[Hemorrhagic colon ulcer as a side effect of non-steroidal anti-inflammatory drugs in five aged patients]

A report is presented of five aged patients with hemorrhagic colon ulcer, which was strongly suspected to be a side effect of non steroidal anti-inflammatory drugs (NSAID). All patients were suffering from orthopedic diseases and NSAIDs were administered for pain: Zaltoprofen for one patient and slow-releasing diclofenac for the other four. Four patients had being treated underlying diabetes mellitus and three of them were being treated with sulfonylurea. Appetite loss was the earliest symptom, 1-2 weeks after administration of NSAID began. Diarrhea occurred 1-2 weeks after appetite loss, and finally hemorrhagic stool developed 1-2 weeks after that. Acute gastric mucosal lesion, hemorrhagic colon ulcer and colitis were diagnosed in all patients by emergency gastro-duodenocolonoscopy. NSAID and oral diet were ceased, and intravenous hyperalimentation was instituted when the patients revealed severe anemia due to bleeding. All patients could take an oral diet after a few weeks. In conclusion hemorrhagic colon ulcer must be prevented in patients treated with NSAID especially those who are aged and have a history of diabetes mellitus.

Mycotic aneurysm of the bilateral tibioperoneal trunks associated with bacterial endocarditis: a case report

Since antibiotics have been widely used in the treatment of bacterial endocarditis, mycotic aneurysms caused by septic emboli have become extremely rare. We report the case of a 34-year-old man who had mycotic aneurysms in the tibioperoneal trunks of both legs six weeks after he had a mitral valve replacement due to Streptococcus viridans endocarditis. Color Doppler sonography was used to diagnose pseudoaneurysms in both legs. Surgical treatment included the closures of the orifices of both aneurysms in both legs and arterial reconstructions were not required. In the literature, however, the location of mycotic aneurysms in peripheral arteries related to endocarditis were usually reported to be in the upper extremities or femoral arteries. Thus, we present the extremely rare case of mycotic aneurysms because the aneurysms occurred in the infrapopliteal vessel and developed in both legs.

Takayasu's arteritis complicating annuloaortic ectasia (AAE) treated with modified Bentall procedure

A case report and a brief review of the literature on Takayasu's arteritis complicating annuloaortic ectasia are presented. The patient successfully underwent modified Bentall procedure during the inactive stage of the disease. Piehler's method is recommended for coronary reconstruction in the presence of severe periaortic adhesions resulting from Takayasu's arteritis.

Effects of free latissimus dorsi dynamic cardiomyoplasty on left ventricular function

In their experimental approach to dynamic cardiomyoplasty (DCMP), the authors hypothesized that a wrapping method using the proximal part of a free latissimus dorsi muscle (LDM) graft might augment ventricular contractility more than the classic Carpentier's wrapping method. The authors divided 12 mongrel dogs into a pedicled LDM graft group (Group 1, n = 6) and a free LDM graft group (Group 2, n = 6) to evaluate the properties of the different wrapping methods. To evaluate the effect of DCMP on left ventricular systolic and diastolic function, the authors used precise indicators that minimize the influences of load conditions. The slope of the linear preload recruitable stroke work relationship (Mw) and an X-intercept (Vo) were utilized as the indicator of left ventricular systolic function. The constants of pressure decay (tau) and peak filling rate (PFR) were measured to determine diastolic function. All experimental animals were evaluated with the acute, non preconditioning model. Mw was significantly increased with LDM stimulation in both groups (postwrap non stimulation 59.1 +/- 6.3; postwrap stimulation 98.6 +/- 9.7 erg.cm-3. 10(3); p < 0.01 in Group 1, postwrap non stimulation 66 +/- 6.7; postwrap stimulation 155 +/- 15.7 erg.cm-3.10(3), p < 0.001 in Group 2). Stimulated free LDM grafts significantly increased the Mw in comparison to pedicled grafts (p = 0.011). Vo was unchanged in both groups and there was no significant difference between the two groups. Tau increased after LDM wrap in both groups (p < 0.05), but there was no difference between the two groups (tau; prewrap 45.8 +/- 6.0; postwrap non stimulation 69.3 +/- 10.3; postwrap stimulation 72.3 +/- 13.9 msec in Group 1, prewrap 50.0 +/- 6.0; post wrap non stimulation 61.8 +/- 5.0; post wrap stimulation in 64.3 +/- 4.7 msec in Group 2). Peak filling rate was unchanged after LDM wrap in both groups. Free LDM grafts significantly increased left ventricular systolic function compared to the pedicled LDM. Although myocardial relaxation was impaired after LDM wrap in both groups, there was no difference between the two groups. The authors' results emphasize the explicit benefit of utilization of a free LDM graft in respect to left ventricular systolic function; the free LDM grafts have no gross detrimental effect on diastolic function when compared with a pedicle graft in the acute model.

Loss of H19 imprinting and up-regulation of H19 and SNRPN in a case with malignant mixed Müllerian tumor of the uterus

In several human cancers, it has been recently reported that abnormally altered status of genomic imprinting is related to oncogenesis. In this study, we investigated the expression of three imprinted genes in a case with malignant mixed Müllerian tumor of the uterus (MMMT). In the tumor, expression of H19 showed marked upregulation (6.3-fold) with biallelic expression compared with that in the corresponding normal myometrium. The 5'-promoter region of H19 was hypomethylated in the tumor, whereas it was hemimethylated in the myometrium. Expression of the small nuclear ribonucleoprotein polypeptide N gene (SNRPN) was also upregulated by 1.9-fold. However, the insulin-like growth factor II gene (IGF2) was expressed at low levels in both myometrium and MMMT. The overexpression of H19 is caused by reactivation of the repressed allele of H19 due to demethylation of CpG islands within its 5'-promoter region. Whether upregulation of SNRPN is caused by its biallelic expression remains undetermined because restriction fragment length polymorphisms (RFLP) sites were not informative in SNRPN and IGF2. In conclusion, H19 and SNRPN may play significant roles in the tumorigenesis of MMMT and H19 may have tumor-promoting activity in addition to its known tumor-suppressing activity, probably depending on the tissue and the local milieu.

Isolation and characterization of the krev-1 gene, a novel member of ras superfamily in Neurospora crassa: involvement in sexual cycle progression

Genes belonging to the ras superfamily encode low-molecular-weight GTP/GDP-binding proteins that are highly conserved in wide variety of organisms. We used the polymerase chain reaction (PCR) to isolate a novel member of the ras superfamily from the filamentous fungus Neurospora crassa and obtained a mammalian Krev-1 homolog. We named the gene krev-1 and analyzed its structure and function. The krev-1 gene encodes a polypeptide of 225 amino acids, which is nearly 60% homologous to the mammalian Krev-1 p21. The krev-1 gene product (KREV1) is functionally analogous to mammalian Krev-1 p21 and Rsr1p/Bud1p, a Krev-1 homolog from the yeast Saccharomyces cerevisiae. GAL1-driven expression of KREV1 in a wild-type yeast strain resulted in a random budding pattern, as did its mammalian counterpart Krev-1 p21. We disrupted the krev-1 gene by RIP (repeat-induced point mutation), but the krev-1 disruptants showed no abnormalities. By in vitro mutagenesis, we constructed several mutant krev-1 genes (G21V, A68T, and D128A) which mimic constitutively active mutants of Ha-ras, and the krev-1 (K25N) mutant which is analogous to a dominant-negative mutant of Ha-ras. Each mutant gene was introduced into the wild-type strain and the phenotypes were analyzed. We could not observe any difference in vegetative growth between these transformants. When each strain was used as the female in mating tests, the development of perithecia from protoperithecia was inhibited in all cases. The results indicate that the krev-1 gene may be involved in sexual cycle progression.

Sarin poisoning on Tokyo subway

On the day of the disaster, 641 victims were seen at St. Luke's International Hospital. Among those, five victims arrived with cardiopulmonary or respiratory arrest with marked miosis and extremely low serum cholinesterase values; two died and three recovered completely. In addition to these five critical patients, 106 patients, including four pregnant women, were hospitalized with symptoms of mild to moderate exposure. Other victims had only mild symptoms and were released after 6 hours of observation. Major signs and symptoms in victims were miosis, headache, dyspnea, nausea, ocular pain, blurred vision, vomiting, coughing, muscle weakness, and agitation. Almost all patients showed miosis and related symptoms such as headache, blurred vision, or visual darkness. Although these physical signs and symptoms disappeared within a few weeks, psychologic problems associated with posttraumatic stress disorder persisted longer. Also, secondary contamination of the house staff occurred, with some sort of physical abnormality in more than 20%.

The reliability of evoked spinal cord potentials elicited by direct stimulation of the cord as a monitor of spinal cord ischemia during temporary occlusion of the thoracic aorta

Paraplegia is a severe and disastrous complication of operations on the thoracic aorta. For preventing this complication, we employed evoked spinal cord potentials elicited by direct stimulation of the cord (ESPs-dsc) during operations on 83 patients with various aortic lesions (37 dissecting and 46 cases of nondissecting aneurysms, 35 descending and 48 thoracoabdominal aortic aneurysms). All of the patients had some form of circulatory adjunct during aortic cross-clamping. Of the 83 patients, three had "immediate" paraparesis and five had "immediate" paraplegia, whereas three other patients had "delayed" paraplegia. During operation, four types of ESPs-dsc response pattern were observed: (1) no change (n = 57), (2) change with return (n = 15), (3) change with inconsistent return (n = 6), (4) change without return (n = 5). "Delayed" paraplegia occurred in two patients with "no change" and "change with return" response (3%), "immediate" paralysis occurred in three and "delayed" paraplegia occurred in one of those with "change with inconsistent return" response (67%), and all of those with "change with inconsistent return" response (67%), and all of those with "change without return" response developed "immediate" paraplegia (100%). We conclude that intraoperative monitoring of spinal cord function utilizing ESPs-dsc is a good indicator of spinal cord ischemia and we can improve the outcome according to its changes.

Prophylactic laparoscopic ovarian ablation for premenopausal breast cancer: medical and economic efficacy

Worldwide analysis showed a highly significant reduction in the annual rates both of recurrence and of death produced by ovarian ablation. We examined the safety, efficacy, and cost-effectiveness of prophylactic laparoscopic oophorectomy for premenopausal breast cancer. Prophylactic laparoscopic oophorectomy was attempted in 15 selected premenopausal patients with breast cancer. After mastectomy, these patients had laparoscopic ovarian ablation as treatment for breast carcinoma with positive estrogen receptors. To evaluate the economic impact of laparoscopic oophorectomy, comparisons were made between patients treated laparoscopically and those treated with conventional surgery, chemotherapy, and hormonal therapy. The average time required for laparoscopic bilateral oophorectomy was 44 min. Oral intake was resumed the next morning, and the patients were discharged 3 days after surgery. No limitation on physical activity and no complications were required during postoperative days. There was no reduction in the overall costs of laparoscopic surgery and conventional surgery in Japan. The cost of one year's supply of tamoxifen was equivalent to the overall cost of surgical oophorectomy. From medical and economic viewpoints, we conclude that laparoscopic ovarian ablation should be considered an alternative to adjuvant chemotherapy in premenopausal women.

[A case report of primary repair for thoracic and thoracoabdominal and iliac artery aneurysms associated with severe visceral artery occlusive diseases--a redo operation for thoracoabdominal aortic aneurysm after infrarenal abdominal aortic aneurysm repair]

Abdominal aortic aneurysms can now be successfully repaired with low mortality and few early complications. On the other hand, the cases that required operations for recurrent aneurysms have been increased during long term follow-up period. In such cases, there are many difficulties for operative procedures compared to their first operations and many risk factors. A case of successful operation for the thoracoabdominal aortic aneurysm associated with severe stenotic lesions of the visceral arteries and descending thoracic aneurysm and left common iliac artery aneurysm are reported. A 74-year-old man who underwent operation for infrarenal abdominal aortic aneurysm and left nephrectomy 7 years and 9 months ago at our institution developed an aneurysm just above the proximal anastomosis with severe stenotic lesions of the visceral arteries. At the same time, descending thoracic aortic aneurysm and left common iliac artery aneurysm were associated. And he had ischemic heart disease. Under selective perfusion of the visceral arteries, graft replacement of these aneurysms and reconstruction of superior mesenteric artery and right renal artery were done. The patient had good post operative course and started oral feeding at 3 post operation day. He returned to his occupation and is doing well with no trouble one and half year after operation.

Operative results of thoracoabdominal repair for chronic type B aortic dissection

From January 1991 to May 1994, we have operated on 15 cases of Type B aortic dissection. In 10 of these patients, thoracoabdominal repair was performed. According to Crawford's classification, 2 patients fell into Type I, 6 patients into Type II, and 2 patients into Type III. The aneurysms were exposed through a left thoracotomy extending into the retroperitoneum with the hemidiaphragm divided circumferentially. The operations were performed under femoro-femoral partial cardiopulmonary bypass. In 6 of these cases selective perfusion of the visceral branches was used. The celiac axis was reconstructed in 10 patients, superior mesenteric artery in 9, right renal artery in 7, left renal artery in 6. Abdominal vessels were reconstructed by the "inclusion" technique described by Crawford in 2 patients, by "beveling" the distal prosthetic end in 6 and by the "interposition" technique in 4 patients. Vessels arising from the false lumen were reconstructed by the "interposition" technique. To prevent paraplegia, the evoked spinal cord potentials by direct stimulation of the cord (ESPs-dsc) were monitored perioperatively and the aneurysms were repaired sequentially in segments. In all patients except 2 with Crawford type III aneurysms, spinal cord ischemia was detected by ESPs-dsc. In 7 of these patients, 2 to 8 pairs of intercostal/lumbar arteries (I/L aa.) that arose from the "responsible" aortic segment were reconstructed. Reconstruction techniques included the "inclusion" technique in 2 patients, the "beveling" technique in 1, the "interposition" technique in 1 and the "on lay grafting" technique in 3 patients. One hospital death occurred in a patient who had chronic renal insufficiency and liver cirrhosis preoperatively. Spinal cord injury occurred in 5 patients, including 4 paraparesis and 1 delayed-onset paraplegia. In 2 of these patients, responsible I/L aa., were not reconstructed correctly despite ESPs changes, and injury might have been prevented if reconstruction of the "responsible" arteries had been performed. Thoracoabdominal repair for chronic Type B aortic dissection could be performed safely with an acceptable mortality rate. Spinal cord injury remains an unsolved problem.

Effects of stimulated free latissimus dorsi muscle graft on LVEDV and LVSW: a new dynamic cardiomyoplasty technique

The effectiveness of dynamic cardiomyoplasty (DCMP) remains controversial. We hypothesized that effectiveness of DCMP using the latissimus dorsi muscle graft (LDMG) depends on the wrapping method. We analyzed pressure-volume relations (PVR), the left ventricular stroke work (LVSW), and the left ventricular end diastolic volume (LVEDV) changes during nonstimulation and stimulation of the LDMG to evaluate the effect of a new wrapping method of DCMP on the LVSW and the LVEDV changes. The new wrapping technique was evaluated in an acute animal experimental model. In 12 mongrel dogs, we performed continuous measurement of the dimensional and pressure dates of the left ventricle (LV) after the DCMP. The measurement was performed 15 min after wrapping during 5 periods. The duration of one measurement period was 15 s. The animals were divided into 2 groups according to the wrapping method. The heart was wrapped with the LDMG using 2 different methods. For Method 1, Carpentier's method, the heart was wrapped primarily with the distal part of the LDMG, the lateral segment. The vasculoneural pedicle of the latissimus dorsi muscle (LDM) was preserved. For Method 2, the LDM was separated, and the vasculoneural pedicle was cut. The medical sternotomy was performed. The thoracodorsal artery of LDMG was anastomosed to the right internal mammary artery, and the thoracodorsal vein was anastomosed to the right atrial appendage. The heart was wrapped primarily with the proximal part of the "free LDMG," the transverse segment. Based on the PVR loops, the changes of the LVSW and the LVEDV in both experimental groups were analyzed. The paired t-test was used for statistical analysis. Using Method 1, the LVSW and the LVEDV showed no significant changes during stimulation (stim) of the LDMG, compared with nonstimulation (nonstim) (LVSW: nonstim, 970 +/- 168 erg x 10(3); stim, 1,181 +/- 203 erg x 10(3); p = 0.126 and LVEDV: nonstim, 36.6 +/- 6.7 ml; stim, 37.2 +/- 6.8 ml; p = 0.36). Using Method 2, the LVSW was increased, and the LVEDV was decreased during stimulation of the free LDMG, compared with nonstimulation (LVSW: nonstim, 694 +/- 117 erg x 10(3); stim, 846 +/- 104 erg x 10(3); p < 0.001 and LVEDV: nonstim, 47.7 +/- 2.8 ml; stim, 46.8 +/- 2.7 ml; p < 0.001). The stimulated free LDMG wrapping of the heart seems to be a more effective wrapping method for DCMP, and it results in an increase of the LVSW and a decrease of the LVEDV, compared with the original Carpentier's method.

[Regulation of growth and survival of germ cells]

Growth and survival of germ cells seem to be strictly regulated by a number of environmental and intrinsic factors. One of the most important factor is Steel factor, which is necessary not only for the rapid proliferation and survival of primordial germ cells(PGCs) in embryos, but also for the development of spermatogonia and oocytes in adult gonads. Other growth factors which are linked to different signaling pathway collaboratively support PGC growth with Stecl factor. Therefore, synergistic action of different signal transduction pathway seems to be important for PGC growth. In adult testis, a large part of spermatogonia undergoes cell death, but the physiological significance and molecular mechanisms of this process are largely unknown. We have investigated the effect of misexpressing Bcl-2 in spermatogonia in transgenic mice. And we found that ectopically expressed Bcl-2 in spermatogonia inhibited their normal apoptosis. In addition abnormally accumulated spermatogonia fail to undergo further differentiation and survival, and they were just deleted from testis. These results indicate that spermatogonial apoptosis is part of the normal program of mammalian spermatogenesis and is regulated by a pathway affected by Bcl-2.

Effects of glycyrrhizin on immune-mediated cytotoxicity

Intravenous administration of glycyrrhizin is known to decrease elevated plasma transaminase levels in patients with chronic viral hepatitis, in which immune-mediated cytotoxicity by cytotoxic T lymphocytes and tumour necrosis factor (TNF)-alpha is considered to play an important pathogenic role. However, the immunological interpretation of the transaminase-lowering action of glycyrrhizin is not known. Studies were performed to elucidate this action immunologically by assessing the effects of glycyrrhizin on immune-mediated cytotoxicity using an antigen-specific murine CD4+ T hybridoma line, which exhibits cytotoxicity against antigen-presenting cells after stimulation with specific antigen, and a murine TNF-alpha-sensitive fibroblast line. Glycyrrhizin inhibited the cytotoxic activity of the T cells against antigen-presenting cells and also suppressed TNF-alpha-induced cytotoxicity in the TNF-alpha-sensitive cell line in vitro. These results suggest that the decrease of elevated transaminase levels by glycyrrhizin in patients with chronic viral hepatitis is mediated in part by inhibition of immune-mediated cytotoxicity against hepatocytes.

Preoperative determination of the surgical procedure for hepatectomy using technetium-99m-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy

Technetium-99m-diethylenetriaminepentaacetic acidgalactosyl human serum albumin (Tc-GSA) is a new liver scintigraphy agent which binds to the asialoglycoprotein receptors. We evaluated the preoperative assessment for hepatectomy using Tc-GSA liver scintigraphy. Ninety patients with hepatocellular carcinoma were admitted for elective hepatectomy. Tc-GSA scintigraphy was conducted after the intravenous injection of Tc-GSA, and maximal removal rate of Tc-GSA (GSA-Rmax) was calculated using a radiopharmacokinetic model. Measurement of GSA-Rmax, conventional liver function, and 15-minute retention rate of indocyanine green (ICGR15) was carried out preoperatively. The relationships between liver functions, histological activity index (HAI), ICGR15, and GSA-Rmax values were estimated. A significant correlation was obtained between GSA-Rmax and ICGR15 (r = .534, P < .0001). Preoperative discrepancies between GSA-Rmax and ICGR15 values were seen in 15 patients. In these cases, the GSA-Rmax values correlated well with the total HAI scores (r = .595, P < .02), but no significant correlation was seen between the ICGR15 and HAI scores. Two patients died of postoperative liver failure within 2 months of the operation. These two patients were found to have severe discrepancies between their preoperative GSA-Rmax and ICGR15 values. We concluded that GSA-Rmax might be useful for selecting candidates for hepatectomy and that extended hepatectomies (di- and tri-segmentectomy) are high-risk surgical procedures in the case of low GSA-Rmax scores (below 0.35).

Vascular involvement in cutaneous sarcoidosis

Sarcoidosis is a systemic granulomatous disease with systemic vascular involvement, that is, granulomatous angiitis and microangiopathy. To determine if there is vascular involvement in cutaneous sarcoidosis, we examined 42 skin specimens taken from 32 patients with cutaneous lesions of sarcoidosis. Cutaneous sarcoidosis was prevalent in older females with high serum angiotensin-converting enzyme (ACE) levels. Most skin lesions appeared during the following-up of sarcoidosis. Granulomatous angiitis was present in 12 specimens of sarcoid skin lesions (30.8%). Eight of the 12 specimens showed venous involvement in the dermis. There was no correlation between the incidence of granulomatous angiitis and the gross pattern of cutaneous sarcoidosis. Immunohistochemically, thrombomodulin was negative in the vascular endothelium close to the granuloma or a periphlebitis lesion. Electron microscopy revealed endothelial swelling, luminal narrowing, and basal lamina layering of the basement membrane in the capillaries and venules in the dermis. These findings demonstrated that granulomatous angiitis and microangiopathy coexist in cutaneous sarcoidosis.

Extensive replacement of the aorta from the ascending aorta to the supraceliac abdominal aorta during a one-stage operation

A successful replacement of the aorta from the ascending aorta to the supraceliac abdominal aorta in one operation is herein reported. The patient was 66-year-old woman who had DeBakey type I chronic aortic dissection with a pre-disseminated intravascular coagulation (DIC) condition. The image diagnosis revealed a markedly enlarged false lumen with a narrow true lumen in the ascending aorta extending to the diaphragm level while below the diaphragm level, the aortic dilatation was mild. The operation was performed through both a thoracoabdominal incision and a median sternotomy to expose the whole thoracic aorta, and the aorta was replaced from the ascending aorta to the supraceliac abdominal aorta. Selective cerebral perfusion was used for cerebral protection and this was a useful adjunct since no time limitations were thus required during repair of the aortic arch. Although the patient developed several complications postoperatively, she eventually recovered and was discharged from the hospital without any neurological disorders.

A receptor tyrosine kinase, Sky, and its ligand Gas 6 are expressed in gonads and support primordial germ cell growth or survival in culture

Although a number of growth factors and their receptors are involved in the proliferation and differentiation of primordial germ cells (PGCs), the only factor that has been shown to be active in vivo is Steel factor, a ligand for c-Kit. To identify new growth factor receptors that may be required for PGCs function in vivo, we used an reverse transcription-polymerase chain reaction-based strategy to screen for protein kinase genes expressed in PGC-derived embryonic germ cells. We report here that one such gene encoding the receptor tyrosine kinase, Sky, is expressed in both PGCs and their supporting cells in male genital ridges after 11.5 dpc. Interestingly, Sky expression was not detected in female genital ridges, although transcripts were detected in supporting cells in the developing ovary at later stages. Gas 6, a ligand for Sky, was also expressed in interstitial cells which surround Sky positive cells in genital ridges, and, in addition, it supported PGC growth or survival in culture. After birth, Sky expression in testis was restricted to Sertoli cells, and Gas 6 was detected around peritubular cells and Leydig cells. These results suggest that Gas 6-Sky signaling plays a role in PGC growth, sexual differentiation, and Sertoli cell functions in vivo. Sky expression in Sertoli cells diminished by 3 weeks of age, when haploid germ cells first appear. On the other hand, the expression in Sertoli cells was markedly upregulated in the testis of germ cell-deficient W/Wv and jsd/jsd mice. The results suggest that signals from differentiated germ cells suppress Sky gene expression in Sertoli cells. High-resolution chromosomal mapping of Sky is also reported.