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Management of recurrent hepatocellular carcinoma in a cirrhotic liver remnant is a difficult but challenging problem. To investigate the difference in survival between treatment by repeat resection and treatment by transcatheter arterial chemoembolization (TAE), a retrospective controlled study was conducted. Four patients with nodular recurrence received limited second operations which included right hepatic segmentectomy (2 patients), left lateral segmentectomy (1 patient), and subsegmental wedge resection (1 patient). Eight matched patients received a total of 16 repeated sessions of chemoembolizations. Complications of the TAE group consisted of gastrointestinal bleeding (2 patients), acute pancreatitis (1 patient), and acute cholecystitis (1 patient). No complication developed in the resection group. The 4 patients undergoing a second operation have survived 21, 26, 34, and 54 months after repeat surgery. Seven (87.5%) of the 8 patients receiving TAE died 4 to 11 months after TAE. The resection group survived significantly longer than the TAE group (p < 0.01). Our results suggest that it is more advisable to perform a second operation than to undertake chemoembolizations for patients with cirrhosis and nodular recurrent hepatocellular carcinoma with acceptable functional liver reserve.

The relationship between microalbuminuria indicated by the logarithm of the albumin index and the stage of diabetic retinopathy was investigated using 175 diabetic subjects. The relationship and its dependence on the duration and the age of onset of diabetes were analyzed statistically with logistic regression. In younger-onset subjects, microalbuminuria was strongly related to the stage of retinopathy, but in older-onset subjects, the relationship showed to lack. For each subject, the frequency of retinopathy was predicted by the estimated probability calculated with the regression model. When the critical probability was 50%, the sensitivity and specificity were 53.1% and 76.2%, respectively. These results indicated that the regression model using the albumin index might be a useful method to predict the frequency of diabetic retinopathy even without ophthalmoscopic examination.

Biliary stricture represents a challenging problem in the treatment of hepatolithiasis because of its association with treatment failure and stone recurrence. The long-segment type of stricture is difficult to manage and is likely to recur. To investigate the necessity for biliary stenting after balloon dilatation therapy, 20 consecutive patients with long-segment strictures who had 22 stents (group 1) were compared with ten patients who refused stenting (group 2). The long-segment strictures in group 1 were located on the right side in 80 per cent of patients, on the left side in 10 per cent, and were bilateral in 10 per cent. The stents, varying from 8 to 12 Fr, were retained for at least 6 months. They were inserted through the routes of a matured T tube track (five cases), percutaneous transhepatic track (14 cases), a jejunal limb (two cases) and a fistula (one case). Complications of stenting consisted of dislodgement (one case), haemobilia (two cases), cholangitis (two cases) and intrahepatic abscess (one case). The cumulative probability of stricture recurrence in group 1 was 10 per cent, 15 per cent and 21 per cent at 2, 3 and 4 years, respectively, whereas in group 2 it was 80 per cent at 2 years (P less than 0.003). The results suggest that intrahepatic biliary stenting after balloon dilatation appears necessary and helpful in the management of hepatolithiasis with long-segment biliary strictures.

The functional response of the left ventricle with scar to increased afterload, was examined in 15 patients with old myocardial infarction and left ventricular aneurysm (OMI). Interventional cine left ventriculography during elevating left ventricular pressure with methoxamine. Wall motion was assessed by the radial and the centerline method. Augmented afterload didn't change ejection fraction in patients with OMI, but normalized wall motion (Z) increased in the aneurysmal region and decreased in the remote region in both methods. In the remote region in patients with OMI, afterload stress shortened left ventricular pressure-radial length (P-L) loops along length axis, and reduced percent systolic radial shortening (SS). In the aneurysmal region, P-L loops showed systolic elongation of length at rest and the slope of end-diastolic point to end-systolic point became steeper with increased afterload, resulting in a decrease of aneurysmal expansion. In summary, with increasing afterload, wall motion decreased in non-infarcted regions and increased in aneurysmal regions, in left ventricles with aneurysm. This mechanism may be interpreted as afterload-induced shifts of P-L loops in each region.

The spasmolytic and antispasmodic effects of Xylocaine in different concentrations were studied. Twenty-five Wistar rats were divided into five groups according to the concentrations of Xylocaine used (2 percent, 4 percent, 10 percent, 20 percent, and 40 percent). The diameters of rat femoral arteries were measured with vernier calipers under the microscope. Effects were evaluated by the percentage of the test arterial diameter compared with that of the control contralateral artery. Vasospasm of both femoral arteries was produced by administration of the fresh blood of other rats. After immersion in the blood for 10 min. Xylocaine was administered into the right femoral artery for 10 min to examine its spasmolytic effect. The effects of the concentrations shown by the percent diameter were 106 percent, 108 percent, 107 percent, 111 percent, and 106 percent, respectively. There was no significant statistical difference between each agent and its control. Thirty minutes after removal of the agent, 2 percent Xylocaine failed to maintain its spasmolytic effect, while 4 percent, 10 percent, 20 percent, and 40 percent Xylocaine did maintain it. Next, blood was again administered after vessel immersion in the agent to examine its antispasmodic effect. The effects of the concentrations were 100 percent, 114 percent, 124 percent, 152 percent, and 146 percent. There were statistically significant differences, except in the case of 2 percent Xylocaine. Twenty-percent Xylocaine demonstrated a superior antispasmodic effect. The duration of the spasmolytic effect and the antispasmodic effect were concentration-dependent, up to approximately 20 percent.

To determine what degree of stenosis should be counted as a significant lesion in each of 3 major coronary arteries in classification of the number of vessels involved, coronary arteriographic percent diameter narrowing (by quantitative angiography) was compared with thallium-201 scinitgraphic redistribution on treadmill exercise in 47 patients with evidence of exercise myocardial ischemia and greater than or equal to 50% diameter narrowing (visual assessment) in at least 1 major coronary artery. Severity of exercise-induced myocardial ischemia for the entire left ventricle (assessed by averaged redistribution index) was separated most sufficiently with definition of 63-64% or greater between patient groups with no- and single-, single- and double-, and double- and triple-vessel diseases. Collaterals and intraventricular contractile interaction are possibly the factors making definition more severe in extensive coronary artery disease. Since the visual method gives an overestimation of stenosis, it was concluded that vessel diameter narrowing of 70% or more should be regarded as significant in patients with single and multiple vessel diseases if the visual method is used.

To investigate the role of balloon dilatation in the management of complicated hepatolithiasis with intrahepatic biliary stricture, 57 consecutive patients who received 208 sessions of dilatation in addition to the usual treatment were analyzed. The strictures were located in the right intrahepatic ducts (84.2%), left intrahepatic ducts (12.3%), or both (3.5%). Dilatation began 3-4 weeks after surgery. The routes of dilatation included the matured T-tube tract (3 cases), percutaneous transhepatic biliary drainage tracts (42 cases), and both (12 cases). The immediate overall success rate of complete stone clearance increased significantly from 0% predilatation to 94.7% postdilatation. The main complications of dilatation therapy consisted of septicemia (10.5%), hemobilia (10.5%), and mild diarrhea (80%). Eight patients (14%) with long-segment strictures received 11 postdilatation biliary stentings. Complications were 1 patient with occlusion and 2 patients with "spontaneous" hemobilia. Severe multiple strictures and coexistent secondary biliary cirrhosis were the contributing factors to complications. During the follow-up of 3.4 +/- 1.2 years, recurrence of strictures was found in 4 patients. Two of them belonged to the stenting group. The cumulative probability of restricture was low: 4% at 2 years, 6% at 2.5 years, and 8% at 3 years. We conclude that in complicated cases of hepatolithiasis with intrahepatic biliary stricture, dilatation and stenting are good adjuvant therapies.

A new finding of a segmental narrowing of the left anterior descending coronary artery in diastole (diastolic narrowing: DN) was reported. DN was found in 6 out of 45 patients (13.3%, 5 males, 1 female) with chronic aortic regurgitation (AR). It is likely that aortic regurgitation was more severe in terms of the history of heart failure, regurgitant fraction, left ventricular end-diastolic volume index and pressure, and aortic diastolic pressure in the patients with DN compared with those without DN. The phasic change of DN in cardiac cycles was analyzed by quantitative angiography, and indicated that DN commences at a point in mid-diastole when coronary vascular driving pressure (the instantaneous aortic and LV pressure difference) becomes abnormally reduced, reaches its maximum at end-diastole, and gradually recovers as aortic pressure increases during systole. In two patients, DN was no longer evident after valve replacement. We concluded that DN, a new coronary arteriographic finding, reflects the integrated severity of AR.

We encountered two patients with complete trachea and esophagus transection due to suicide and traffic accident respectively. Primary repair of both trachea and esophagus with tracheostomy and adequate drainage were performed. Nothing per oral, and intermittent suction in oral and nasogastric tube, followed by hyperalimentation and broad spectrum antibiotics. The patients were discharged in good condition without dysphagia and chocking.

Regional myocardial function during acute coronary artery occlusion was studied with ultrasonic dimension gauges in 20 open-chest anesthetized dogs. Two pairs of ultrasonic crystals were implanted in the left ventricular free wall near the epicardium in an ischemic segment and in a control nonischemic segment, and the segment length (SL) and maximum velocity of systolic shortening (max dL/dt) were measured. In six dogs, the wall thickness (WT) was measured simultaneously in the same regions with sonomicrometry. Left ventricular pressure (LVP), aortic pressure (AoP), and plasma norepinephrine concentration in the coronary sinus (NECS) were also measured. The heart rate was kept constant (180 beats/min) with atrial pacing. The left anterior descending coronary artery was occluded at its distal portion without propranolol in 12 dogs (group 1) and 30 min after propranolol in eight dogs (group 2). In the ischemic region, coronary artery occlusion resulted in an increase in end-diastolic SL (50% at 3 min after occlusion in group 1, P less than 0.005), and a decrease in max dL/dt in systole (36% at 5 min after occlusion in group 1, P less than 0.02). In the nonischemic region, end-diastolic SL did not change significantly, but an increase in max dL/dt (29% at 10 min after occlusion in group 1, P less than 0.005) was observed in systole. Under propranolol (group 2), the results were similar to those of group 1. There were no significant changes in LVP, AoP, AoP, and NECS during occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Some interesting features in the morphological study of rat cardiac cells were obtained by use of the light and phase-contrast microscopy. The histological approach and comparison of the ultrastructures of the cultured cardiac cells with uncultured cells were included in the studies as a control. Four main points are discussed: the process of single beating cells that eventually constitutes the cell cluster and network, the function and histological content of the network, the mechanisms of synchronized beating cells, the substance of the cell surface coat and intercellular connection.

Effect of intracoronary infusion of diltiazem (1 microgram/min) on regional myocardial blood flow (RMBF) was studied using 15-microns radioactive microspheres in 11 excised cross-circulated canine left ventricles. With total coronary blood flow (CBF) and heart rate (HR) held constant, regional ischemia was induced by ligating the left anterior descending coronary artery (LAD). Diltiazem at the dose used had no effects on ventricular Emax before and after LAD ligation. RMBF expressed by the counts divided by the counts averaged in all segments in each layer significantly (p less than 0.05) increased under diltiazem only in the low-flow region that had less than 50% RMBF before diltiazem; from 21% (+/- 12%) to 35% (+/- 18%) in the epicardial, from 22% (+/- 12%) to 32% (+/- 18%) in the midwall, and from 24% (+/- 10%) to 31% (+/- 12%) in the endocardial layers. We conclude that the beneficial effect of diltiazem on the ischemic heart involves a direct action on the coronary vascular system and does not necessarily depend on the concomitant changes in hemodynamics.

Digital subtraction angiography (DSA) has been confirmed to be an accurate method for determining left ventricular function. It is a relatively non-invasive technique without inducing premature ventricular complexes. The response of left ventricular function to afterload stress was assessed using DSA for eight patients with old anterior myocardial infarction and ventricular aneurysm including that of the anterior wall (averaging 30.3 months after the acute episodes). Their ages ranged from 36 to 65 years and one patient was a woman. Prior to the investigation, we confirmed that a single DSA procedure did not alter left ventricular function in a pilot study of one patient (No. 8). After initial DSA in the basal state, methoxamine was infused intravenously (1 to 2 mg/min). When aortic systolic blood pressure increased by 30 to 50 mmHg, a second DSA was performed for each patient. Left ventricular volumes and ejection fractions were calculated by the area-length method, and regional wall motion was assessed by the visual method according to the AHA classification and the curvature radius of the apical ventricular aneurysm was calculated. Methoxamine induced neither acute heart failure nor angina pectoris in the present series. The heart rates decreased, and there were a significant increase in end-systolic volumes (p less than 0.05), end-systolic radii (p less than 0.05), and a significant decrease in ejection fractions (p less than 0.02) after methoxamine infusion. In 32 of 40 segments, regional wall motion was unchanged by methoxamine as assessed by the visual method; whereas, in the other eight, there was a deterioration.(ABSTRACT TRUNCATED AT 250 WORDS)

A quantitative index for describing the severity and extent of coronary artery disease has not been established yet, although it is certain that the stenosis causes myocardial ischemia induced by stress. To establish the most meaningful scoring system, we developed the grading of stenosis which is "critical" or significant in the single-, double-, and triple-vessel method (SDT), and the extent of improvement in the predictive value which may be induced by accounting for the predominance of the three major coronary arteries nourishing the left ventricle. Thirty-three patients (six were women), whose average age was 58.6 years, all having exertional angina pectoris and fixed organic coronary artery stenosis documented by coronary arteriography, but no old myocardial infarction, were the subjects of this study. For these patients the mean redistribution index (RDI) was determined by ergometer stress myocardial perfusion imaging using 201T1. The number (nST) of significant ST segment depressions by body surface ECG mapping after treadmill stress tests was compared with the sigma Pujadas grade, which is the sum of each grade assigned to each of the three major coronary arteries, and with the Pujadas score, which is the weighted sum of grades by dominance in the coronary artery distribution. The SDT method was a better predictor of ischemia if the criterion for critical stenosis is selected at a more severe stenosis (greater than 90% diameter stenosis). Among factors predicting ischemia, the length of the stenosis and the presence of collaterals did not seem to be definitive. However, the distribution of the arteries was an important factor.(ABSTRACT TRUNCATED AT 250 WORDS)

The brachial plexus of rabbits was stretched until mechanical failure. The level and site of rupture varied according to the direction of the stretching force. Upward and lateral traction of the forelimbs caused spinal nerve-root avulsions combined with nerve-trunk ruptures distal to the dorsal root ganglions. In such tractions the C5 nerves consistently exhibited postganglionic nerve-trunk rupture. The C6, C7, and C8 nerves had root avulsions. The T1 nerve was avulsed from the spinal cord in 7 cases out of 10; the other 3 cases had postganglionic nerve-trunk rupture. Downward traction of the forelimbs caused nerve avulsions from the scapulohumeral muscles innervated by the terminal branches of the brachial plexus and peripheral nerve ruptures in the course of the arm. The force producing trunk rupture of the C6 nerve was twice as great as that for root avulsion. The required stain was similar for nerve trunk rupture and root avulsion.