recurrence of varus deformity; there were no cases of overcorrection. Split posterior tibial tendon transfer was effective for treating spastic varus deformity of the hind part of the foot. This treatment also could be considered for a patient with spastic-athetoid cerebral palsy, if the deformity was determined to be caused by overactivity of the tibialis posterior muscle.

Background The purpose of this study was to reveal any association between cardiorespiratory fitness level and excess post-exercise oxygen consumption (EPOC) using three cycling protocols with varying degrees of exercise intensity, i.e., sprint interval training (SIT), high-intensity interval aerobic training (HIAT), and continuous aerobic training (CAT). Findings Ten healthy men, aged 20 to 31 years, attended a cross-over experiment and completed three exercise sessions: SIT consisting of 7 sets of 30-s cycling at 120% VO2max with a 15-s rest between sets; HIAT consisting of 3 sets of 3-min cycling at 80~90% VO2max with a 2-min active rest at 50% VO2max between sets; and CAT consisting of 40 min of cycling at 60~65% VO2max. During each session, resting VO2, exercise VO2, and a 180-min post-exercise VO2 were measured. The net exercise VO2 during the SIT, HIAT, and CAT averaged 14.7 ± 1.5, 31.8 ± 4.1, and 71.1 ± 10.0 L, and the EPOCs averaged 6.8 ± 4.0, 4.5 ± 3.3, and 2.9 ± 2.8 L, respectively. The EPOC with SIT was greater than with CAT (P < 0.01) and HIAT (P = 0.12). Correlation coefficients obtained between subjects’ VO2max and the ratio of EPOC to net exercise VO2 for SIT, HIAT, and CAT were −0.61 (P = 0.06), -0.79 (P < 0.01), and −0.42 (P = 0.23), respectively. Conclusions Our data suggest that cardiorespiratory fitness level correlates negatively with the magnitude of EPOC, especially when performing aerobic-type interval training.

Background Fucosylated haptoglobin (Fuc-Hpt) is a novel cancer biomarker in a variety of pathological conditions. We previously found that the level of Fuc-Hpt is increased in the sera of patients with pancreatic cancer, and established a lectin antibody ELISA using Aleuria aurantia lectin, which specifically binds to fucosylated residues on oligosaccharides. Methods To apply this assay system to the clinical detection of several diseases, several assay conditions such as serum dilutions and inhibitory factors were investigated. The Fuc-Hpt kit was available for 25–625 fold serum dilution. Results While the values of Fuc-Hpt assay using sera and plasma were different, they showed positive correlation. The addition of bilirubin and formagine did not influence on Fuc-Hpt assay, but hemoglobin inhibited this assay in a dose-dependent manner. Conclusions We reevaluated this lectin antibody ELISA kit for measuring fucosylated haptoglobin in various conditions in this study.

Introduction Astronauts experience weight loss during spaceflight. Future space missions require a more efficient exercise program not only to maintain work efficiency, but also to control increased energy expenditure (EE). When discussing issues concerning EE incurred through exercise, excess post-exercise energy expenditure (EPEE) must also be considered. The aim of this study was to compare the total EE, including EPEE, induced by two types of interval cycling protocols with the total EE of a traditional, continuous cycling protocol. Methods There were 10 healthy men, ages 20 to 31 yr, who completed 3 exercise sessions: sprint interval training (SIT) consisting of 7 sets of 30-s cycling at 120% VO2max with a 15-s rest between each bout; high-intensity interval aerobic training (HIAT) consisting of 3 sets of 3-min cycling at 80-90% VO2max with a 2-min active rest at 50% VO2max; and continuous aerobic training (CAT) consisting of 40 min of cycling at 60-65% VO2max. During each session, resting metabolic rate, exercise EE, and a 180-min post-exercise EE were measured. Results The EPEEs during the SIT, HIAT, and CAT averaged 32 +/- 19, 21 +/- 16, and 13 +/- 13 kcal, and the total EE for an entire exercise/ rest session averaged 109 +/- 20, 182 +/- 17, and 363 +/- 45 kcal, respectively. While the EPEE after the CAT was significantly less than after the SIT, the total EE with the CAT was the greatest of the three. Discussion The SIT and HIAT would be potential protocols to control energy expenditure for long space missions.

We described the clinical results and efficacy of laparoscopic pelvic lymphadenectomy for localized prostate cancer. This procedure was followed by radical prostatectomy, if metastasis was not found in frozen section. In the presence of positive nodes, optional treatment, such as TUR or castration, other than radical prostatectomy was performed. We performed laparoscopic lymphadenectomy on twenty seven patients between April 1992 and September 1993. They range from 52 to 78 years in age and consist of 4 patients with stage A2, 17 with stage B, and 6 with stage C. We dissected the obturator lymph nodes on bilateral sides. The average operating time was 162 minutes (range 86 to 320 minutes). The average number of nodes removed from the right side was 7.1 +/- 5.9 and 6.1 +/- 4.5 from the left side, which was comparable to the number of lymph nodes obtained by open dissection. Colon injury occurred in one patient, which was managed by laparotomy procedure. Nodal metastases were found in 6 patients by frozen section, and in 10 patients by permanent section. This discrepancy suggested that two-staged operation might be preferable for the localized prostate cancer. Six patients were given suitable therapies besides radical prostatectomy. Laparoscopic pelvic lymphadenectomy is a safe and useful procedure for prostate cancer, especially for the patients who are likely to have nodal metastasis.

This case report describes a rare case of recurrent dislocation of the patella which was accompanied with trochlear dysplasia and malalignment of the patella in a 15-year-old girl. She complained of hemoarthrosis and recurrent patellar dislocation in the early knee flexion phase. Plain radiography and computed tomography (CT) showed patellar malalignment (quadriceps angle 20°) and severe dysplasia of the trochlea of the femur (sulcus angle 170°). Surgery was performed, consisting of trochleoplasty in addition to proximal and distal realignment. Trochleoplasty was undertaken using a modified Dejour technique. After surgery, the patient complained of joint contracture. Arthroscopic release of fibrous tissue relieved symptoms and obtained normal range of motion without patellar dislocation. Postoperative radiography and CT demonstrated improvement of the quadriceps angle (10°) and sulcus angle (140°).

Since July 1991, we have performed laparoscopic nephrectomy for removal of damaged kidneys in thirteen patients. In addition, we recently developed a new procedure of laparoscopic nephrectomy for renal cell carcinoma and successfully removed the kidney with renal cell carcinoma. Patients' age ranged from 18 to 80 years with the average being 50 years. There were 8 male and 6 female patients. Original disease was calculous disease in 5 patients, vesicoureteral reflux in 4, renovascular disease in 2, ureteropelvic junction obstruction in 1, ectopic ureter in 1 and renal cell carcinoma in 1. The mean size of the diseased kidney was 9 x 5 x 4 cm in the initial 13 cases and 13 x 7 x 6 cm in the case with renal cell carcinoma. The size of the tumor was 2.5 x 2 x 2 cm. In the first 13 patients, nephrectomy was performed as described previously. In the patient with renal cell carcinoma, a new procedure was applied. In the new procedure, five trocars were introduced into the abdominal cavity through the lateral abdominal wall. The kidney was removed en bloc together with the adrenal gland, perirenal fat and Gerota's fascia in the same fashion as traditional radical nephrectomy. Thirteen kidneys were successfully removed, but one failed because of dense adhesion to the surrounding tissue. Three of the 13 patients required additional laparotomies to control bleeding or to remove missed stone.(ABSTRACT TRUNCATED AT 250 WORDS)

Transrectal hyperthermia was performed on 13 patients with chronic non-bacterial prostatitis which failed to respond to the conventional treatments. We used "Prostathermer" (Biodan-Medical system, Israel) for heating the prostate gland. The prostate was heated at 42 degrees C-43 degrees C, for 60 minutes in 1 session. Treatment consisted of 6 sessions, and was performed during a period of three weeks on an outpatient basis. Of 11 patients re-evaluated after 3 months, 6 (55%) achieved improvement of subjective symptoms. Of 9 patients, 4 (44%) showed reduction of the number of white blood cells (> or = 10 leukocytes count per high-power field) in their expressed prostatic secretion (EPS), which however was not always correlate with improvement of subjective symptoms. No complications were encountered in our series. Our result indicates that local hyperthermia is safe, and would become new modality in the treatment for chronic prostatitis.

Endopyeloureterotomy has been accepted as a procedure to relieve obstruction of the ureteropelvic junction and upper ureteral stenosis. However, in patients with a long stenotic segment poor results are often obtained with the conventional technique. To resolve this problem we developed a new technique using a 22F urethrotome and a transpelvic extraureteral approach. In this technique the renal pelvis was incised for 1 to 1.5 cm. from the ureteropelvic junction in the direction of the parenchyma using the cold knife of the urethrotome under direct vision. For upper ureteral stenosis the dilated pelvic and ureteral posterolateral walls were incised 1 to 1.5 cm. from the stenotic segment toward the ureteropelvic junction. Then, the stenotic segment was treated with the urethrotome after it was advanced into the retroperitoneal space through the incision in the renal pelvis. We treated 21 patients with the new technique between August 1988 and August 1990. Our series included 3 patients with the high insertion type of ureteropelvic junction obstruction and 4 with a long stenotic segment. The success rate was 95% without any severe complication. These results indicate that our new technique could become a useful procedure for endopyeloureterotomy.

Objectives: We retrospectively reviewed the clinical outcome and long-term cancer control of patients with localized large renal-cell carcinomas (RCCs) who underwent laparoscopic radical nephrectomy in comparison to open procedure. Patients and Methods: One hundred and thirty-one patients with RCCs greater than 7 cm who underwent radical nephrectomy between 1996 and 2008 were studied: 52 patients in the laparoscopy group and 79 in the open group. In this analysis patients who had metastasis or pT4 disease or tumor thrombus in the inferior vena cava were excluded. The median follow-up period was 41 months in the laparoscopy group and 51 months in the open group. Results: Patients in the laparoscopy group had tumors similar in size to those in the open group (88 and 89 mm, respectively), lesser blood loss (245 and 663 mL p < 0.01), but more intraoperative complications (15% and 2.5%). One laparoscopy patient was converted to open surgery because of an injury to the inferior vena cava (IVC). The 5- and 10-year disease-free rates and patient-survival rates were comparable in both groups. Conclusions: Laparoscopic nephrectomy is feasible for localized large RCC, although intraoperative complications were more frequent. No statistically significant differences were found in either disease-free or cause-specific patient survival rates between the laparoscopy and the open groups. Laparoscopic nephrectomy can be an alternative to the open procedure for localized large RCC. However, a longer follow-up period is necessary to confirm the oncological efficacy of this procedure.

As a prospective study on asymptomatic microhematuria, complete urological examinations including cystoscopy, IVP, ultrasound and urinary cytology were performed on 422 patients over 40 years old between January 1987 and December 1988 (group A). The results of group A was compared with that of retrospective study on 266 patients, who had incomplete urological examination between January 1984 and December 1985 (group B). Cystoscopy was performed on 321 patients (87.2%) in group A and on 108 patients (40.6%) in group B. Bladder tumor was found in 10 cases (2.4%) in group A, including 7 cases of male patients (5.7%), but in only 1 case (0.4%) in group B. Since the negative rate of abnormal urinary cytology was 50% and that of abnormal IVP was 90% in 10 cases of bladder tumor in group A, cystoscopy was considered to be an essential examination for the screening of patients with asymptomatic microhematuria over 40 years old patients.

To develop a screening test to identify community dwelling elderly people who are in need of assistive care but whose activities of daily living (ADLs) can be improved by appropriate rehabilitation intervention, so-called 'quasi-in-need-of-care state (QUINOCS)'.A total of 32 persons (mean age 77.3 years) from the metropolitan area and 51 persons (mean age 82.7 years) from a rural area were enrolled. Two physiatrists examined them and judged whether they could benefit from rehabilitation intervention while visiting nurses evaluated their ADLs using the Functional Independence Measure (FIM). A screening test to identify the QUINOCS was created using a seven-item subset score of the FIM (feeding, bathing, dressing lower-body, bladder management, bed/chair/wheel chair transfer, walking/wheel chair, stairs).Fourteen in the metropolitan and 19 in the rural inhabitants were judged as the QUINOCS by the physiatrists. Persons whose subset scores included or ran across the intermediate range of independent levels (scores 3 and 4 of the FIM) showed tendency to be judged suitable for rehabilitation intervention. This finding was applied for screening algorism to identify the QUINOCS. Sensitivity and specificity of this test were 0.71 and 0.78 for the metropolitan, and 0.74 and 0.78 for the rural groups, respectively.The screening method using the 7-item subset of the FIM can be used for identification of the QUINOCS among elderly people efficiently.

The present study was prospectively conducted for female patients with wet overactive bladder to assess the efficacy of propiverine hydrochloride in improving their symptoms and quality of life (QOL). Propiverine hydrochloride was administered orally to 58 patients for 8 weeks. Prior to administration and at 4 and 8 weeks after administration, symptoms and QOL were assessed by the micturition diary, the International Consultation on Incontinence-Short Form (ICIQ-SF), and the King's Health Questionnaire (KHQ). After administration, numbers of daily micturitions, incontinence episodes, urgency episodes and severity of urgency which were assessed based on the micturition diary and urgency scale questionnaire showed significant improvement when compared to baseline values. Furthermore, both ICIQ-SF and KHQ scores improved significantly after administration. The incidence of adverse events was 23.8% and none were serious. Propiverine hydrochloride was shown to contribute not only to the improvement of symptoms in female patients with wet overactive bladder but also to their QOL.

One hundred and forty-four patients primarily receiving kidneys from cadaver donors between Jan., 1978 and Oct., 1989, were reviewed. The patients' ages ranged 14-53 with a mean +/- S.D. of 34.7 +/- 8.0 years old. There were 100 males and 44 females. Twenty kidneys were harvested from heart-beating donors and 124 from non-heart-beating donors. In harvest from non-heart-beating donors, we performed in situ cooling through a double balloon catheter placed in the aorta to minimize prolonged warm ischemia. The number of matched HLA A, B antigens was (mean +/- S.D.) 1.7 +/- 0.8 antigens and for HLA DR antigens, it was 1.2 +/- 0.5. One hundred and nineteen of the 144 recipients have had a history of blood transfusion preoperatively. The patients were treated with four different immunosuppressive protocols; regimen I consisting of horse antilymphocyte globulin (ALG), regimen II of large-dose (14 mg/kg/day) of cyclosporin (CsA) and steroid, regimen IIIa of low-dose (4 mg/kg/day) of CsA, steroid and a short course of ALG (500 mg/day) and regimen IIIb of low-dose (6 mg/kg/day) of CsA, steroid and a short course of ALG (1000 mg/day). Fifteen patients received regimen I therapy from Jan., 1978 to Nov., 1982, 49 received regimen II from Nov., 1982 to Dec., 1986, 23 received regimen IIIa from Jan., 1987 to Dec., 1987 and 57 received regimen IIIb from Jan., 1988 to Oct., 1989.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of 20 HLA 1-haploidentical donor kidney transplant patients treated with preoperative lymphocyte deletion through thoracic duct drainage and low dose of cyclosporine and steroid immunosuppressive therapy, were presented. The number of removed lymphocytes was 114 +/- 36 X 10(9) (mean +/- SD) and the duration of thoracic duct drainage was 35 +/- 7 days. Graft survival was 100% at 3-9 months and 89% at 1-2 years after transplantation. Patient survival was 100% at 3-9 months and 89% at 1-2 years. A patient died from lung cancer (adenocarcinoma) in the 9th posttransplant month. Acute rejection was not seen in 20 patients during the first 3 months. Life-threatening infectious disease was never seen either. Diabetes mellitus was observed in 1 patient. No other complications were observed. These results indicated that thoracic duct drainage and low dose cyclosporine and steroid postoperative immunosuppressive treatment might yield complete success in HLA 1-haploidentical kidney transplant patients.

We appreciate Chawla et al.’s interest in our article. Succinylcholine may be associated with an increase in heart rate, corresponding with elevation of plasma norepinephrine.1 Indeed, in the control group in our study, heart rate was significantly elevated one minute after intubation.2 Therefore, it is unlikely that succinylcholine augmented the negative chronotropic response observed in the landiolol groups. However, since we administered vecuronium immediately after intubation, we cannot exclude the possibility that this drug may have attenuated catecholamine release after succinylcholine, resulting in smaller changes in heart rate and blood pressure.1, 2 We recognize that perioperative β–blocker administration to obtain perioperative hemodynamic optimization must be done selectively. The use of short-acting β–blockers including landiolol, may confer specific benefits in the setting of brief, but intense periods of autonomic stimulation in patients with coronary artery disease.

Tacrolimus (Tac), developed in 1990, has been applied as an immunosuppressive agent for liver, heart, and kidney transplantation and is known to have more powerful immunosuppressive effects than cyclosporine (CyA). To evaluate the efficacy of Tac in cadaveric kidney transplants from non-heart beating donors, we present the long-term outcome of patients receiving kidneys with ischemic damage, and compared it with that of CyA. Between July 1990 and December 2000, 55 patients with end-stage renal disease received kidneys from non-heart beating donors (Maastrichy category 3) and were treated with Tac and steroid immunosuppressive therapy. During the same period, we also performed 137 non-heart beating cadaveric renal transplants treated with CyA-based immunosuppressive therapy. The patient survival rate was 98% at 1 yr and 96% at 3–10 yr in the Tac group, and 97% at 1–3 yr, 93% at 5 yr and 85% at 10 yr in the CyA group. The graft survival rate was 91% at 1 yr, 80% at 3 yr, 63% at 5 yr and 34% at 10 yr in the Tac group, and 88% at 1 yr, 75% at 3 yr, 63% at 5 yr and 49% at 10 yr in the CyA group. There was no significant difference in either patient or graft survival rates between the two groups. Acute early rejection in the Tac group was less than that in the CyA group but acute tubular necrosis was the same in both groups. This indicates that Tac is available for cadaveric kidney transplants from non-heart beating donors. In conclusion, Tac is available as an immunosuppressive agent even for kidney transplants from non-heart beating donors.