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Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Intraoperative anaphylaxis caused by blood products is uncommon, but it is unclear whether the rarity of this reaction is attributable to the difficulty of diagnosis, underreporting, or both. We investigated the incidence of intraoperative transfusion anaphylaxis and its reporting to the hemovigilance system.We retrospectively reviewed cases wherein general anesthesia was used at a single hospital during a 12-year period. Cases of intraoperative anaphylaxis were extracted using an electronic search strategy and determined using the recently developed grading and clinical scoring system. The causative blood products were determined by the onset duration based on literature regarding intraoperative transfusion anaphylaxis cases.Among the 62,146 general anesthesia cases, 22 cases of intraoperative anaphylaxis were identified, and 11 of the 22 cases received transfusions before the onset of anaphylaxis. Intraoperative transfusion anaphylaxis was defined as occurring within 30 min of transfusion. Finally, nine cases of intraoperative transfusion anaphylaxis were analyzed. The overall incidence of intraoperative transfusion anaphylaxis was 1/3,994, with the highest incidence noted for fresh frozen plasma (1/2146; 95% confidence interval [CI] 1/6610-1/920), platelet concentrate (1/2348; 95% CI 1/92,742-1/422), and red blood cells (1/22,867; 95% CI 1/903,199-1/4,105). No evidence indicated that these cases were reported to the Japanese hemovigilance system, although all intraoperative transfusion anaphylaxis cases were diagnosed by anesthesiologists.The incidence of intraoperative anaphylaxis caused by blood products was higher than that reported and may be underreported to the Japanese hemovigilance system. Further research, particularly multicenter studies, is needed to confirm our results.

Several strategies are employed for administering fresh frozen plasma (FFP) during weaning from cardiopulmonary bypass (CPB). This study evaluated by coagulation function aimed to compare two strategies of administering FFP in cardiovascular surgery: administering 4 units of FFP before separating from CPB or administering it after weaning from CPB. Thirty patients who underwent CPB and were expected to receive 8 units of FFP and 20 units of platelet concentrate were randomly allocated into group A (8 units of FFP and 20 units of platelet concentrate administered after separating from CPB) and group B (4 units of FFP administered before separation, and 4 units of FFP and 20 units of platelet concentrate administered after separating from CPB). Thromboelastography (TEG6s®, HAEMONETICS Japan GK, Tokyo, Japan) was conducted at four time points before and after separation. Blood test results, blood loss, and required amounts of blood transfusion were compared. The primary outcome was the difference in coagulation function evaluated by TEG6s 90 min after protamine administration. Twenty-eight patients were enrolled in the study. Coagulation function after separating from CPB was not significantly different between the groups. Additionally, no significant differences were found in intensive care unit outcomes, such as 24-h transfusion requirements. Coagulation function 90 min after separating from CPB was not significantly different between the groups. Prior FFP administration before separation did not provide significant improvement in coagulation function.

Several pieces of evidence suggest that volatile anesthetics (VAs), which were originally used as sedatives, have myocardial protective effects against cardiac ischemia-reperfusion injury. In Europe and the United States, the use of VAs during cardiopulmonary bypass (CPB) is widespread, as 2019 European Association for Cardio-Thoracic Surgery (EACTS)/European Association of Cardiothoracic Anaesthesiology/European Board of Cardiovascular Perfusion, 2011 American College of Cardiology/American Heart Association, and 2017 EACTS guidelines recommend their use in cardiovascular surgery, based on their potential myocardial protective effects. In other countries, including Japan, the use of VAs is gradually increasing. Therefore, it is important to be aware of the risks and possible adverse events associated with VA use during CPB to ensure safe sedation management. Herein, we describe in detail issues such as intraoperative awareness, air pollution, and damage to oxygenators due to VA use and propose precautions.

To report maternal outcomes in a cohort of women who received autotransfusion of vaginally shed blood and to describe the feasibility of blood collection and cell salvage processing at the time of vaginal hemorrhage.We conducted a retrospective case series of patients who received autotransfusion of vaginally shed blood at the time of obstetric hemorrhage from January 2014 to August 2020. Maternal data and cell salvage utilization characteristics were abstracted from the electronic medical record.Sixty-four cases were identified in which autotransfusion of vaginally shed blood occurred during an obstetric hemorrhage. Median quantitative blood loss was 2175 ml (interquartile range 1500-2250 ml) with 89% of cases having a blood loss greater than 1000 ml. Patients on average received approximately 1.3 units of autologous blood product (384 ml, interquartile range 244-520 ml) and no direct adverse events were observed during transfusion. We observed heterogeneity in autologous blood volume across all values of quantitative blood loss. The need for allogenic blood transfusion was common and occurred in 72% of all cases (N = 46). There were no documented cases of maternal sepsis or severe infectious morbidity.In 64 cases where autotransfusion of vaginally shed blood occurred, autotransfusion was well tolerated. Heterogeneity in autologous blood volume collection likely represents the lack of standardized protocols for blood collection in the delivery room. Autotransfusion of vaginally shed blood is a feasible and reasonable technique to employ during severe obstetric hemorrhage.

Background This study aimed to compare the postoperative analgesic effects of ultrasound-guided posterior quadratus lumborum block with spinal morphine, after cesarean section, using the visual analogue scale pain score. Methods One-hundred-and-seventy-six pregnant women scheduled for elective cesarean section with spinal anesthesia were randomly allocated into four groups to receive spinal morphine 0.1 mg (group M+); spinal saline (M−); posterior quadratus lumborum block using either 0.3% ropivacaine (0.45 mL/kg each side, maximum 150 mg) group pQ+); or saline (pQ−). All patients received 11–13 mg hyperbaric bupivacaine 0.5% and 10 μg fentanyl. Intravenous droperidol, fentanyl and acetaminophen were administered during surgery. Bilateral posterior quadratus lumborum block was performed immediately after surgery. Postoperative pain was assessed at 0.5, 1, 2, 4, 6, 18 and 24 h after surgery, and the pain score 6 h after surgery was the primary endpoint. Results One-hundred-and-forty-six patients were included in the final analysis. Pain scores 6 h after surgery, both at rest and when moving, were significantly different when comparing the M+pQ+ group with the M−pQ+ or M−pQ− groups, and when comparing the M+pQ− group with the M− pQ+ or M− pQ− groups (all P Conclusion Spinal morphine improved postoperative analgesia but the combination of posterior quadratus lumborum block with spinal morphine did not lead to further improvement.

Volatile anesthetics (VAs) protect myocardial cells during cardiovascular surgeries, including cardiopulmonary bypass (CPB). In CPB, blood is gradually transferred from the body to a CPB unit until the target cardiac index is achieved, following which human lung (HL) ventilation is stopped. This pilot study aimed to evaluate changes in the blood sevoflurane concentrations 5 min after the start of CPB when its delivery to the oxygenator began after HL ventilation with sevoflurane was completed. Six patients were recruited and participated in this study. For each patient, the equilibrated blood sample, collected 20 min after starting the delivery of 1.7% sevoflurane (HL group), and another blood sample, collected 5 min after starting the CPB, were analyzed using gas chromatography equipped with a flame ionization detector. The mean (± standard deviation) sevoflurane concentrations in the HL and 5 min after starting CPB groups were 58.6 ± 4.7 and 14.5 ± 5.0 μg/ml, respectively (

Background. The optimal dose and concentration of analgesic efficacy of ropivacaine (RPV) and bupivacaine (BPV) for postoperative pain relief in paediatric abdominal surgery patients is still unclear. Therefore, this meta-analysis compared the efficacy of these analgesics, their administered modes (ultrasound-guided RSB versus LAI) for postoperative pain relief, and side effects. Methods. Three databases, PubMed, Embase, and Cochrane Database of Systematic Reviews, were exhaustively searched with predefined keywords. Eight randomized clinical trials and retrospective studies were selected. Analgesic effect, postoperative pain score, level of side effect, applied dose, and concentration of drug were analysed. Results. Drug dose ranged from 0.5–2.5 mL/kg of 0.2 to 0.5% concentrations. Male participant for RSB and LAI treatment groups varied from 40–62% and 25–83%, respectively. Mean age of RSB and LAI groups ranged from 3.8–11.65 years and 4.3–11.27 years, respectively. Our meta-analysis revealed that RSB could reduce total opioid use postoperatively (WMD = −0.02, 95% CI: −0.02, −0.02), with I2 value of 15%. We found that the RPV (0.25%, 2.5 ml/kg) was optimal in suppressing the pain. Its lower concentration (0.2%) was ineffective, whereas higher one (0.375%) seems to increase risk of systemic toxicity. Similarly, BPV (0.25%, 2.5 mg/kg) efficaciously reduced the pain score, while its lower concentration was ineffective. The combined postoperative pain score in the RPV-treated group was found to be significantly reduced ( p < 0.01 ) with I2 value of 85% indicating high heterogeneity. Conclusion. Both RPV and BPV were significantly effective in reducing postoperative pain score. It appears that RSB could be a preferred choice to deliver analgesia, due to reduced opiate dose requirement and improved clinical safety without significant postoperative adverse events.

We aimed to compare the effects of saline with and without heparin on the catheter-occlusion rate and coagulation-related blood test results for the management of arterial catheters among patients admitted to a short-term intensive care unit postoperatively. This prospective, triple-blinded, randomized controlled study recruited patients aged 20–90 years scheduled to undergo radial arterial catheter insertion and postoperative intensive care unit admission between February and August 2019. Patients were randomly allocated to two groups (1:1 ratio) depending on the use of heparin: study (normal saline with heparin, 3000 units to 500 ml of normal saline) and control (normal saline without heparin) groups with arterial catheters. The allocated management method was employed immediately after intensive care unit admission. Occlusion assessment (every 12 h), arterial blood gas tests (every 6 h), and blood sample collection (every 24 h) were performed. The occlusion of arterial catheter was assessed using occlusion rate, and blood test results were assessed using a linear mixed model. There were 147 patients in the arterial catheter groups. There were no significant differences in occlusion rates and changes in platelet counts and activated partial thromboplastin time between the groups with arterial (p = 0.98, 0.16, and 0.32, respectively) catheters during the first 6 days after intensive care unit admission. Normal saline with and without heparin showed similar efficiency for both the prevention of occlusion and the results of coagulation.

Platelet Mapping can measure both the degree of platelet inhibition and fibrinogen activation, was not originally designed to measure fibrinogen concentration. Traditional laboratory fibrinogen concentration testing requires around 60 minutes; however, fibrinogen activation only takes 10 minutes, and is indicated as maximum amplitude of activator f. If Platelet Mapping can predict fibrinogen concentration during cardiopulmonary bypass, this could facilitate rapid hemostasis management. The aim of this study was to verify whether fibrinogen concentration could be predicted using Platelet Mapping results. Thus, a pilot study was conducted to evaluate this concept during cardiopulmonary bypass. This prospective, observational pilot study investigated 15- to 90-year-old patients who underwent cardiac or aortic surgery from August 2019 to September 2019. Twenty-one patients enrolled in this study, and 43 blood samples were obtained for both fibrinogen activation measurements using Platelet Mapping and traditional laboratory-based tests, respectively. Correlations between results were analyzed using linear regression and the receiver operating characteristic curve. Correlation by Pearson’s correlation analysis indicates a significant relationship (correlation coefficient of r = 0.91), and a receiver operating characteristic curve indicated that sensitivity, specificity, and receiver operating characteristic area were 100% (95% confidence interval, 75.3–100%), 93.8% (79.2–99.2%), and 0.995 (0.984–1.00), respectively. Our results indicate a strong correlation between fibrinogen activation and serum fibrinogen concentration. The maximum amplitude of activator f can estimate low fibrinogen concentration faster than traditional methods; this method quickly provides important information for anesthesia and hemostatic management in cardiac surgery.

Cell salvage is frequently used to avoid unnecessary allogeneic blood transfusions, which results in a reduction in blood transfusion volume and cost. The aspirated blood is washed with normal saline and centrifuged to recover only blood cells, salvaged blood is then made. In cardiovascular surgery, heparin is used to maintain activated clotting time over 400 seconds. Some practitioners believe that heparin remains in the salvaged blood. Therefore, we hypothesized that salvaged blood during cardiovascular surgery includes heparin. A pilot study was conducted to evaluate our hypothesis using three different salvage systems. This study was a prospective, observational, pilot study, with patients aged 20–85 years old who were scheduled for cardiovascular surgery from May 2018 to October 2018. The intent of this study was to evaluate whether salvaged blood with three different devices includes large enough quantities of heparin to influence activated clotting time in cardiovascular surgery. Between May and October 2018, 12 samples during heparinization were collected, and 12 samples of salvaged blood from 3 devices were collected after administrating protamine. The heparin concentration of the 24 samples was measured. All heparin concentrations in salvage blood sample from two devices was below the limit of measurement (0.10 IU/mL). Slightly measurable heparin was detected in salvaged blood sample from one device (mean 0.15 IU/mL). Salvaged blood during cardiovascular surgery intervention does not contain enough heparin to influence activated clotting time.

Purpose Volatile anesthetics (VAs) protect myocardial cells in cardiovascular surgery. A recent clinical trial of cardiopulmonary bypass (CPB) surgery reported no significant difference in mortality rates between the use of VAs and total intravenous anesthetics at 1 year postoperatively. However, oxygenator function may affect the VA pharmacokinetics. Thus, we measured the VA blood concentrations during CPB in patients managed with four different microporous polypropylene hollow fiber membrane oxygenators. Methods Twenty-four patients scheduled for elective CPB were randomly allocated to one of the two VA groups (desflurane and sevoflurane groups) and, then, randomly divided into one of four oxygenator groups: Terumo, LivaNova, Medtronic, and Senko (n = 3). Additionally, in each VA group, three patients were randomly selected and redundantly allocated to the human lung group (for control blood VA concentration without oxygenator). Blood samples collected 20 min after starting 6.0 vol% desflurane or 1.7 vol% sevoflurane were analyzed using gas chromatography. Oxygenator-related complications and structural changes in the membrane surface of each oxygenator after surgery were evaluated. Results The mean (standard deviation) concentrations of desflurane and sevoflurane in the human lung were 182.4 (23.2) and 54.0 (9.6) μg/ml, respectively; not significantly different from those in the four oxygenator groups. No oxygenator-related complications occurred. Structural changes in membrane fibers did not occur after clinical use, except for difficulty in image acquisition with Senko products. Conclusion Our results demonstrated that the blood concentrations of desflurane and sevoflurane passing through oxygenators used during CPB were similar to those in the human lung control. Electronic supplementary material The online version of this article (10.1007/s00540-020-02844-1) contains supplementary material, which is available to authorized users.

Previous work showed that 20 mL of local anesthetic (LA) did not spread into the paravertebral space (PVS) via the intramuscular quadratus lumborum block (QLBi). If spread of LA into the PVS can be achieved by increasing the total LA volume, QLBi can be more effective. We hypothesized that a larger volume of LA for the QLBi would spread into the PVS. This crossover volunteer study included five healthy men. For comparison, both the ultrasound-guided QLB type 2 (QLB2) and QLBi were employed on opposite sides of each volunteer, and the spread of LA solution (0.7 mL/kg) mixed with contrast media in the PVS was assessed 1 h after the first injection using magnetic resonance imaging. Sensory loss was evaluated by pinprick 90 min post-injection. Each volunteer underwent both QLB types, and the same procedures were administered on opposite sides 7 days after the first experiment. In total, 20 QLB blocks (10 QLB2 and 10 QLBi) were performed. LA did not spread into the PVS after the QLBi. The sensory block area included the lower abdomen after the QLB2, but not after the QLBi. The sensory block area did not extend to the upper abdominal region or the midline of the lower abdomen with either block method. LA administered by the QLB2 spreads into the PVS of T10–T12, resulting in lower and lateral abdominal sensory loss. In contrast, LA administered by the QLBi does not spread into the PVS and results in only lateral abdominal sensory loss.

The present study examined the effect of the perceived parent–child relationship in childhood on resilience in youth. It recruited 268 university students majoring in education and college students majoring in welfare science to investigate the relationship between their perception of parent–child relationship in their childhood and their current resilience by their responses on the Adolescent Resilience Scale and the Children's Perceived Affiliation for Parents Scale. The results indicated that female's positive perception of their relationship with their mothers in childhood had a positive influence on their resilience. On the other hand, the positive influence was inconspicuous and limited with regard to the perception of female's relationship with their fathers in childhood. In contrast, this positive influence was not confirmed in male participants regardless of the perception of their relationship with mothers and fathers in childhood. Although limited to females, these results suggest that youth's perception of their parent–child relationships in childhood significantly affected the development of resilience. In addition, sex difference was observed in this effect. The findings have been discussed with respect to the process of the development of resilience.

Background and Objectives Several types of quadratus lumborum block (QLB) are used for postoperative analgesia and are believed to be effective against both somatic and visceral pain via a local anesthetic (LA) effect in the paravertebral space (PVS). However, it remains unclear whether all QLB techniques result in LA spread into the PVS. We hypothesized that LA administered via intramuscular QLB would spread into the paravertebral space and investigated the spread and sensory block area of LA in intramuscular QLB. Methods This volunteer study included 5 healthy men and 1 woman, with no previous medical history. Intramuscular QLB and lateral transversus abdominis plane block were performed under real-time ultrasound guidance for comparison of sensory deprivation range. Two days later, the same procedure was performed on the contralateral side of the body. The spread of LA via intramuscular QLB spread to the PVS was assessed 1 hour after the first injections using magnetic resonance imaging. Sensory perception was also evaluated by the pinprick test at 90 minutes after injection. Results In total, we performed 11 intramuscular QLBs and 11 lateral transversus abdominis plane blocks. Magnetic resonance imaging showed that LA did not spread into the PVS after ultrasound-guided intramuscular QLB. The analgesic area corresponded to the side of the body that was ipsilateral to the block. Conclusions Ultrasound-guided intramuscular QLBs are not clinically useful for procedures requiring LA spread into the PVS but do result in an ipsilateral analgesic effect in healthy volunteers. Clinical Trial Registration This study was registered at University Hospital Medical Information Network Clinical Trials Registry, UMIN 000019149.

We conducted a comparative study to evaluate analgesic efficacy between paravertebral block via the surgical field (PVB-sf), in which the catheter was inserted into the ventral side of the sympathetic trunk in the paravertebral space by a thoracic surgeon under thoracoscopic visualization, and epidural block (Epi) using ropivacaine for post-thoracotomy pain relief. Lung cancer patients scheduled for lobectomy via thoracotomy were randomly allocated to receive either PVB-sf or Epi (n = 36 per group). Before thoracotomy closure, 0.375% ropivacaine was administered as a bolus (PVB-sf, 20 mL; Epi, 5 mL), followed by a 300-mL continuous infusion of 0.2% ropivacaine at 5 mL/h. Postoperative pain was assessed using a visual analog scale (VAS) score at various time points, including the primary endpoint of 2 h after ropivacaine bolus injection. Sensory block area, vital signs, serum ropivacaine concentrations, and side effects were also evaluated. The Epi group showed significantly lower VAS scores and blood pressure and a wider sensory block area than the PVB-sf group at all evaluation time points. While the mean serum ropivacaine concentration in the PVB-sf group was significantly higher than that in the Epi group until 1 h after injection of the ropivacaine bolus, there was no significant difference at any subsequent assessment point. The incidence of side effects was similar between the groups. The Epi was superior to PVB-sf for the management of post-thoracotomy pain in this patient cohort. The number of dermatomes anaesthetized by Epi was greater than that anaesthetized by PVB-sf. No difference in complication rates was observed between the two groups.

Tumor necrosis factor–related apoptosis-inducing ligand (TRAIL) induces apoptosis in cancer cells. However, TRAIL is not toxic against most normal cells. We have accordingly examined by in vivo electroporation whether TRAIL induces apoptosis in renal cell carcinoma. In addition, combination treatment with TRAIL and 5-fluorouracil (5-FU) against renal cell carcinoma was also investigated. The NC65 renal cell carcinoma line was used as a target. pCAGGS TRAIL was injected into the NC65 tumors in the right flanks of severe combined immunodeficient mice. Tumors were pulsed with the CUY21 electroporator. Electroporation was done once on day 0 or thrice on days 0, 2, and 4. Apoptosis was determined by terminal deoxyribonucleotide transferase–mediated nick-end labeling assay. When TRAIL gene therapy using in vivo i.t. electroporation was done once only, the growth of NC65 tumors was not inhibited. However, when TRAIL gene therapy was done thrice, growth suppression of the NC65 tumors was observed. Transfection of the TRAIL gene by in vivo electroporation induced apoptosis in NC65 tumors. When NC65 cells were treated with TRAIL gene therapy in combination with 5-FU, stronger growth suppression was obtained. TRAIL gene therapy did not induce liver dysfunction in severe combined immunodeficient mice. This study shows that TRAIL gene therapy induced growth suppression and apoptosis in NC65 tumors without severe side effects, and that combination treatment of NC65 cells with TRAIL gene therapy and 5-FU resulted in higher antitumor activity. These findings suggest that TRAIL gene therapy and/or 5-FU may be effective against renal cell carcinoma without harmful toxic effects. [Mol Cancer Ther 2006;5(9):2165–71]

Two experiments were conducted to test 100 children (aged five years) on an object named novel word selection task. In Experiment 1, the experimenter labeled a novel word to a target object (an elephant) which was in a cage alone, or which was in a cage with many objects (other animals and instruments) around it. In the former case, the subjects usually qualified the word meaning only when similarly restricted by its peripheral objects (a cage). In the latter case, the subjects were likely to qualify the word meaning with a conceptual level name (an elephant). In Experiment 2, the experimenter labeled a novel word to a target object which was in a small cage, or in a large cage. In the former case, the subjects were likely to qualify the word meaning only when being similarly restricted by its peripheral objects. In the latter case, the subjects were likely to qualify the word meaning with a conceptual level name. These findings suggested that, for young children, objects peripheral to a target object had an effect on the meaning of the qualifying word.

Osteolysis and hypercalcemia are observed in 5-15%, and 10%, respectively, of malignant lymphoma patients during their clinical course. However, both osteolysis and hypercalcemia are uncommon at onset of the disease. We encountered a 24-year-old male non-Hodgkin's lymphoma patient who had multiple osteolytic lesion from the onset of the disease and repeated episodes of hypercalcemia during the clinical course. The patient died with refractory disease. We studied the expression of chemokines which might affect bone resorption using the reverse transcriptase-polymerase chain reaction (RT-PCR) method. Increased expressions of MIP-1alpha, MIP-1beta and RANKL, which are osteoclast-activating factors, were observed in the RNA derived from the patient's lymphoma cells. The secretion of osteoclast-activating factors such as MIP-1alpha by the tumor cells (and/or bone marrow stromal cells) might be involved in the etiology of osteolysis and hypercalcemia in some malignant lymphoma cases.

This case report concerns a 59-year-old man with acute myocardial infarction associated with a giant organized thrombus occupying the right sinus of Valsalva that developed into chest pain and bradycardia. Magnetic resonance imaging showed low intensity in both T1-weighted and T2-weighted images, indicating that the mass was a thrombus. A direct approach involving grafting effectively resolved the embolization and myocardial ischemia, even during the subacute period.

In this experiment with a Novel Label Task, 48 children ages 5 to 6 years were given a novel word for a target item, e.g., a dog. They were also given one of two types of featural information for the target item, a feature naturally common to animals, i.e., “This has a heart inside,” or an accidental feature uncommon to animals, i.e., “This gets a splinter.” As a result, the number of children who interpreted the novel word at the superordinate level (animal) increased significantly when they were given the feature naturally common to animals. On the other hand, there was no significant increase for an accidental feature. Further, the children were given the instruction that all animal items in this task had the same featutes as the target item. As a result, although the number of children who interpreted the novel word at the superordinate level (animal) increased significantly when they were given both the feature naturally common to animals and also the accidental feature, there were more when the instruction was with the feature naturally common to animals than with the accidental feature. The findings were discussed in relation to the factors corresponding to young children's interpretation of a novel word at the superordinate level.

The aim of this study is mainly to elucidate the relation between the modification of skin temperature and MMG signal properties depending on the contractile force. Ten healthy male volunteers, aged 22.8 +/- 0.7 (mean+/-SE) years, participated in this study. EMG and MMG signals were recorded during voluntary isometric contraction (20, 40, 60, and 80% MVC) of biceps brachii muscle under a skin temperature of 34 degrees C (control), 28 degrees C (cooling), and 40 degrees C (heating), respectively. A significant difference of MVC during elbow flexion was not recognized among the thermal conditions. Root mean square values of EMG and MMG (i.e., rms-EMG and rms-MMG) increased depending on the contractile level (P0.01). In the heating condition, the rms-MMG progressively increased in response to an increase of up to 60% MVC, however, it was nearly unchanged at a contractile force higher than 60% MVC The rms-EMG was not significantly influenced by the skin temperature. The rms-MMG significantly increased depending on the skin temperature at each contractile level (P0.01). There were significant interactions between contractile force and skin temperature for rms-MMG (P0.01). In conclusion, by modification of passive muscle temperature, rms-MMG was significantly altered in comparison with MVC and rms-EMG, which might be reflective of the changes of the mechanical contractile properties of muscle fibers.

Acute myeloblastic leukemia cases carrying the translocation t(8;16) (p11;p13) are characterized by the M4 and M5 subtypes, erythrophagocytosis by the blast cells and a poor prognosis, suggesting a new clinical entity. The t(8;16) fuses the MOZ gene which encodes a histone acetyltransferase, located on 8p11 with the CBP gene which also encodes a histone acetyltransferase, located on 16p13, and recent reports suggested that the chimeric transcription MOZ-CBP is essential for leukemogenesis. A 68-year-old woman who had been treated mainly with paclitaxel and carboplatin for preceding ovarian cancer was admitted to our hospital, complaining of right breast mass. She was diagnosed as having breast cancer and acute monocytic leukemia (M5b). Cytogenetic study with spectral karyotyping analysis revealed the development of 47 XX, + 8, t(8;16)(p11;p13). Eleven cases of therapy-related t(8;16) leukemia including the present case have been reported, but prior treatment with paclitaxel and carboplatin-based chemotherapy has never been reported. The relation of histone acetylase and therapy-related leukemia is discussed.

Myelofibrosis following peripheral T-cell lymphoma has rarely been reported. Described here is a case of peripheral T-cell lymphoma with myelofibrosis and elevated transforming growth factor beta (TGF-beta). A 69 years old male was admitted due to anemia and thrombocytopenia. His bone marrow showed fibrosis and was infiltrated with small lymphoid cells and a few residual normal hematopoietic cells. He had presented with hepatosplenomegaly and left inguinal lymph node swelling. Biopsy of the left inguinal lymph node revealed diffuse mature small lymphoid cells with atypical nuclei. Immunophenotyping of the small lymphoid cells were positive for CD3, CD8, TCR alphabeta and HLA-DR and were negative for CD4, CD19, CD20 and CD56. T-cell receptor beta-chain gene was rearranged in bone marrow cells. He was diagnosed as having peripheral T-cell lymphoma complicated with myelofibrosis. Chemotherapy was administrated which improved his pancytopenia and symptoms. Two years later, anemia and thrombocytopenia developed rather quickly, he died because of progression of myelofibrosis with severe pancytopenia.

Background: A variable region, R2, on the varicella–zoster virus (VZV) genome contains a repeated 42-bp unit. Objective: The purpose of this study is the derivation of significance from tandem reiteration structure in the R2 region. Methods: Fifty-two specimens were collected from 52 patients with herpes zoster in Osaka and Tokyo, Japan. After treatment of the specimens to release viral DNA, the samples were amplified directly by polymerase chain reaction. In addition, 14 samples were collected from 7 of these zoster patients after valaciclovir or aciclovir therapy. Results: Analyses of the 52 specimens revealed that the number of repeats ranged from 4 to 13. Interestingly, the numbers of repeats among various VZV strains showed a normal distribution pattern, so that 6–9 repeats were found to be predominant in both Osaka (85%) and Tokyo (72%). The pre- and post-treatment strains taken from the same individuals showed the same numbers of repeats (7–9 in 6 cases and 11 in one). Conclusion: Our results suggest that the 6–9 repetitions of the 42-bp unit, with presumed stability, may offer these virus strains an advantage in virulence to human skin.

The development of central pontine myelinolysis (CPM) has rarely been reported in association with hemophagocytic syndromes (HPS). Here we report a unique case of Epstein-Barr Virus (EBV)-related HPS which was accompanied with CPM. A 72-year-old man who had no significant medical history was admitted to our hospital due to high fever and progressing dysphasia and dysarthria. Physical examination revealed anisocoria of the right pupil, fixed reaction to light, and paralysis of the left vagus nerves. Magnetic resonance imaging revealed low signal intensity on T1-weighted images and high signal intensity T2-weighted images in the patient's central midpontine lesion. Initial work-up showed anemia and thrombocytopenia with elevated levels of serum ferritin, lactate dehydrogenase, and soluble IL-2 receptor. Bone marrow aspiration revealed hemophagocytosis. The EBV genome was detected in the peripheral blood using the polymerase chain reaction method. He was diagnosed as having EBV-related HPS and CPM. Despite intensive treatment with methylpredonisolone, immunoglobulin, and etoposide, he died due to progressive disease and fungal septicemia. The etiology and relation between CPM and HPS are discussed.

A 50-year-old woman with a 4-year history of Evans syndrome was admitted to our hospital because of progressive nausea, appetite loss, body weight loss, diarrhea and abdominal pain. Abdominal ultrasonography revealed pleural effusion, ascites, bilateral hydronephrosis, dilatation of the bilateral ureter, and irregular wall thickness of the urinary bladder. Immunological studies revealed decreased complement components (C3; 72 mg/dl, C4; 7 mg/dl, CH50; 28.8 mg/dl), a x 80 antinuclear antibody titer (homogeneous pattern), antibody against single-stranded DNA 19 U/ml, anti-SS-A antibody over 500 U/ml and negativity for antibody against double-stranded DNA (anti-dsDNA Ab). Although the patient did not fulfill the criteria for systemic lupus erythematosus (SLE), we diagnosed her as having lupus cystitis. Bolus methylprednisolone (mPSL) therapy (1,000 mg mPSL over 3 days, div) was administered, followed by 60 mg PSL, and this led to immediate improvement of the patient's symptoms and laboratory data. Later, anti-dsDNA Ab became positive, and the patient thereby fulfilled the criteria for SLE. Lupus cystitis following Evans syndrome has rarely been reported. The present such case was treated successfully with bolus mPSL therapy.

Interferon-alpha (IFN-alpha) has been accepted as an effective agent in the treatment of chronic myelogenous leukemias (CML). Cardiac toxicity of IFN-alpha has rarely been reported in cases of CML. A 62-year-old woman with a two-year history of chronic myelogenous leukemia who had been treated with IFN-alpha (10 million U/3 days/week) given subcutaneously with oral hydroxycarbamide 500 mg, presented with chest pain, dyspnea and subconsciousness. Chest X-ray revealed cardiomegaly and congestion, and ultrasonography showed diffuse hypokinesis of the heart with decreased left ventricular ejection fraction (LVEF) 34%. She was diagnosed cardiomyopathy caused by IFN-alpha administration. She was treated with furosemide, dobutamine hydrochloride, milrinone and carperitide. The administration of IFN-alpha was terminated. LVEF was improved to 50% within one month from the onset of events, and the patient was discharged. We discuss herein the cardiomyopathy caused by IFN-alpha in CML.

A 65-year-old man, who is a Jehovah's Witness, was admitted to our hospital due to progressive anemia following a four-year history of biclonal gammopathy of no clinical significance. He was diagnosed with pure red cell aplasia (PRCA) associated with plasma cell dyscrasia. Despite a markedly decreased red blood cell count (hematocrit 5.6%), the patient refused transfusion. He was intravenously administered bolus methylprednisolone. Reticulocytosis and recovery from anemia were observed on day 7 after the start of therapy. Secondary PRCA following plasma cell dyscrasia is a rare disorder; the treatments for this rare condition are discussed.

Th2 dominancy in the peripheral T helper (Th) cell subsets were reported to be involved in the pathogenesis of pure red cell aplasia (PRCA). We encountered a PRCA case secondary to plasma cell dyscrasia that showed Th2 dominancy at the relapse of PRCA. Increased expression of c-maf, a transcriptional factor which induces Th2 differentiation of naive T-cells, and elevated expression of interleukin (IL)-4 were observed in the RNA derived from patient's bone marrow at relapse of PRCA. Following the administration of methylprednisolone which improved PRCA, normalization of Th1/Th2 ratio and decreased expression of c-maf and IL-4 were observed, which suggests that the upregulation of c-maf might have played a role in the pathogenesis of PRCA secondary to plasma cell dyscrasia.

Detection of varicella-zoster virus (VZV) DNA was carried out in the conjunctivas of 18 patients with herpes zoster by polymerase chain reaction. The rate of VZV DNA detection in conjunctivas was 3/4 in herpes zoster ophthalmicus associated with eruption on the dorsum nasi, 2/5 in herpes zoster ophthalmicus without eruption on the dorsum nasi, 1/2 in herpes zoster with eruption on the cheek and lower jaw, 1/2 in generalized herpes zoster and 0/5 in herpes zoster associated with eruption on the trunk or extremities, respectively. The reason for the detection of VZV DNA in conjunctivas is discussed.

Sera of 154 recipients of renal allografts were studied for transplantation heterophile (T-H) antibodies by means of immunodiffusion, mixed agglutination (MA) and enzyme immunoassay (EIA). T-H antibodies were found by immunodiffusion against bovine red blood cell (BRBC) extracts (15%) and sheep red blood cell (SRBC) extracts (12%): The specificity of antibodies to BRBC was shown to be distinct from that of antibodies to SRBC. Both of these T-H antibody types were absorbable by guinea pig kidney ( GPK ) tissue sediments and, therefore, they could be classified into the GPK -positive group of heterophile antibodies. The MA test was successfully employed to demonstrate directly T-H antibodies combining with antigens of GPK . Results of the MA inhibition studies and those of EIA indicated that some of the BRBC antibodies are directed to antigens of asialo-high molecular-weight glycoprotein of BRBC.