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Patients with primary aldosteronism have a higher risk of chronic kidney disease. Visceral fat tissue is hypothesized to stimulate the adrenal glands to overproduce aldosterone, and aldosterone promotes visceral fat tissue to produce inflammatory cytokines. However, it is unclear whether the volume of accumulated visceral fat tissue is associated with renal impairment among patients with hyperaldosteronism. We conducted a single-center cross-sectional study to assess the association between the estimated glomerular filtration rate and the ratio of the visceral-to-subcutaneous fat volume calculated by computed tomography. One hundred eighty patients with primary aldosteronism were enrolled. The mean ± SD age was 52.7 ± 11.0 years, and 60.0% were women. The ratio of visceral-to-subcutaneous fat volume was highly correlated with the estimated glomerular filtration rate (r = 0.49, p, The ratio of visceral-to-subcutaneous fat tissue volume was significantly associated with eGFR among 180 primary aldosteronism patients, showing an interaction between the ratio and plasma aldosterone concentration.

A woman in her thirties developed complex regional pain syndrome in her left shoulder due to a traffic accident. She demonstrated autonomic nervous symptoms (swelling, sweating, and skin color asymmetry) in her left hand, severe allodynia, neglect-like symptoms (NLS), impaired body image associated with impaired body awareness, and functional impairment of the left shoulder and elbow. She also reported physical self-disgust toward her affected limb, describing it as “reptilian,” as well as aversion to touching others; this body awareness exacerbated her pain and NLS. We therefore conducted stepwise interventions using body shadows. The intervention did not trigger physical self-disgust, enabling formation of body ownership and a body image unaccompanied by pain. Consequently, the patient showed improvements in pain, NLS, and autonomic nervous symptoms.

Background We previously showed Lipin1 (LPIN1) to be a candidate gene for essential hypertension by genome-wide association studies. LPIN1 encodes the Lipin 1 protein, which contributes to the maintenance of lipid metabolism and glucose homeostasis. However, little is known about the association between LPIN1 and blood pressure (BP). Methods We evaluated the BP of LPIN1-deficient [fatty liver dystrophy (fld)] mice and explored related mechanisms. Results Fld mice have very low expression of LPIN1 and exhibit fatty liver, hypertriglyceridemia, insulin resistance and peripheral neuropathy. Fld mice had significantly elevated SBP and heart rate (HR) throughout the day as measured by a radiotelemetric method. Diurnal variation of SBP and HR was also absent in fld mice. Furthermore, urinary excretion of adrenaline and noradrenaline by fld mice was significantly higher compared with that of control mice. The BP response of fld mice to clonidine (a centrally acting α2-adrenergic receptor agonist) was greater than that of control mice. However, levels of Angiotensinogen and Renin 1 mRNA and urinary nitric oxide excretion were comparable between the two groups. The decrease in SBP at 8 weeks after fat grafting surgery was significantly greater in the transplant group compared with the sham operated group. Conclusion The elevated BP in fld mice may result from activation of the sympathetic nervous system through decreased levels of adipose cytokines. These results indicate that LPIN1 plays a crucial role in blood pressure regulation and that LPIN1 is a new target gene for essential hypertension.

The target of diastolic blood pressure (DBP) remains controversial in patients with coronary artery disease (CAD). We systematically searched PubMed/Medline and the Cochrane Central database for randomized controlled trials (RCTs) assessing the efficacy and safety of reducing DBP in CAD patients from January 1965 to July 2017. Seven placebo-controlled RCTs enrolling 34,814 CAD patients who achieved DBP

The carotid bulb has a high density of baroreceptors that play an important role in maintaining blood pressure. We hypothesized that atherosclerosis of the carotid bulb would reflect the severity of orthostatic hypotension more accurately than would atherosclerosis of other carotid artery segments.This cross-sectional study included 198 non-diabetic adults. We measured the cardio-vascular ankle index as an index of arterial stiffness, intima-media thickness in each carotid artery segment (internal carotid artery, carotid bulb, distal and proximal portions, respectively, of the common carotid artery) as a measure of atherosclerosis, and heart rate variability as a measure of cardiac autonomic function. The sit-to-stand test was used to assess severity of orthostatic hypotension.Intima-media thickness of the carotid bulb was correlated with orthostatic systolic blood pressure change (r = -0.218, p = 0.002), cardio-ankle vascular index (r = 0.365, p0.001) and heart rate variability parameters. Multivariate regression analysis revealed that among all of the segments, only intima-media thickness of the carotid bulb was an independent predictor of orthostatic systolic blood pressure change (p = 0.022).Atherosclerosis of the carotid bulb was associated with severity of orthostatic hypotension, arterial stiffening and cardiac autonomic dysfunction than that of other carotid artery segments.

ATP2B1 is a gene associated with hypertension. We reported previously that mice lacking ATP2B1 in vascular smooth muscle cells (VSMC ATP2B1 KO mice) exhibited high blood pressure and increased intracellular calcium concentration. The present study was designed to investigate whether lack of the ATP2B1 gene causes a higher response to calcium channel blockers (CCBs) than to other types of anti-hypertensive drugs. Both VSMC ATP2B1 KO and control mice were administered anti-hypertensive drugs while monitoring blood pressure shifts. We also examined the association of nitric oxide synthase (NOS) activity in those mice to investigate whether another mechanism of hypertension existed. VSMC ATP2B1 KO mice exhibited significantly greater anti-hypertensive effects with a single injection of nicardipine, but the effects of an angiotensin II receptor blocker (ARB), an α-blocker and amlodipine on blood pressure were all similar to control mice. However, long-term treatment with amlodipine, but not an ARB, significantly decreased the blood pressure of KO mice compared with control mice. Both mRNA and protein expression levels of the L-type calcium channel were significantly upregulated in KO VSMCs. There were no alterations in neural NOS protein expression of VSMCs or in urinary NO production between the two groups. VSMC ATP2B1 KO mice had a higher response to CCBs for blood pressure-lowering effects than other anti-hypertensive drugs. These results mean that increased intracellular calcium concentration in VSMCs due to lack of ATP2B1 and subsequent activation of L-type calcium channels mainly affects blood pressure and suggests increased susceptibility to CCBs in this type of hypertension.

We have found that the LPIN1 is the candidate gene for essential hypertension (EHT) by genome-wide association analysis in 2007. Mice characterized by loss of body fat, fatty liver, insulin resistance and peripheral neuropathy were discovered in nature and named fatty liver dystrophy (fld) mice in 2000. Recently, the fld mice were shown that they exhibit few LPIN1 genes, and the LPIN1 gene was proved as the cause of phenotype of fld mice. However, the blood pressure (BP) and the alteratios of the vasoactive factors in fld mice have not yet been elucidated. Therefore, to clarify the BP and the effects of LPIN1 gene defeciency, we analyzed the BP and regulatory factors of the fld mice. Furthermore, we transplanted the fat to fld mice, and clarify the importance of adipocytokine on BP in the model mice. The BP were measured by the tail cuff method and the telemetry method. We performe fat grafting or sham surgery on fld mice, and systolic BP (SBP) was measured by tail cuff method 8 weeks after surgery. We confirmed that the SBP of fld mice were higher than that of CO by the tail cuff method( fld 134±5 vs CO 111±4 mmHg P

Angiotensin-converting enzyme inhibitors (ACEIs) are considered primary drugs for the secondary prevention of myocardial infarction (MI), and angiotensin receptor blockers (ARBs) are used when ACEIs cannot be tolerated. However, it is unclear whether ACEIs or ARBs are more appropriate first-line drugs in hypertensive patients with MI or heart failure (HF). The present study aimed to compare the effects of ACEIs and those of ARBs in these patients. Sixty randomized controlled trails (RCTs) that compared the effects of ACEIs and ARBs in patients with MI or HF were extracted by searching PubMed/MEDLINE, Cochrane Database, and the Medical Central Journal database according to the PRISMA guidelines. We finally selected six eligible RCTs and identified three systematic reviews and meta-analyses. The proportion of hypertensive patients ranged from 36 to 69%. Meta-analyses were performed for recurrence or new onset of MI (risk ratio 0.97 [95% confidence interval: 0.88, 1.06]), hospitalization for HF (0.98 [0.84, 1.14]), cardiovascular or total mortality (0.98 [0.91, 1.05]), cardiovascular events or stroke (1.02 [0.94, 1.11]), and adverse events (1.40 [1.11, 1.77]). There were no significant differences between ACEIs and ARBs for all outcomes, except adverse events. Study discontinuation owing to adverse events was significantly more common with ACEIs than with ARBs. Among hypertensive patients with MI or HF, it appears desirable to select the most appropriate drugs, ACEIs or ARBs, in each case by considering the function level, patient background, comorbidity presence, blood pressure target, drug price and other such factors comprehensively in addition to considering tolerability.

Few studies have examined how renin–angiotensin system inhibitors (RASI) delay dialysis initiation in patients with advanced chronic kidney disease (CKD). We conducted a retrospective survey to examine this subject. We reviewed the records of patients with advanced CKD for the 60-month period before dialysis initiation between 1990 and 2015. Patients were classified based on the decade of dialysis initiation into the 1990s, 2000s, and 2010s groups. The rates of antihypertensive medications administered were assessed. The rate of decline of renal function was evaluated by the slope of reciprocal serum creatinine (SRSC). Multiple regression analyses were conducted to evaluate factors contributing to renoprotection. The duration of RASI administration was longer in the 2010s than in 2000s and 1990s. Both diabetic and non-diabetic patients had lower SRSC in the 2010s compared to the 2000s. In the 2010s, the rate of RASI administration during the 60-month pre-dialysis period showed an initial rise followed by a downward trend, although the rates of administration of the other classes of antihypertensives increased continuously. Multivariate regression analyses identified age, blood pressure, diuretics, α-blockers, α-methyldopa and RASI as independent predictors of SRSC in the 2010s. The rate of RASI administration correlated with serum potassium concentration. Our findings suggest that in the 2010s, RASI with other antihypertensive agents contributed to renoprotection in advanced CKD patients, but they were underused because of the concern over hyperkalemia. In real-world clinical practice, physicians may feel great hesitation in using RASI in patients with advanced CKD.

We reported previously that ATP2B1 was one of the genes for hypertension receptivity in a large-scale Japanese population, which has been replicated recently in Europeans and Koreans. ATP2B1 encodes the plasma membrane calcium ATPase isoform 1, which plays a critical role in intracellular calcium homeostasis. In addition, it is suggested that ATP2B1 plays a major role in vascular smooth muscle contraction. Because the ATP2B1 knockout (KO) mouse is embryo-lethal, we generated mice with vascular smooth muscle cell-specific KO of ATP2B1 using the Cre-loxP system to clarify the relationship between ATP2B1 and hypertension. The KO mice expressed significantly lower levels of ATP2B1 mRNA and protein in the aorta compared with control mice. KO mice showed significantly higher systolic blood pressure as measured by tail-cuff method and radiotelemetric method. Similar to ATP2B1, the expression of the Na + -Ca 2+ exchanger isoform 1 mRNA was decreased in vascular smooth muscle cells of KO mice. However, ATP2B4 expression was increased in KO mice. The cultured vascular smooth muscle cells of KO mice showed increased intracellular calcium concentration not only in basal condition but also in phenylephrine-stimulated condition. Furthermore, phenylephrine-induced vasoconstriction was significantly increased in vascular rings of the femoral artery of KO mice. These results suggest that ATP2B1 plays important roles in the regulation of blood pressure through alteration of calcium handling and vasoconstriction in vascular smooth muscle cells.

Dialysis-related amyloidosis (DRA) is one of the major complications often seen in long-term dialysis patients, and is one of the factors that decreases quality of life. β2-microglobulin (β2-m) is considered to be a major pathogenic factor in dialysis-related amyloidosis. The Lixelle adsorbent column, with various capacities, has been developed to adsorb β2-m from the circulating blood of patients with dialysis-related amyloidosis. Using a minimum type of β2-m-adsorbing column (Lixelle S-15), we evaluated its therapeutic efficacy and safety in dialysis patients. Seventeen hemodialysis patients with DRA were treated with the S-15 column for one year. Treatment was performed three times a week in this study. During the study period, pinch strength, visual analog scale for joint pain, and activities of daily living were evaluated every three months, and blood sampling was performed every six months. After one year's treatment with the S-15 column, the β2-m level decreased from 29.3±9.6mg/L to 24.7±5.1mg/L (P

Introduction The study aimed to clarify the difficulties concerning insertion of advanced airway devices during cardiac arrest. Method In an observational study using manikins, we examined the airway management techniques of 19 teams at the Osaka Senri medical rally. For ex-post verification, we recorded chest compression and ventilation using the Resusci® Anne Advanced Skill Trainer (Laerdal, Norway) and recorded actions of the teams using a video camera. Results Only a small proportion of teams did not adopt advanced airway management (4 teams, 21.1%). Thirteen teams selected tracheal intubation. None showed chest compression interruptions during intubation manipulation, and the median duration of chest compression interruption during confirmation of postintubation was 6.4 seconds. The median duration of ventilation interruption during intubation was 45.5 seconds. When teams were evaluated for the duration of direct laryngoscopy, that is, so-called duration of intubation, the median duration was 19 seconds, which constituted a large underestimate compared with the duration of ventilation interruption. This represents an underestimation of about 27 seconds. We considered the issues to be identified for shortening the duration of ventilation interruption. Conclusion From this study, it is clear that the strategy of Guideline 2005 that was designed to minimize chest compression interruption has permeated deeply. The recommendation that the duration of intubation manipulation should not exceed 30 seconds has had various interpretations, but it is important to focus on the duration of ventilation interruption.

左肺上葉切除後に残存気管支の変形による閉塞性肺炎を繰り返し残存肺全摘を余儀なくされた肺癌の１例を報告する．患者は７３歳，男性．左B1＋2原発の扁平上皮癌に対し左肺上葉切除術を施行し，気管支断端は手縫いによるSweet法で閉鎖した．術後１年目から左残存肺の肺炎を発症し，気管支鏡検査では残存気管支の強い変形によりスリット状に狭窄した底幹入口部が認められた．一時的には保存的治療にて改善したが，その後も閉塞性肺炎による入退院を繰り返した．バルーン拡張術も試みたが効果なく，残存肺は徐々に線維化が強くなり感染コントロールが困難となったため初回手術後８年目に左残存肺全摘術を施行した．切除標本では下葉支の変形により気管支軟骨部が内腔に突出し底幹が強く狭窄していた．気管支が屈曲した原因として気管支断端が短く，Sweet法で閉鎖したことが考えられた．

Ipsilateral distal femoral fracture after postoperative femoral neck fracture is a rare complication and treatment is often difficult. We treated three cases in which retrograde supracondylar intramedullary nails were used for internal fixation. The patients consisted of three females with ages ranging from 75 to 89. Two patients underwent hemiarthroplasty and another underwent Gamma nailing. According to AO classification, they were classified into A1 (2 cases) and C1 (1 case), respectively. All patients tended to fall down easily after postoperative femoral neck fracture.Consequently all fractures healed within four months. The average knee range of motion was —10 to 93 degrees. Clinical results were evaluated according to Neer's criteria. All cases were ranked as unsatisfactory. In generally, walking ability tended to deteriorate because multiple fractures occurred ipsilatelly. One case developed secondary femoral fracture at the mid shaft postoperatively, because of jamming between the distal tip of the cement and proximal tip of the intramedullay nail.Use of retrograde supracondylar intramedullary nail is effective for this type of fracture, but we have to be careful about the length of the intramedullary nail before surgical planning. As rigid fixation is difficult for the osteoporotic bone, post operative treatment is also important.

重症例に対しても待機せず可及的速やかに脳動脈瘤根治術を行うという方針のもと診断治療を行った,1996年1月から2000年12月までの5年間の235名のクモ膜下出血(SAH)患者につき検討した。患者の内訳は男性85名,女性150名,平均年齢60.8歳であった。来院時WFNS Grade (G)はGI 21名,GII 48名,GIII 2名,GIV 51名,GV 79名,および来院時心肺機能停止(CPA): 34名であり,GIV, GV, CPAが全体の70%を占めた。原則としてGIからGIVまでの全例,GVでは脳幹反射がみられるものを脳動脈瘤根治術の対象とし,待機せず直ちに診断,治療を開始した。CPAで早期に心肺蘇生が施行され自己心拍の再開をみたものはGVに準じた。167名(71.1%)に脳血管撮影(DSA), 146名(62.1%, 8名3.4%はDSA未施行)にクリッピング術,19名(8.1%)にGuglielmi detachable coil瘤内塞栓術を施行した。発症からの時間経過(中央値)は,来院まで47分,脳血管撮影まで200分,手術まで338分であった。1998年以降,21名に脳低温療法を行った。6か月後のGlasgow outcome scaleによる全体の転帰は,Good recovery (GR): 67名(29.5%), moderate disability (MD): 19名(8.4%), severe disability (SD): 38名(16.7%), persistent vegetative state (VS): 10名(4.4%), death (D): 93名(41.0%)であった。軽症例(GI, II, III)の転帰良好(GR+MD)は78.3%,不良(SD+VS) 10.1%,死亡11.6%,重症例(GIV, V)の転帰良好は24.8%,不良31.2%,死亡44%であった。CPAから蘇生後の4例に根治術施行,3名が生存,うち1名はGRであった。重症SAH症例が過半数を占める救命救急センターにおいて,“救いうる”SAH患者に一人でも多く良好な転帰を得るためには,来院後の再破裂予防と迅速な根治術施行とともに,低酸素脳障害の予防を含め,病院外救護体制の面からも取り組みが必要と思われた。

現在,小児救急医療の惨状が社会問題になっている。行政と地区医師会,大阪医科大学(以下,大阪医大)が診療協力する高槻島本夜間休日応急診療所(以下,応急診療所)での経験を踏まえて初期小児救急の現状と問題点を考察した。現状:地域内の小児救急医療機関として大阪医大と二次救急医療機関の1病院,他に輪番制で3病院が協力して小児救急医療体制を構築している。応急診療所の小児救急患者数(2000年度)は8,020人で総来院患者数の42.6%に当たる。診療体制は年間通じ24時間体制で地域開業医と大阪医大が参画,延べ人数510人で週5日大学の小児科医が347人,週2日は開業医で163人。ただし祝祭日および年末年始は開業医と勤務医との2人体制ないし3人体制である。二次医療機関搬送例は187人で,大阪医大がその42%を受けている。医療圏外搬送は2.5%とほとんどない。問題点:開設当初から医師会会員のすべてが平等に負うべき当然の義務との立場に立って出向してきた開業医の高齢化と当節の医療事情を考慮した専門性の配慮から出向可能な会員の数が大幅に減少してきている。それをカバーしているのが大学の勤務医である。そのため彼らは平常業務診療に支障が出るほどの過剰労働を強いられている。ちなみに出向延べ人数は年間1,404人である。当節の医療事情で小児科医に診てもらわなければよしとしない状況がこれに拍車をかけている。結語:地域によっては必ずしも医療資源(小児科医の数,医療施設等)は均一でない。地域の医師が小児救急医療に参画すること,また地域全体,時に医療圏を越えて体制を組むことの意義は大きい。

Stanford B型急性大動脈解離90例の治療成績と保存療法における早期離床の有用性について検討した.90例中の破裂は来院時破裂11例,入院後破裂1例の計12例(13.3%)であった.このうち8例に手術を行い死亡は1例(12.5%)であった.来院時非破裂例79例に保存療法を行った.保存療法中の破裂は1例(1.3%)で,死亡は破裂1例と腹部臓器壊死2例の計3例(死亡率3.8%)であった.来院時破裂例も含めたB型全体の死亡は90例中6例(6.7%)であった.偽腔閉鎖例の死亡は1例のみで,合併症頻度も開存例より少なかった.1週間で立位,2週間で自由歩行とする早期離床プログラムを作成し最近の31例に用いた.早期離床例に破裂例はなく,肺炎や薬剤を要する不穏などの合併症は有意に減少した.破裂例を除けばB型解離の保存療法の成績は良好で,降圧療法を厳密に行ったうえでの早期離床は合併症減少にも役立った.

Neglect-like symptoms have been defined as a loss of perception of a limb, with pain and excessive effort necessary to move the limb. This phenomenon has been studied in patients with complex regional pain syndrome, but has not been assessed in patients who have undergone orthopedic procedures such as total knee arthroplasty. The authors of this study assessed neglect-like symptoms in a group of 90 patients three and six weeks after total knee arthroplasty., BACKGROUND: Persistent postoperative pain has a significant relationship with patient health and satisfaction. OBJECTIVES: To investigate the prevalence and association of neglect-like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain. METHODS: The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State-Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two-point discrimination in the thigh) and NLS were also investigated. RESULTS: At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS. CONCLUSIONS: These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.

We report a patient with severe liver injury and traumatic rupture of the aorta successfully managed by staged operation. A 40-year-old man injured in a motor vehicle accident was taken to a hospital in hemorrhagic shock. Chest roentogenography showed left hemothorax and widening of the upper mediastinum. Abdominal computed tomography (CT) showed type III b liver injury and periaortic hematoma. Abdominal packing and coil embolization were conducted for the liver injury. The patient was transferred to our hospital because aortography showed a pseudoaneurysm of the proximal descending aorta. On admission, the hemodynamic state was relatively stable, and we decided to conduct delayed repair of the traumatic aortic injury due to hypothermia-acidosis-coagulopathy syndrome. The second operation was performed 48 hours after the initial operation. Prosthetic graft replacement was conducted for the aortic injury, and hepatorrhaphy for the liver injury. The patient was discharged on day 70 after the second operation. Urgent surgical treatment is necessary for traumatic rupture of the aorta. However, in severe injury to other organs, repair of the aortic injury should be considered after hemorrhage from other organs is controlled or hypothermia-acidosis-coagulopathy syndrome improves.

アメーバ性肝膿瘍腹腔内破裂の1例を報告する.【症例】37歳男性,不特定多数の女性と接触があった. 1カ月前より全身倦怠, 6日前より悪寒・発熱を認めていた.安静時に突然右季肋部激痛が出現し,腹部全体に広がった.肝S7に10cm大の膿瘍,腹腔内に液貯留を認めた.腹腔穿刺で膿性腹水を認め,検鏡にて赤痢アメーバ虫体を確認し,本症と診断した.経皮経肝膿瘍ドレナージ(PTAD)後に開腹し,腹腔洗浄ドレナージを行った.直ちに化学療法を開始し,速やかに解熱した.膿瘍の縮小は順調で, 1カ月後に軽快退院した.

症例は40歳,女性.突然の腹痛とその後の呼吸困難を主訴に搬入された.腹部CTで卵巣腫瘍の破裂が疑われた.頻呼吸,血圧低下,外頸静脈怒張から肺動脈塞栓症(PE)を疑い,肺動脈造影でPEと診断した.同日,血栓溶解療法と抗凝固療法を施行した.翌日,症状が軽減し,卵巣腫瘍に対して左附属器摘出術を施行した.病理組織は卵巣明細胞癌であった.術後下肢静脈造影で両下肢静脈に血栓を認めたこと,血栓溶解療法後の肺血流シンチで血流欠損が消失していたことから卵巣癌破裂を機に発症した稀なPEと考えた. PEに対する血栓溶解療法と卵巣腫瘍破裂に対する手術の治療優先順位が問題であったが,作用時間の短いtPAを用いてまず血栓溶解療法を行い,翌日に準緊急手術として左卵巣を含めた腫瘍摘出術を施行した.さらに止血を確認した後に再び血栓溶解療法を行い,良好な経過が得られた.

A 77-year-old woman suddenly lost consciousness and presented with right hemiparesis. Computed tomography showed a large subcortical hematoma in her left frontal lobe associated with subarachnoid hemorrhage. The first impression was hemorrhage due to a ruptured aneurysm of the middle cerebral or the internal carotid artery on the left. Left internal carotid angiography showed no aneurysm or vascular anomaly, but back flow of contrast medium into the external carotid artery disclosed two saccular aneurysms arising from the anterior branch of the left middle meningeal artery (MMA). Emergent surgical intervention confirmed that the hematoma was due to ruptured MMA aneurysm. Nontraumatic MMA aneurysm should be recognized as a possible causative lesion of intracranial hemorrhage despite the extremely low incidence. External carotid angiography should be performed in patients with intracranial hemorrhage in whom no vascular cause can be detected in the internal carotid system.

最重症くも膜下出血(SAH)に対する可及的早期脳低温療法の有用性の検討するため,1999年4月以降に経験した75歳未満のWFNS Grade VのSAH 16名に診断確定直後より脳低温療法を施行し,脳動脈瘤根治術を施行した。内訳は男性10名,女性6名,年齢50-72歳(平均63.1歳),Glasgow Coma Scale (GCS)は,心肺停止から蘇生しGCS 3となったもの2名,3が6名,4が1名,5が3名,6が4名であった。CT上4名が10mm以上の正中偏位を伴う血腫を合併し,4名が鋳型状脳室内血腫を伴った。SAHの診断確定後,速やかに脳低温療法を開始し,クリッピング術,外減圧術を施行した。経過時間(中央値)は発症後搬入まで33分,脳血管撮影まで86分(7名は3D-CTAのみ施行),手術まで174分であった。33-34℃の脳低温療法を2-3日施行後,復温した。復温終了まで平均8.3日であった。発症24時間以内に経腸栄養を開始,穿刺式気管切開を行い肺理学療法を徹底した。脳低温療法施行16名のGlasgow Outcome Scaleによる転帰はgood recovery (GR) 2名,moderate disability (MD) 3名,severe disability (SD) 8名,persistent vegetative state (VS) 2名,death (D) 1名であった。脳低温療法の合併症による症状の悪化や中断例はなく,一次性脳損傷が転帰不良の原因と考えられた。脳低温療法導入直前のGrade VのSAH連続24名と導入後,脳低温の適応外となった6名を含む連続22名を比較すると,転移良好(GR+MD)率に関しては有意差は認めなかったが(12.5% vs. 22.7%), VS+Dの率は71.8%から29.2%と有意に低下した。最重症SAHに対する超急性期からの脳低温療法は少なくとも植物症への移行と死亡を減少させ,一次性脳損傷を軽減させる可能性がある。

Although there is increasing evidence for anti-oxidized low-densitiy lipoprotein (LDL) autoantibodies in human sera, their diagnostic utility remains controversial. We examined the difference in autoantibody titers between patients with Achilles tendon xanthoma and control subjects. Fifteen hyperlipidemic patients with Achilles tendon xanthoma (group A+) and 94 hyperlipidemic patients without Achilles tendon xanthoma (group A−) were studied. Quantification of anti-oxidized LDL and anti-native LDL autoantibodies was performed using an ELISA method. To calculate antibody titers, we used the ratio between the spectrophotometric reading of anti-oxidized LDL and anti-native LDL wells. Using oxidized LDL that was purified by gel-permeation chromatography as antigen, immunoglobulin G level differed significantly between groups A+ and A− (p ＜ 0.01). In contrast, using native and oxidized LDL as antigens without chromatographical purification revealed no significant difference between the two groups. Furthermore, immunoglobulin autoantibody titer did not correlate with age, body mass index, total cholesterol, high-density lipoprotein cholesterol, LDL cholesterol, or triglyceride in the entire group of subjects. Thus, immunoglobulin G autoantibody values appear to correlate with Achilles tendon xanthoma.

This paper deals with a successful total hepatic vascular exclusion (THVE) for hepatic injury of IIIb+IVC according to the classification by the Japan Traumatic Association. A 19-year-old man in hemorrhagic shock state was transferred to the center after diagnosed as having hepatic injury of type IIIb due to a traffic accident at another hospital. While an aortic occlusion baloon catheter (AOBC) was inserted to maintain blood pressure, a laparotomy was performed. There existed asteroid rupture in the right hepatic lobe, and circulatory blockade at the hepatic hilar region was performed by means of Pringle method. When the right lobe was turned to resect the right lobe, massive venous bleeding from the posterior surface of the liver was found. Inferior vena cava (IVC) injury was suspected. IVC was interrupted at the top and bottom of the liver to make THVE, the IVC injury was repaired under non-hemorrhagic field, and a right lobectomy was performed. A total ischemic time came to 56 minutes, including 15 minutes for Pringle method alone and 41 minutes for continued THVE. No particular problems in hepatic function arose after the operation and the patient was discharged from the hospital on 22nd hospital day. As an adjuvant treatment for hepatic injury of IIIb+IVC, THVE associated with AOBC that can be done safely and easily appears to be of great value.

Compared with intussusception in children as a common entity, the disease is relatively rare in adults and the rate of its occurrence after gastrectomy is said to amont to about 1% of all adult cases. This paper presents a case of retrograde jejunal intussusception 9 years after total gastrectomy in an adult. A 75-year-old man was seen at the hospital because of abrupt abdominal pain and vomiting. The abdomen was soft and no tumor was palpable. Abdominal x-ray film revealed a slight gas image in the small intestine. After admission, bloody discharge from a nasal tube was observed. Abdominal CT scan revealed a tumor with layered structure in the left upper abdomen. Intussusception was diagnosed and a laparotomy was performed. Macroscopically, the invaginated bowel progressing antiperistaltic direction over about 20cm was present at the anal side of Y-anastomosis after total gastrectomy (with Roux-Y reconstruction). After manual replacement, no ischemic changes nor organic disorders were confirmed in the invaginated jejunum and so the surgical incision was closed without any procedure. Although intussusception after gastrectomy rarely occurs, we must keep it in mind as a probable diagnosis after gastrectomy.

We report a case of primary group A Streptococcal peritonitis complicated by acute renal failure in a previously healthy 35-year-old woman. The patient complained of a 30-hour history of fever and lower abdominal pain. She was anuric, but not in shock on hospital admission. Her abdomen was slightly tender and rebound tenderness and muscle guarding were observed. Laboratory examination revealed leukocytosis (WBC 14, 300/mm3) with a shift to the left, and azotemia (BUN 106mg/dl, Cre 7.5mg/dl). A clinical diagnosis primary peritonitis was suggested, and laparotomy was performed with initiation of fluid resuscitation. At operation, purulent ascites was observed, but no gastrointestinal tract perforation could be identified. Abdominal lavage and drainage were conducted. Postoperatively, hemofiltration was carried out for acute renal failure, and urination returned on the 11th postoperative day. On microbiological investigation, group A Streptoccus (S. pyogenes) (serotype T1/M1, Streptococcal pyogenic exotoxin: SPE/A+B) was detected in the intraperitoneal pus. Serum analysis revealed interleukin-6 level of 3, 910pg/ml, thrombomodulin 8.1FU/ml, and tissue plasminogen activator·plasminogen activator inhibitor-1 complex (t-PAI·C) 124ng/ml. Discussion of the relevance of these findings to toxic shock-like syndrome (TSLS) is included.

The use of autogenous bone patellar tendon bone graft (BTB) has been well established in anterior cruciate ligament (ACL) reconstruction.A round shaped drill hole at the femur and tibia is commonly used for ACL reconstruction. BTB is on the other hard rectangularly shaped. Therefore, a gap fwms between BTB and bone tunnels. In this study, we attempted rectangular bone tunnel (RBT) for ACL reconstruction. Between 1996 and 1997, RBT for ACL reconstruction was carried out in 43 patients (22 males, 21 females). It suggests that RBT has two advantages, RBT is effective for preventing tunnel enlargement of the tibia, and reproduction of graft rotation is possible by RBT.

Type IIIb liver injury by classification of Japanese association for the surgery of trauma is a most severe type of blunt liver injury and its prognosis is very poor compared with other types of injuries. We experienced a case of type IIIb liver injury which was successfully treated with a right hepatectomy and gauze packing, so-called staged laparotomy. A 28 year-old woman was injured by a traffic accident and a CT scanning showed a widespread liver injury in the right lobe with massive intraperitoneal hemorrhage. Hemodynamic state on admission was stable, but soon became unstable in the emergency room. Right hepatectomy was performed because of massive injured volume and no sign of coagulopathy. But after the hepatectomy, coagulopathy was revealed and gauze packing was immediately performed. In ICU, coagulopathy was improved but intraperitoneal bleeding continued, and 2nd laparotomy was decided for intra-abdominal hypertension. In the 2nd laparotomy, the hemorrhage from the stump of the liver was almost controlled that demonstrated the effectiveness of Gauze packing. Staged laparotomy with gauze packing is recommended for the treatment of severe blunt liver injury from the standpoint of damage control surgery. Staged laparotomy was very effective for our case but early gauze packing before coagulopathy might be more effective.

We treated 9 children with acute osteomyelitis between October 1992 and October 1998. The sites of osteomyelitis were femur in 4 cases, tibia in 3 cases, humerus in 1 case, and radius in 1 case. The age at onset was from 1 month to 13 years g months. After diagnostic aspiration and/or blood culture, we treated all cases at first by administering intravenous antibiotics. Two cases were cured by conservative methods, and we operated on 7 cases in which the presence of an abscess was confirmed by aspiration or the symptoms persisted after the administration of sufficient antibiotics. All cases were cured uneventfully. We conclude that we should surgically treat cases with acute osteomyelitis with confirmed abscess by aspiration or symptoms do not improve immediately after the administration of antibiotics.

病院到着前に心停止となった急性心筋梗塞(AMI)症例の臨床的特徴を,蘇生に成功した症例をもとに検討した。対象と方法:1985年11月から1996年8月までの10年9ヵ月に搬入され,蘇生に成功した内因性院外心肺停止(OHCPA)症例257例のうち,AMIと確診した47例(18.3%-CPA群)を対象とし,同期間に発症24時間以内の生存入院したAMI651例(nonCPA群)と比較した。結果:CPA群のAMI発症はnonCPA群と同様の日内変動を示し,時刻は午前10時から12時と午後8時から12時に多かった。CPA群の72%の症例が,自宅で心停止を起こしていた。71%の症例はAMI発症から1時間以内に,残る29%は1時間以上経過し搬入された。搬入時自己心拍の再開はなく,心室細動が19例(40%),電導収縮解離が10例(21%),心静止が18例(38%)にみられた。CPA群はnonCPA群に比べ急性前壁中隔梗塞の発症が多く(72% vs 53%, p=0.016),心筋梗塞の既往をもち(32% vs 12%, p=0.0002),梗塞前狭心症を有していた(57% vs 29%, p=0.0003)。64%が虚血性心疾患により医師の管理下にあった。喫煙者は40%でnonCPA群の59%より少なかった(p=0.01)。来院時胸部X線写真で,CPA群に肺うっ血像を示す症例が多かった(17% vs 6.5%, p=0.015)。13例の冠動脈造影では全例に責任冠動脈の近位部に閉塞が認められ,剖検の2例と他院での冠動脈検査5例の計20例から,50%が多枝病変,25%が左主幹部病変であった。bystander CPR施行6例中4例(66%)が,bystander CPR非施行41例中3例(7%)が社会復帰した(p=0.006)。心室細動が質の問わない生存と相関があった(60% vs 26%, p=0.049)。結論:AMI後に急性心停止する危険性が高いのは,心筋梗塞症の既往と梗塞前狭心症があり,冠動脈に多枝病変あるいは左主幹部病変が認められ,急性の前壁中隔梗塞を発症した症例と考えられた。急性心停止の病態として,17%の症例にポンプ失調の関与が示唆された。bystander CPRの施行と心室細動は良好な転帰につながる可能性が高いと考えられた。

The short-term results of 62 knees in 55 patients with osteoarthritis treated by Prolix total knee arthroplasty were evaluated clinically and radiologically. The average age was 74.0 years (range; 60-89 years) at the time of surgery. The follow-up period was an average of 21 months (range: 6-38 months).The mean JOA knee rating score improved from 46.1 to 74.8 points. The mean FTA improved from 186.1° to 172.0°. The mean range of motion went from 101.8° preoperatively to 99.3° postoperatively.There were no significant complications (infection, DVT), patellofemoral disorders, and loosening or sinking radiographically. The short term results of the Prolix system were good.

The association between elevated levels of low-density lipoprotein (LDL) cholesterol and an increased risk of premature coronary heart disease (CHD) is well documented. Most clinical laboratories estimate LDL cholesterol concentrations according to the Friedewald formula. It provides a relatively reliable estimate of LDL cholesterol concentration, provided the triglyceride concentration is200 mg/dL. However, the reliability is considerably decreased if the triglyceride concentration isor =400 mg/dL. The interactions between lipoproteins and surfactants, divalent cations, sugars, and lectins were investigated, and we developed a new assay protocol to chemically measure the LDL cholesterol level in serum that does not require immunoseparation or centrifugation. The assay protocol was evaluated by measuring serum samples obtained from 88 patients and 20 healthy volunteers. The triglyceride levels of the patient samples ranged from 66 to 2199 mg/dL, and the samples were classified as200 mg/dL (n=36) andor =400 mg/dL (n=52; 23, 3, and 26 patients had type IIb, type III, and type IV hyperlipoproteinemia, respectively) for comparative studies. The accuracy and precision of our assay protocol fulfilled the criteria of the NCEP Lipid Standardization Panel, and no matrix effect influenced the measurements. The assay protocol is less sensitive to LDL-I than to LDL-II and LDL-III. LDL cholesterol measurements correlated well with those obtained by the ultracentrifugal assay of normotriglyceridemic and hypertriglyceridemic samples. This evidence shows that the results obtained with our assay protocol are superior to those obtained with the Friedewald formula.

A 73-year-old woman presented with rapidly destructive changes of the knee joint due to calcium pyrophoshate dihydrate crystal deposition disease. The patient was complaining of pain and swelling of the left knee joint. She became progressively limited in movement and got around using crutches with difficulty. Radiographs showed osteoarthritic changes and chondrocalcinosis in the knees, shoulders, and hips. On X-ray, the left knee showed destructive changes affecting the medial femoral condyle and tibial plateau on June sixth, 1996. On July forth the destructive change was more marked and on August eighth gross destruction had occurred. Investigations showed a normal erythrocyte sedimentation rate (ESR), serum calcium, and alkaline phosphate. The serological test for syphilis was negative and no increase in rheumatoid factor was found. Deep pain sensation was normal and there were no abnormal neurological signs. We performed total joint replacement with bone graft of the left knee joint. At the operation, calcium pyrophosphate dihydrate crystals were found in the meniscus. After the operation, the left knee joint was stable and painless.

We report a case of Waterhouse-Friderichsen syndrome with excessive hypercytokinemia in a previously healthy 59-year-old man. The patient complained of a 20 hour history of fever and multiple pain. He was in shock on arrival and diffuse petechiae were observed on his trunk. The laboratory data evaluated metabolic acidosis (BE-16.9mmol/l), leukopenia (WBC 3, 900/μl) with a shift to the lef, obvious thrombocytopenia (1.8×104/μl), hypoglycemia (49mg/dl), and disseminated intravascular coagulation (DIC). Abdominal computerized tomography (CT) scan showed bilateral adrenal swelling and irregular shape of left gland. Immediately he developed adult respiratory distress syndrome (ARDS), then died 17.5 hours after arrival without recovery from shock. On microbiological investigation, group 12 (Danish classification) of penicillin sensitive Streptococcus pneumniae was detected in his blood. The serum data demonstrated excessive hypercytokinemia (interleukin [IL]-1β 1, 010pg/ml, IL-6 1.03×106pg/ml). An autopsy revealed massive hemorrhagic necrosis and fibrinous thrombosis in a half of bilateral adrenal cortex and DIC in multiple organs, while the spleen was intact. Neither focus of original infection nor what aggravated the infection was clear.

Deep venous thrombosis (DVT) is an important complication following total knee arthroplasty (TKA). Various methods have been used to prevent DVT including venous foot pump (VFP).However, only a few authors have reported the usefulness of the VFP. In this study, we evaluated the effectiveness of the VFP by examining coagulation and fibrinlytic factors and changes in calf and foot cicumference measurments.

We reviewed 21 patients, and 22 knees operated on because of the rupture ofthe posterior cruciate ligament (PCL). The clinical outcome was evaluated using the Lysholm score. All 21 patients had undergone magnetic resonance imaging (MRI). According to MRI findings, knees were divided into three groups; high, iso, and low intensities. The evaluation of BTB (bone patella tendon bone) by MRI tended to change from high intensity to low intensity. The average Lysholm score of the low intensity group (93.6points) was higher than the score of the high intensity group (87.0points). The intensity of the reconstructed PCL on MRI correlated with the clinical results.

The principal aim was to assess the rate of unilateral knee osteoarthritis (OA) and to identify the major factors that influence effects of arch support therapy. We studied the basic radiographic evaluation of the knee in the standing and extended view and its clinical application. Lateral wedge insole is prescribed in patients with medical osteoarthritis (OA) of the knee. Nole to author: This deleted sechon did not make the meanug clear. I have charged this but please confirn meaning. The utility of this therapy is recognized, however the effechveness in unilateral disease needs to be further assessed. This study was carried out in order to investigate what factors, are useful for indicating insole therapy.Factors which were found to be significant indicators for insole therapy included FTA, and %MA, which were measured by radiography. BMI was also meaningful, being lower in the group effectively Neated by insolo therapy.

来院時心肺停止例 (CPAOA), 心肺蘇生後例, 非手術死亡例を含めた破裂性腹部大動脈瘤50例の治療成績や問題点を検討した. 状態別症例数と死亡率は非 shock は17例で5.9%, shock は21例で57.1%, 蘇生後は3例で66.7%, CPAOAは9例で88.9%, 合計は46%であった. 人工血管置換術40例ではそれぞれ5.9%, 52.6%, 66.7%, 66.7%で合計は35.7%であった. 治療成績に影響する術前因子は人工血管置換術例では shock 持続時間, 血圧の最低値であった. 非手術例を含む全例ではさらに年齢, 動脈血の base excess 値で有意差がみられ, 高齢者では術前に死亡する症例が多かった. 紹介搬送47例中19例で前医の初期診断が誤っており, これが搬送の遅れと状態の悪化を招いていた. 治療成績向上には的確な初期診断と迅速な術前対応が重要である.

Stress fractures of the lower limbs are a well-known entity to the orthopaedic surgeon. The most frequent locations are the tibia, fibula and metatarsals. However stress fractures of the patella are a rare injury. We describe a case of stress fracture of the patella in a 21-year-old hand-ball player who had been followed up for three years with a diagnosis of jumper's knee. Our case revealed a non displaced fracture of the distal portion of the patella. We operated on the patient due to his desire for an early return to playing sports. Five months after surgery, the patient had no problems with his knee function and had recovered his previous level as a hand-ball player.

破裂性腹部大動脈瘤では治療開始前に死亡する症例も多く,救命率の向上のためには手術例を対象とした検討では不十分である。そこで開設以来10年間に当センターに来院した破裂性腹部大動脈瘤例50例のうち,来院時心肺停止例(CPAOA) 9例(男7例,女2例,平均年齢は76歳)を中心に治療成績や問題点について検討した。全50例の死亡率は46%であったが,非shock例(17例)では6%, shock例(21例)では53%,他院での心肺蘇生後症例(3例)では67%, CPAOA例(9例)では89%であった。CPAOA例は病院からの搬送例7例,救急隊からの直接搬送2例で,すべて救急車内での心肺停止であった。心拍再開は8例(89%),蘇生(入院)は7例(67%)であった。手術は5例に行い,術中死亡は2例,人工血管置換術を施行しえたのは3例であった。このうち1例は術後脳死となったが,2例では術後に意識が回復し,このうち1例は多臓器不全で死亡したが,1例(11%)が完全社会復帰した。CPAOA例における既往歴は高血圧が5例,高脂血症,狭心症,心筋梗塞,胃潰瘍,糖尿病が各1例で,腹部大動脈瘤をすでに指摘されていた症例が3例あった。病院からの搬送7例で前医での初期診断は原因不明の腹痛3例,尿管結石2例,急性腹症として開腹術を受けたもの1例で,破裂性腹部大動脈瘤と的確に診断されたものは1例のみであった。CPAOA例では初期診断が的確でない症例が多く,deep shockや腹部膨満が著明となって初めて診断がなされていた。初期診断の遅れが心肺停止を招き,発症から心肺停止までの時間は30分から3日,平均12.8時間であった。破裂性腹部大動脈瘤の治療成績向上のためには第一線の医療機関での迅速かつ的確な初期診断が重要であり,そのためには腹痛,shock,拍動性腹部腫瘤の3徴や既往歴の聴取が重要である。

Objectives. Using a prospective, randomized design, we tested our hypothesis that the augmentation of diastolic pressure by intraaortic balloon counterpulsation (IABP) would improve the late patency of the occluded coronary artery in patients with early failure of thrombolytic therapy. Background. Rescue angioplasty is often performed in patients in whom thrombolysis has failed, although 30% to 60% of the infarct-related arteries that are closed early after thrombolytic therapy will open later with conservative therapy. Methods. The study included 45 patients in whom thrombolysis had failed, despite treatment with intravenous tissue-type plasminogen activator (alteplase 0.75 mg/kg body weight) delivered over 60 min within 12 h of the onset of symptoms. All patients underwent coronary angiography 60 min after initiation of thrombolytic therapy (baseline), and Thrombolysis in Myocardial Infarction (TIMI) grade 0, 1 or 2 flow was defined as failed thrombolysis. The patients were randomized to groups receiving IABP for 48 h (n = 23) or conservative therapy (n = 22, control subjects) at the end of cardiac catheterization. The late patency of the infarct-related artery, the primary end point of the study, was evaluated 3 weeks after myocardial infarction. Stenosis of the infarct-related artery was measured using a computer-assisted quantitative angiographic system in blinded manner. Data are expressed as mean value ± SEM. Results. There was no difference with regard to the baseline value for TIMI flow grade between the groups. However, 3 weeks after myocardial infarction, the patients treated with IABP had a significantly higher frequency of TIMI flow grade 3, lower residual percent stenosis and larger minimal lumen diameter of the infarct-related artery than did the control subjects (74% vs. 32%, p < 0.05; 42 ± 5% vs. 68 ± 6%, p < 0.01; and 1.6 ± 0.1 vs. 0.9 ± 0.2 mm, p < 0.01, respectively). Conclusions. These findings suggest that in patients with early failure of thrombolytic therapy, IABP may improve late patency of the occluded coronary artery, probably due to augmented perfusion pressure.

Stress fracture of the rib is comparatively rare. We experienced three cases of stress fracture of the rib in high school baseball players. Case 1 and 3 were pitchers and had an 8th rib fracture on the dominant side. Case 2 was a third baseman who developed a second rib fracture on the dominant side.Diagnosis was based on a history of increased training, and bone scintigraphy which was a very useful examination for early stage diagnosis.Early diagnosis and treatment are necessary for those players who develop symptoms of stress fracture.