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Purpose: This study explored the morphologic changes and clinical symptoms related to the temporomandibular joint (TMJ) associated with long-term lack of mandibular continuity., Patients and Methods: The subjects were 20 patients (40 TMJs) who underwent mandibulectomy including the condyle or segmental mandibulectomy without mandibular reconstruction more than 6 months previous to the study. The 40 TMJs were classified into the following 3 groups: group I: TMJs with a major mandibular fragment including the mandibular body (n = 21), group II: TMJs with a minor mandibular fragment including only the condylar process or the mandibular ramus (n = 10), and group III: TMJs without a condyle (n = 9). All TMJs were examined with respect to disc position, condylar position, bony changes, and appearance of joint effusion on magnetic resonance imaging, as well as for the presence of joint or muscle pain and joint noise., Results: The rate of anterior disc displacement was 28.6% in group I, 10.0% in group II, and 100% in group III. All condyles in group I were located in the glenoid fossa. Seven of 10 condyles in group II were dislocated anteriorly out of the glenoid fossa. However, these condyles were situated in the intermediate zone of the disc. Osteoarthritic changes was found in 1 joint in group II. Joint effusion was not observed in group I. However, joint effusion was detected in the posterior region of the upper joint compartment in 7 of 10 TMJs in group H and in 8 of 9 TMJs in group III. In group II, the 7 TMJs with joint effusion were the same joints with anteriorly dislocated condyles. Clinical symptoms of TMJ pain, TMJ noise, or muscular pain were not found in any patients., Conclusions: Partial mandibulectomy does not affect the relationship between the disc and the condyle or the bony condition of the TMJ. The disc without a condyle will become anteriorly displaced with time. The condyle not connected to the mandibular body often dislocates anteriorly out of the glenoid fossa, while retaining a normal relationship with the disc. Joint effusion, which is detected in nonfunctional TMJs, is not associated with an inflammatory reaction in the joint compartment.

This study evaluated the correlation between the acute course and prognosis of patients with acute myocardial infarction complicated by heart failure. Heart failure was defined as a mean pulmonary capillary wedge pressure equal to or greater than 20 mmHg with radiographic evidence of pulmonary congestion during hospitalization in the coronary care unit. A total of 77 heart failure patients underwent primary percutaneous transluminal coronary angioplasty or thrombolysis. Twelve patients who died within the first 3 days (group I) had a higher incidence of unsuccessful reperfusion (50 vs 19%, p < 0.05) and cardiogenic shock (64 vs 4%, p < 0.01), compared with the 65 patients who survived at least the initial 4 days (group II). These 65 patients were classified into three subgroups according to the course of heart failure: early regression type (group IIA, n = 38); prolonged type (group IIB, n = 18); delayed-onset type (group IIC, n = 9). Patients in group IIB had a higher incidence of multivessel disease than group IIA. Patients in group IIC had a higher incidence of unsuccessful reperfusion. Cardiac index in group IIB was lower than in group IIA (2.50 +/- 0.70 vs 1.91 +/- 0.39 l/min/m2). Changes in left ventricular ejection fraction were 4.1 +/- 9.2% in group IIA, -6.6 +/- 16.8% in group IIB, and 0.9 +/- 7.3% in group IIC. The hospital mortality rate was 0% in group IIA, 11% in group IIB, and 33% in group IIC, the reinfarction rate was 0, 17 and 22%, and sustained arterial patency was demonstrated in 81, 62 and 43%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study was to define the risk factors linked to the rupture of esophageal varices following endoscopic injection sclerotherapy. A total of 197 patients with esophageal varices who had been treated by endoscopic injection sclerotherapy between 1985 and 1991 were observed for post-therapeutic bleeding from esophageal varices. Among 197 patients, 96 had esophageal varices and concomitant hepatocellular carcinoma. Analysis by the multivariate Cox's proportional hazard model disclosed that incomplete eradication of esophageal varices, the presence of hepatocellular carcinoma, and Child-Pugh classes were statistically significant predictors for rupture of esophageal varices after sclerotherapy. We conclude that complete eradication of esophageal varices is essential for sustained effectiveness of endoscopic injection sclerotherapy. The presence of hepatocellular carcinoma and a lack of hepatic functional reserve, as indicated by Child's classification, are also major determinants of post-therapeutic bleeding.

A case of Saber-sheath type tracheo-bronchomalacia complicating bronchial asthma was treated by external fixation of Marlex mesh, and good results were obtained. The patient was a 43-year-old male who had been treated for bronchial asthma for over nearly 20 years. Since 4 years ago, dyspnea and a feeling of obstruction of the larynx developed and gradually aggravated. He lost consciousness twice and was hospitalized on an emergency basis. Pulmonary function tests performed during remission of asthma attacks revealed an obstructive disorder: FEV1.0% was 30.5% and peak flow was 4.11 L/sec. Bronchoscopy and tracheo-bronchography revealed Saber-sheath type tracheo-bronchomalacia in the trachea and the right main bronchus. The severity of the obstruction was, in terms of Johnson's classification, II. for the trachea and I. for the right main bronchus. In accordance with the method reported by Hanawa and Ikeda, external fixation was applied to the trachea and the right main bronchus; that is, Marlex mesh was applied around to the trachea and the right main bronchus, and additional Lyodura was applied over the Marlex mesh. The postoperative course was satisfactory. Both FEV1.0% and the peak flow improved, and constriction of the trachea and the right main bronchus at the time of coughing was also reduced.

Aortic valve replacement was performed in 2 patients with severe aortic stenosis. They showed severe calcified valve and narrow aortic annulus. The aortic annulus was enlarged to 22 mm and 23 mm in diameter in each patient by the technique of Nicks. Then aortic valve replacement was performed with Medtronic-Hall valve (#21) which is supposed to get larger valve area than Björk-Shiley valve. They had good operative course except a complication of complete AV block in the first patient. In this patient a DDD pacemaker was implanted 19 days after operation. Cardiac catheterization was performed 11 or 12 months after operation and good hemodynamics was obtained in both patients. The aortic mean pressure gradient was 6 and 5 mmHg at rest, and 9 and 13 mmHg during exercise on bicycle ergometer in each patient. The aortic valve area was 1.7 and 1.9 cm2, respectively. Body surface area in these patients was 1.29 and 1.36 m2. We concluded that in the small patients we could get a good result with Medtronic Hall valve (#21).

Invasion of the neoplasma to the upper airway tract is the life threatening factor. We experienced a 74-year-old female with thyroid carcinoma invading the trachea, for whom radical resection was infeasible. So for the palliation of airway obstruction we inserted the silicone rubber T-tube stent from 0.5 cm above the vocal cord to 2 cm before the carina after endotracheal tumor resection with Nd-YAG laser. As the result, she has led an active life for the last 6 months after the operation. We consider that the T-tube stent is effective tool in the management of airway obstruction for the slow growing neoplasma.

We experienced a case of late-onset myasthenia gravis associated with Hashimoto's disease. A 74-year-old female with chief complaints of extremities acratia and hypohidrosis was diagnosed as having myasthenia gravis by the Tensilon test. In addition severe hypothyroidism was noted, and histological examination of a thyroid biopsy revealed Hashimoto's thyroiditis. Extended thymectomy was carried out, and the postoperative course was uneventful due to administration of an anti-ChE drug and a thyroid hormone. This case is extremely rare because only 10 patients with late-onset (over 70 years old) myasthenia gravis have been reported in the literature in Japan, and only three of them were associated with Hashimoto's disease. It was suggested that, in cases of myasthenia gravis in elderly patients, we should take into consideration radical therapy including thymectomy as a positive approach to treatment.

A 56-year-old man, a heavy cigarette smoker, had his left upper lobe resected for lung cancer. Seventeen months later, he was diagnosed as early laryngeal cancer by bronchofiberscopy. In this case, postoperative follow-up study with septum cytology was extremely effective. He underwent radiation therapy for the laryngeal cancer. Today, three and a half years later, no signs or symptoms of any cancer can be found. Cases of preceding lung cancer in multiple primary cancer patients having lung and laryngeal cancer are very rare in the literature. All of them have been heavy cigarette smokers and majority of them men.

Twenty-two patients with chronic empyema thoracis underwent decortication. In 11 of them, simple decortication achieved sufficient reexpansion of the lung. In the other 11 patients, our new method was indicated because the pleural space was not closed completely by simple decortication. In our procedure, the parietal wall is collapsed, without rib resection, to contact the surface of the decorticated lung. All 11 patients had a one-stage cure. Two of these 11 patients had bronchopleural fistula. The preoperative and postoperative percentage of vital capacity, percentage of forced expiratory volume in 1 second, arterial oxygen tension, alveolar-arterial oxygen pressure difference, and xenon 133 radiospirometry revealed that pulmonary function was well preserved in patients treated by our method as well as in those undergoing simple decortication. The alveolar-arterial oxygen pressure difference during oxygen inhalation improved significantly (p less than 0.05) after operation compared with the preoperative values in both groups. From the pulmonary function studies, we conclude that our method achieves results comparable with those of simple decortication for the treatment of chronic empyema thoracis. Our procedure is indicated in patients for whom it is thought simple decortication will not lead to primary cure of empyema.

The effects of oral and intravenous thyrotropin-releasing hormone (TRH) were studied in 11 male, chronic schizophrenic inpatients in an open trial and a double-blind, crossover design. The general beneficial effects of TRH as assessed on the Brief Psychiatric Rating Scale were not obtained, although improvement of contact, apathy and emotional rapport was observed in a few patients. Serum prolactin, L-triiodothyronine and thyroxine were assayed throughout the study. Since the effects of TRH on behavior were not related to changes in these endocrine factors, the mechanism of action might be independent of its original functions on the pituitary-thyroid axis.

Nineteen patients with giant bulla were followed for more than 1 year after bullectomy. They were divided into two groups according to their postoperative symptoms. Group 1 consisted of 16 patients who had no problems in their postoperative clinical course, while Group 2 included 3 patients who complained of severe dyspnea at 5 to 6 years of follow-up. Prior to operation, the forced expiratory volume in 1 sec over vital capacity (FEV1%) was 66.8 +/- in Group 1 and 27.6 +/- 5.4% in Group 2. Differences in preoperative and postoperative FEV1% were statistically significant within Group 1 and between the two groups. Postoperative FEV1% (Y) correlated significantly with preoperative FEV1% (X) (Y = 0.74X + 25.4; r = 0.836; p less than 0.001). Thus, we were able to predict the postoperative FEV1% from the preoperative value. Regional ventilation over volume was computed from the washout curve of xenon 133 after reaching equilibrium with rebreathing in a closed circuit (V/V dynamic). Group 2 had significantly lower regional ventilation over volume in all regions, both before and even after bullectomy, compared with normal subjects or Group 1 patients. Preoperative V/V dynamic was below 0.5 in all regions of Group 2. Furthermore, postoperative V/V dynamic (Y) correlated significantly with preoperative V/V dynamic (X) in the upper region (Y = 0.46X + 0.40; r = 0.638; p less than 0.02) and in the lower region (Y = 0.72X + 0.33; r = 0.869; p less than 0.001). We conclude that functional indications of bullectomy for giant bulla are that FEV1% should be greater than 40%, and that regional V/V dynamic should be greater than 0.5. On the other hand, symptomatic and functional improvement following bullectomy was reduced in patients whose FEV1% was less than 35% in whose V/V dynamic was remarkably disturbed in all regions of the involved hemithorax.