Successful management of critical limb ischemia with intravenous sodium thiosulfate in a chronic hemodialysis patient

Vascular calcification is common among hemodialysis (HD) patients and contributes to the development of peripheral arterial disease. A 57-year-old Japanese man who had been on HD for 30 years was referred to us for severe pain with multiple ulcers on his toes and fingers. He was an ex-smoker and had no diabetes mellitus. On admission, he had ulcers on his big toes bilaterally and right 2nd - 4th fingers. Peripheral pulses were strong and his ankle-brachial pressure index was above 1.3. Laboratory data were as follows: calcium 9.9 mg/dl, albumin 3.3 g/dl, phosphate 3.0 mg/dl, Ca x P product 30, and parathyroid hormone 98 pg/ml. He had a parathyroidectomy in 1998 and 1999. X-rays of his hands and legs showed diffuse subcutaneous arteriolar calcification. Angiography revealed no local stenotic lesions. Despite intensive therapies including hyperbaric oxygen therapy, painful gangrene developed on his right big toe and the pain was so intense that he could not go to sleep in a supine position. We infused intravenous sodium thiosulfate (20 g) 3 times weekly, based on previous reports. Within 4 - 5 days, he experienced rapid and dramatic symptom relief. The score of the visual analogue pain scale improved from 10/10 - 2/10. The signs of ischemia, measured by transcutaneous partial oxygen pressure and thermography, improved significantly. During the infusion of sodium thiosulfate, the patient complained of nausea, vomiting and hyperosmia. These adverse symptoms were resolved after discontinuation of the infusion. Pain relief was sustained and he could walk after 2 weeks of infusion. Our case supports the use of sodium thiosulfate as a novel therapeutic choice for critical limb ischemia with severe vascular calcification in chronic HD patients.

Suppression of myofibrillar proteolysis in chick skeletal muscles by α-ketoisocaproate

We previously reported that L-leucine suppresses myofibrillar proteolysis in chick skeletal muscles. In the current study, we compared the effects of L- and D-enantiomers of leucine on myofibrillar proteolysis in skeletal muscle of chicks. We also assessed whether leucine itself or its metabolite, alpha-ketoisocaproate (alpha-KIC), mediates the effects of leucine. Food-deprived (24 h) chicks were orally administered 225 mg/100 g body weight L-leucine, D-leucine or alpha-KIC and were sacrificed after 2 h. L-Leucine administration had an obvious inhibitory effect on myofibrillar proteolysis (plasma N(tau)-methylhistidine concentration) in chicks while D-leucine and alpha-KIC were much more effective. We also examined the expression of the proteolytic-related genes (ubiquitin, proteasome, m-calpain and cathepsin B) by real-time PCR of cDNA in chick skeletal muscles. Ubiquitin mRNA expression was decreased by D-leucine and alpha-KIC but not L-leucine. Proteasome and m-calpain mRNA expressions as well as cathepsin B mRNA expression were likewise decreased by L-leucine, D-leucine and alpha-KIC. These results indicate that D-leucine and alpha-KIC suppress proteolytic-related genes, resulting in an decrease in myofibrillar proteolysis while L-leucine is much less effective in skeletal muscle of chicks, may be explain by conversion of D-leucine to alpha-KIC.

A key role for the subunit SUR2B in the preferential activation of vascular KATP channels by isoflurane

BACKGROUND AND PURPOSE

It has been postulated that isoflurane, a volatile anaesthetic, produces vasodilatation through activation of ATP-sensitive K+ (KATP) channels. However, there is no direct evidence for the activation of vascular KATP channels by isoflurane. This study was conducted to examine the effect of isoflurane on vascular KATP channels and compare it with that on cardiac KATP channels.

EXPERIMENTAL APPROACH

Effects of isoflurane on KATP channels were examined in aortic smooth muscle cells and cardiomyocytes of the mouse using patch clamp techniques. Effects of the anaesthetic on the KATP channels with different combinations of the inward rectifier pore subunits (Kir6.1 and Kir6.2) and sulphonylurea receptor subunits (SUR2A and SUR2B) reconstituted in a heterologous expression system were also examined.

KEY RESULTS

Isoflurane increased the coronary flow in Langendorff-perfused mouse hearts in a concentration-dependent manner, which was abolished by 10 microM glibenclamide. In enzymically-dissociated aortic smooth muscle cells, isoflurane evoked a glibenclamide-sensitive current (i.e. KATP current). In isolated mouse ventricular cells, however, isoflurane failed to evoke the KATP current unless the KATP current was preactivated by the K+ channel opener pinacidil. Although isoflurane readily activated the Kir6.1/SUR2B channels (vascular type), the volatile anesthetic could not activate the Kir6.2/SUR2A channels (cardiac type) expressed in HEK293 cells. Isoflurane activated a glibenclamide-sensitive current in HEK293 cells expressing Kir6.2/SUR2B channels.

CONCLUSION AND IMPLICATIONS

Isoflurane activates KATP channels in vascular smooth muscle cells and produces coronary vasodilation in mouse hearts. SUR2B may be important for the activation of vascular-type KATP channels by isoflurane.

Prevention of onset of Parkinson's disease by in vivo gene transfer of human hepatocyte growth factor in rodent model: a model of gene therapy for Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disorder characterized by the loss of dopaminergic neurons in the substantia nigra (SNi). As neurotrophic factors support the survival and enhance the function of dopaminergic neurons, gene therapy using neurotrophic factors has become the center of interest. Thus, we focused on hepatocyte growth factor (HGF) as a neurotrophic and angiogenic growth factor. At 7 days before injection of 6-hydroxydopamine into the SNi, stereotaxic transfection of human HGF or lacZ plasmid was performed into the unilateral striatum of rats. Expression of human HGF in the injected sites could be detected in rats transfected with HGF plasmid DNA, using immunohistochemical staining. Consistently, human immunoreactive HGF protein could be detected at least up to 12 days after transfection. Interestingly, PD rats transfected with lacZ demonstrated amphetamine-induced rotational asymmetry. However, transfection of HGF plasmid DNA resulted in significant inhibition of abnormal rotation up to 24 weeks in a dose-dependent manner. Over 90% of dopaminergic neurons were lost in PD rats transfected with lacZ, whereas over 70% survived in rats transfected with HGF, as assessed by immunohistochemical staining. Overall, the present study demonstrated that overexpression of HGF prevented neuronal death in a PD rat model, providing a potential novel therapy for PD.

[Surgical technique of aortic valve replacement for small aortic annulus in elderly patients]

Recent reports have shown that aortic valve replacement in elderly patients over 65 years with atherosclerotic aortic stenosis and a small aortic annulus is possible by using a small sized bioprosthesis (Carpentier-Edwards pericardial valve). Here we present out surgical technique. Firstly, the native calcified aortic valve was removed completely to gain total exposure of the surrounding aortic root and sinus of Valsalva like Bentall procedure. Secondly, a small sized bioprosthesis was implanted with intermittent noneverting mattress 2-0 sutures with spaghetti and small polytetrafluoroethylene (PTFE) felt. Aortic annulus is the dilated by inserting Hegar dilator sizing from 25 to 27 mm. Therefore, aortic valve replacement for small aortic annulus in intra- or supra-annular position should be easily accomplished. Good surgical results and hemodynamic state were achieved in 25 consecutive cases using this technique.

Echocardiographic assessment of early circulatory status in preterm infants with suspected intrauterine infection

OBJECTIVE

To assess early circulatory status in very low birthweight (VLBW) infants with suspected intrauterine infections.

PATIENTS

Thirteen VLBW infants who were diagnosed with prenatal infections because of raised serum IgM at birth (infectious group), and 39 infants matched for gestational age and birth weight (control group).

METHODS

Echocardiographic assessments were performed consecutively from birth to day 28 in all VLBW infants. Left ventricular output (LVO) and left ventricular stroke volume (LVSV) were measured using Doppler echocardiography. Pulsed Doppler assessment of pulmonary artery pressure (PAP) was performed using the corrected ratio of the pulmonary artery acceleration time to the right ventricular ejection time (AT/RVET(c)). Blood flow in the superior mesenteric artery (SMA) was also evaluated by Doppler ultrasound.

RESULTS

Mean LVO and LVSV were both significantly higher in the infectious group than in the control group at 12 hours (LVO; 188 v 154 ml/kg/min) and 72 hours (LVO; 216 v 173 ml/kg/min) of life. Pulsed Doppler assessment of PAP showed that mean AT/RVET(c) values were significantly lower in the infectious group than in the control group at 48 hours, 96 hours, day 14, and day 28. In the analysis of SMA flow velocities, both peak systolic velocities and time averaged velocities had decreased significantly in the infectious group compared with the control group at 24 hours, 36 hours, 96 hours, and day 28.

CONCLUSIONS

VLBW infants with suspected prenatal infection showed a unique circulation status, namely high cardiac output, latency of high PAP, and low organ flow.

The Lower Lumbar Spine Moment and the Axial Rotational Motion of a Body During One-Handed and Double-Handed Backhand Stroke in Tennis

To analyze the load on the lumbar spine and the motion pattern of a body during a backhand stroke when playing tennis, kinematic and kinetic data of eleven amateur tennis players were collected. Each subject performed one-handed and double-handed strokes at low, medium, and high racket speeds. The three-dimensional motion of the strokes was optically measured by tracking markers attached to their body segments. Floor reaction forces were measured for the right and left feet separately. Using the body motion and the floor reaction force data, the lower lumbar spine moment was calculated based on a segment-link model. Peak and plateau values of the joint moment before and after ball impact were analyzed statistically using a factorial ANOVA (stroke, racket speed). Similarly, the axial rotation angle of the pelvis against the feet and that of the shoulder against the pelvis were analyzed. In all the moments except the lateral bending moment before ball impact and all the rotation angles, there were significant main effects of racket speed. The one-handed strokes showed significantly smaller extension moment before ball impact as well as smaller lateral bending and axial rotation moments after ball impact than the double-handed strokes. The one-handed strokes also showed a significantly smaller axial rotation angle of the shoulder against the pelvis and that of the pelvis against the feet. These results indicate that during one-handed strokes the shoulder and elbow joints share the rotational motion necessary for backhand strokes and consequently reduce the maximal moments imposed on the spinal joints.

Human standing posture control system depending on adopted strategies

Control of the standing posture of humans involves at least two distinct modes of operation to restore the body balance in the sagittal plane: the ankle strategy and the hip strategy. The objective of the study was to estimate the contribution of vestibular, visual and somatosensory feedbacks to these distinct strategies. The body dynamics was described as the motion of two linked rigid segments that represented the legs and the rest of the body. The posture controller received the inclination angles of the two body segments as inputs and regulated the moments around the ankle and hip joints. The controller had four feedback paths that were characterised by transfer functions connecting the two inputs and the two outputs. To evoke the distinct strategies, the floor conditions were varied by narrowing the support surface under the feet. A continuous pseudo-random external disturbing force was applied to the waist and the thigh independently. The inclination angles of the body segments and the ground reaction force were measured, and the transfer functions of the controller were estimated with the maximum-likelihood system identification procedure. Six healthy male adult subjects participated in the experiment. When the hip strategy became evident under the narrow support surface conditions, the transfer function relating the leg inclination angle and the ankle joint moment decreased its DC gain (16%), whereas the other three transfer functions increased the gains (20-140%) (ANOVA, p < 0.05). Based on a criterion for simplicity in the modification of the posture controller, these changes suggest a new hypothesis that, when posture control becomes difficult, the central nervous system selectively activates the somatosensory feedback paths from the hip joint angle to the moments around the ankle and hip joints.

Early hypocarbia of preterm infants: its relationship to periventricular leukomalacia and cerebral palsy, and its perinatal risk factors

AIM

To clarify clinical interactions between early hypocarbia, periventricular leukomalacia (PVL) and cerebral palsy of preterm infants.

METHODS

Serial measurements of PaCO2 using arterial blood samples at 3, 6, 12, 24 and 48 h of life were performed for 115 very-low-birthweight infants admitted between 1995 and 1999. Severe early hypocarbia, defined when at least two of five PaCO2 values showed 3.3 kPa or less, was observed in eight infants (hypocarbia group). Preterm PVL was diagnosed by serial ultrasonographic examinations and cranial magnetic resonance imaging, and subsequently classified into early-onset PVL diagnosed within 14 d, or late-onset PVL after 14 d. Perinatal risk factors for early hypocarbia were investigated from the mothers' records and interviews with obstetricians.

RESULTS

The average birthweight in the hypocarbia group was significantly smaller than that in the control group (p < 0.01). The occurrence of PVL in the hypocarbia group was not different from that in the control group. Early hypocarbia was significantly related to late-onset PVL (p < 0.001), but not related to early-onset PVL. The incidence of cerebral palsy in the hypocarbia group was significantly higher than that in the control group (p < 0.001). Multivariate analysis showed that both low birthweight and number of maternal previous abortions were predictive for early hypocarbia.

CONCLUSION

Early hypocarbia of preterm infants in our hospital was significantly associated with both cerebral palsy and late-onset PVL, but not with early-onset PVL. The background of the three clinical events, early hypocarbia, PVL, and cerebral palsy, may not be identical in human newborns.

[Kinking of skeletonized internal thoracic artery graft]

A 66-year-old woman underwent coronary artery bypass grafting (CABG). Postoperative angiography on postoperative day (POD) 11 revealed that right internal thoracic artery (RITA) anastomosed to left anterior descending artery (LAD) had a kinking. The angiography performed 30 months after operation revealed no specific changes in the kinking of RITA and in the left ventricular function. Another case was a 74-year-old man with chronic renal failure under hemodialysis. He underwent CABG with left internal thoracic artery (LITA) to LAD. Post-operatively he had chest pain during hemodialysis. On POD 10, angiography revealed that LITA had a kinking with moderate stenosis and normal left ventricular function. The angiography performed 10 months after operation revealed no specific changes in the kinking of LITA. However, left ventriculography revealed akinesis in the antero-apical region. It suggested that the viability was lost due to the graft kinking of LITA and steal phenomenon on hemodialysis.

[Surgical treatment of thymic carcinomas]

Five cases of surgically treated thymic carcinoma are reported. The patients (4 men and a woman) ranged in age from 46 to 76 years old with a mean of 64.6. Four patients were asymptomatic and an abnormal shadow on X-ray films was noted. One remaining patient suffered from hoarseness. One patient had stage II disease and the others had stage III. Surgical tumor resection was performed in all cases. Only 1 patient among the 5 underwent a successful complete resection. Histological examinations of the resected specimens revealed squamous cell carcinoma of thymus. Four specimens were poorly differentiated and 1 is moderately differentiated carcinoma. All patients received radiation therapy post operatively. Three patients are alive without any recurrence 6, 8 and 109 months after the surgery. Thymic carcinomas are frequently invasive or metastatic at the time of diagnosis. But poorly differentiated group, in squamous cell carcinoma, mucoepidermoid carcinoma and besaloid carcinoma, are characterized by a low incidence of local recurrence and distant metastasis. They also have a good sensitivity for the radiation. Therefore complete surgical resection combined with postoperative radiation therapy should be a choice in treating thymic carcinomas. We considered that complete resection and postoperative radiation therapy is a curative therapy for thymic carcinomas.

[Is the quality of off-pump coronary artery bypass grafting equivalent to that of conventional coronary artery bypass grafting]

We analyzed 44 patients undergoing coronary artery bypass grafting (CABG) from November 2001 to March 2003. Of 44 patients, 40 patients (29 men and 11 women; mean age 68.1 +/- 9.2 years) underwent off-pump CABG (OPCAB) [90.9%]. The mean number of bypass grafts was 2.53 +/- 0.78. In-hospital mortality was none and major complications except for one case of reexploration for bleeding were not seen. The early patency rate of over-all grafts was 94.6%. The quality of OPCAB was considered to be equivalent to conventional CABG.

Determination of the position and orientation of artificial knee implants using markers embedded in a bone: preliminary in vitro experiments

This study describes the method of determination of the position and orientation of artificial knee implants using a single-plane radiograph. To simplify the 3D/2D matching problem, we proposed to use small markers embedded in a bone. From the image coordinates of markers, it is possible to estimate the position and orientation of implants if the relationship between the markers and the implant is known. The results of the in vitro experiment showed that rms errors in in-plane/out-of-plane translations and rotations were 0.2/2.3 mm and 0.2/0.2 degrees, respectively.

The effects of Coptidis Rhizoma extract on a hypercholesterolemic animal model

The serum cholesterol (total, free, esterified, low density lipoprotein (LDL) and oxidized LDL) levels of rats fed a diet containing, by weight, 1% cholesterol and 0.5% cholic acid increased, as compared with those of rats fed a normal diet. The levels, especially of total cholesterol, LDL and oxidized LDL, were reduced significantly in a dose-dependent manner, in rats given Coptidis Rhizoma extract orally at doses of 50 and 100 mg/kg body wt./day for 30 days. These results indicate that Coptidis Rhizoma extract is effective in reducing the pathological damage caused by hypercholesterolemia, through lowering of serum cholesterol levels. In addition, Coptidis Rhizoma extract reduced the level of liver cholesterol, but it did not reduce that of fecal cholesterol, suggesting that the cholesterol level-lowering effect resulted from the reduction of cholesterol synthesis, not the enhancement of its excretion. Furthermore, the serum thiobarbituric acid-reactive substance level decreased after oral administration of Coptidis Rhizoma extract, indicating that Coptidis Rhizoma could prevent hypercholesterolemic disease through reducing lipid peroxidation. This study demonstrates that Coptidis Rhizoma may be a useful therapy for hypercholesterolemia through reducing oxidative stress and cholesterol levels.

Granulocyte transfusion as a treatment for enterococcal meningoencephalitis after allogeneic bone marrow transplantation from an unrelated donor

Bacterial meningoencephalitis occurring in the pre-engraftment period after bone marrow transplantation (BMT) is a rare complication, and the feasibility of granulocyte transfusion (GTX) in such cases remains to be elucidated. A 37-year-old man developed enterococcal meningoencephalitis during a severely granulocytopenic pre-engraftment period after BMT. Despite therapy with appropriate antibiotics, cultures of blood and cerebro-spinal fluid (CSF) continued to grow Enterococcus faecalis, and he developed rapid mental deterioration and seizure. Granulocytes were collected from his HLA-mismatched, ABO-matched sibling with subcutaneous injection of granulocyte colony-stimulating factor (G-CSF) and oral dexamethazone. Transfusion of 4.4 x 10(10) granulocytes resulted in a 12-h post-transfusion granulocyte increment of 2.0 x 10(9)/l, and maintained peripheral blood granulocyte counts above 0.5 x 10(9)/l for 3 days. A rapid increase of granulocytes in CSF was also observed, and cultures of blood and CSF became negative after GTX. A transient worsening of seizure was observed as a potential side effect of GTX. The patient subsequently developed septic shock because of Pseudomonas aeruginosa and died. Further studies are warranted to evaluate the clinical efficacy of GTX for the treatment of uncontrolled infections in granulocytopenic stem cell transplant recipients.

Detection of Japanese yam mosaic virus by RT-LAMP

Arapid and simple procedure is described to detect the genomic RNA molecule of Japanese yam mosaic potyvirus (JYMV). This method, named RT-LAMP, allows direct detection of RNA from infected plants without careful RNA extraction, rapid thermal cycling and gel electrophoresis. RT-LAMP was successfully applied to leaves, propagules and roots of Japanese yam infected with JYMV. One of the characteristics of the RT-LAMP method is its ability to synthesize an extremely large amount of DNA. Accordingly, a large amount of by-product, pyrophospate ion, is produced yielding a white precipitate of magnesium pyrophosphate in the reaction mixture. The presence or absence of this white precipitate allows easy detection of the amplification of JYMV genomic RNA without gel electrophoresis.

Intralobar pulmonary sequestration supplied by multiple anomalous arteries: report of a case

Pulmonary sequestration is abnormal pulmonary tissue that has separated from the normal pulmonary parenchyma, is not connected to the tracheobronchial tree, and is supplied by a systemic artery. We describe herein a case of intralobar pulmonary sequestration found in a 66-year-old man who was admitted to our hospital with hemoptysis, coughing, and fever. Angiography showed that the branches of the 11th left intercostal artery and a bronchial artery had formed a hypervascular area in the lower part of the left lung. Bronchial artery embolization and subsequent embolization of the left 11th intercostal artery were performed in an attempt to control the recurrent hemoptysis. These treatments were unsuccessful, and he was transferred to our department of surgery after coughing up about 400 ml of fresh blood. A left lower lobectomy was performed. The resected lung contained a large feeding artery, some acute and partly organizing inflammatory lesions within collapsed lung parenchyma, and massive intra-alveolar hemorrhage in the peripheral area. The patient had an uneventful recovery and was discharged 22 days after his operation.

Spontaneous nontraumatic rupture of the thoracic aorta: report of a case

Spontaneous nontraumatic rupture of the thoracic aorta is a very rare, life-threatening condition for which emergency diagnostic and therapeutic measures are indicated. The patient reported herein suffered a spontaneous rupture of the thoracic descending aorta through an atheromatous plaque without aneurysmal formation. When acute intrapericardial, mediastinal, or intrapleural bleeding develops without any evidence of aortic aneurysm or dissection, the possibility of spontaneous rupture of the thoracic aorta should be considered in the differential diagnosis, and appropriate emergency surgery may be life-saving.

Serial pulsed Doppler assessment of early left ventricular output in critically ill very low-birth-weight infants

Serial, detailed assessments of left ventricular output (LVO) in critically ill very low-birth-weight (VLBW) infants of four different gestational ages were performed in the early neonatal period using pulsed Doppler echocardiography. Initially, the LVO values of all groups at 3 hours of age were relatively high. However, LVO dropped transiently at 12 hours and then increased again after 24 hours reaching a steady level of 160-180 ml/kg/min after 48 hours of age. In all four groups, heart rate also decreased significantly at 12 hours of age but did not increase at 24 hours of age. Both the left ventricular stroke volume and the left ventricular ejection fraction in all groups exhibited similar longitudinal changes to those observed for LVO. The LVO values observed in the lower gestational age group were significantly lower than those observed in the upper gestational group before 24 hours of age. Both patent ductus arteriosus and mechanical ventilation did not significantly influence the changes in LVO of VLBW infants at least before 36 hours of age. Our results suggest that in the early neonatal period, there are drastic changes in LVO of VLBW infants that reflect not only changes in heart rate but also changes in myocardial contractility.

The nature of facilitation of leg muscle motor evoked potentials by knee flexion

Knee flexion is a movement that initiates rising from a sitting position, which is a common therapeutic exercise for patients unable to ambulate. We investigated how voluntary isometric biceps femoris contraction affects motor evoked potential (MEP) amplitude following transcranial magnetic stimulation, background electromyographic (EMG) amplitude, and H-reflex amplitude in ipsilateral leg muscles. Subjects were seated on the edge of a bed with their hips and knees flexed at 90 degrees, and the soles of their feet on the floor. MEP and background EMG were recorded from the tibialis anterior (TA) and soleus (SOL), and H reflexes from SOL of 30 volunteers. Background EMG and MEP also were recorded while voluntarily contracting tested muscles. Biceps femoris contraction increased MEP and background EMG for TA and SOL (p < 0.01). Maximal background EMG and MEP increased with increasing voluntary contraction of tested muscles (p < 0.005). Regression slope differed little between TA and SOL. Biceps femoris contraction facilitated MEP comparably for TA and SOL, while SOL background EMG exceeded that of TA (p < 0.02). The relationship between MEP facilitation and background EMG changed to favor more efficient facilitation in TA (p < 0.05), but not SOL (p > 0.1). MEP recorded from TA and SOL with subthreshold stimuli using needle electrodes were more frequent with biceps femoris contraction (p < 0.04). H-reflex amplitude of SOL decreased during biceps femoris contraction (p < 0.001). We concluded that biceps femoris contraction affects leg muscle MEP, background EMG, and H reflexes differently.

[Total arch replacement using prior selective cerebral perfusion]

Prior selective cerebral perfusion is the method whereby selective cerebral perfusion and systemic perfusion start almost simultaneously, and the arch vessels are clamped. Cerebral circulation is isolated from systemic circulation to avoid cerebral embolization owing to detachment of atherosclerotic material from the aorta, caused by the "sandblasting" effect of high-velocity jets of blood exiting the aortic canula. Twenty-seven consecutive patients underwent total arch replacement for degenerative aortic arch aneurysm using prior selective cerebral perfusion from 1992 to 2001. Surgical death (within 1 month after operation) was 2 cases (7.4%), in-hospital death was 5 cases (18.5%). Systemic circulatory arrest time is almost equal to the time which distal anastomosis takes. The time was 81.4 +/- 24.3 minutes. Selective cerebral perfusion time was 194.9 +/- 30.9 minutes. Extracorporeal circulation time was 280.6 +/- 55.3 minutes. The time for emergence from anesthesia was 6.0 +/- 2.7 hours. Permanent neurologic dysfunction which was thought to occurred within 48 hours after surgery was noted in 1 case (3.7%). Postoperative survival at 8 years was 73.3%. There was 1 arch aneurismal related accident. Prior selective cerebral perfusion may be useful for avoiding cerebral embolization.

Kinematic analysis of mobile-bearing and fixed-bearing knee prostheses by simulation

The object of the study was to model fixed-bearing knee prostheses (FBKs) and mobile-bearing knee prostheses (MBKs) during weight-bearing deep knee bends and to analyse and compare the kinematics of the two prosthesis types. To obtain quantitative data, an overall model of a leg was constructed, and this included a three-dimensional model of the tibiofemoral joint and simplified two-dimensional models of the ankle and patellofemoral joint. The simulated movement pattern of the tibiofemoral contact point in the FBK was analysed to show the posterior contact position on the tibia at full extension and anterior translation as the knee was flexed from 30 degrees to 90 degrees. The simulated maximum displacements of the medial and lateral contact positions of the FBK were 5.6 and 6.2 mm, respectively. These results were almost in agreement with experimental studies. Compared with the FBK, the movement pattern of the tibiofemoral contact point in the MBK for the anterior contact position on the tibia at full extension and posterior translation, with respect to the tibia as the knee was flexed, gave results closer to those of the normal knee. The simulated displacements of the medial and lateral contact positions of the MBK with respect to the tibia were 9.0 and 13.0 mm from full extension to 90 degrees flexion, respectively. The difference in the kinematic results between the FBK and the MBK could be accounted for by movement of the insert and the larger force of the posterior cruciate ligament on the MBK.

Identification and characterization of CaMKP-N, nuclear calmodulin-dependent protein kinase phosphatase

Calmodulin-dependent protein kinase phosphatase (CaMKP) dephosphorylates and concomitantly deactivates multifunctional Ca(2+)/calmodulin-dependent protein kinases (CaMKs), such as CaMKI, CaMKII, and CaMKIV. In the present study, a nuclear CaMKP-related protein, CaMKP-N, was identified. This protein consisted of 757 amino acid residues with a calculated molecular weight of 84,176. Recombinant CaMKP-N dephosphorylated CaMKIV. The activity of CaMKP-N requires Mn(2+) ions and is stimulated by polycations. Transiently expressed CaMKP-N in COS-7 cells was localized in the nucleus. This finding together with previous reports regarding localization of CaMKs indicates that CaMKP-N dephosphorylates CaMKIV and nuclear CaMKII, whereas CaMKP dephosphorylates CaMKI and cytosolic CaMKII.

[Behavior of drinking alcoholic beverages among junior and senior high school students in the area covered with Wakkanai Health Center of Hokkaido, Japan]

We conducted a survey on behavior of drinking alcoholic beverages among students in November, 2000 in the area covered with Wakkanai Health Center of Hokkaido, Japan. A questionnaire was completed by 743 junior high school students (88.9% of the study subjects) and 791 senior high school students (76.3% of the study subjects). As a result, the proportion of the students who drank more than once per month was higher in this area than in other places of Japan. For example, 90.2% and 87.9% in the male and female senior high school students of the third grade drank more than once per month. Their frequent drinking was not related to their early onset of drinking. They often drank alone or only with their friends. Frequent drinkers among the students tended to get alcohol beverages from various roots, including face-to-face salespersons in package stores, convenience stores, or bars. Frequent drinkers among the students tended to have more experienced the problems associated with drinking such as blackout and vomiting. A large proportion of the students in this area had relatively poor knowledge about harmfulness of drinking. It has been suggested that people in this area are permissive to drinking among youngsters, as compared to other places in Japan. We think that it is indispensable to communicate or educate harmfulness of drinking during adolescence for students as well as for their parents, especially, in this area.

Expression of vascular endothelial growth factor receptors in smooth muscle cells

Vascular Endothelial Growth Factor (VEGF) has been typically considered to be an endothelial-specific growth factor. However, it was recently demonstrated that VEGF can interact with non endothelial cells. In this study, we tested whether vascular smooth muscles cells (VSMCs) can express VEGF receptors, such as flk-1, flt-1, and neuropilin (NP)-1, and respond to VEGF in vitro. In cultured VSMCs, flk-1 and flt-1 expression was inversely related to cell density. The expression of flk-1 was down-regulated with increasing passage numbers. However, NP-1 levels were not affected by cell density or passage numbers. Flk-1, Flt-1, and NP-1 protein levels were confirmed by Western Blotting. Although the functional mature form of Flk-1 protein is expressed at low levels in VSMCs, phosphorylation of Flk-1 following VEGF(165) stimulation was still observed. SMCs migrated significantly in response to VEGF(165) and VEGF-E, whereas Placenta Growth Factor (PlGF) induced migration only at higher concentrations. Since VEGF-E is a specific activator of flk-1 while PlGF specifically activates only flt-1, SMC migration induced by VEGF(165) is likely to be mediated primarily through the flk-1 receptor. VSMCs did not significantly proliferate in response to VEGF(165), PlGF, and VEGF-E. In conclusion, our studies demonstrate the presence of VEGF receptors on VSMCs that are functional. These studies also indicate that in vivo, VEGF may play a role in modulating the response of VSMCs.

Design and synthesis of a highly selective EP4-receptor agonist. Part 1: 3,7-dithiaPG derivatives with high selectivity

A series of 3,7-dithiaPGE(1) analogues 3, 4, 11, 16 and 19 were identified as highly selective EP4-receptor agonists starting from the chemical modification of 7-thiaPGE(1) analogue 1. EP4-receptor selectivity and agonist activity were maximized in 3 and 4.

Design and synthesis of a highly selective EP2-receptor agonist

EP2-receptor selective agonist 3 was identified by the structural hybridization of butaprost 1a and PGE(2) 2a. Based on this information, a chemically more stabilized 4 was discovered as another highly selective EP2-receptor agonist, iv administration of which to anesthetized rats suppressed uterine motility, while PGE(2) 2a stimulated uterine motility.

Prolonged suppression of brain nitric oxide synthase activity by 7-nitroindazole protects against cerebral hypoxic-ischemic injury in neonatal rat

Nitric oxide mediates glutamate-induced excitotoxicity associated with cerebral hypoxia-ischemia through production in the brain by several isoforms of nitric oxide synthase (NOS). We examined the influence of the selective neuronal NOS inhibitor, 7-nitroindazole (7-NI), on brain NOS activity and its neuroprotective effects against cerebral hypoxic-ischemic injury in the postnatal day (PND) 7 rat. In the first set of experiments, 7-NI (50 mg/kg) administered intraperitoneally (i.p.) transiently inhibited NOS activity to 40% below the vehicle control level at 1 h after injection (P<0.001, analysis of variance (ANOVA)). In contrast, 7-NI (100 mg/kg, i.p.) inhibited NOS activity to 56% below the control level at 1 h with prolonged suppression of NOS activity at 3, 6, 9 and 12 h after injection. Two-factor ANOVA revealed an overall effect on NOS activity of 7-NI treatment (P<0.001) and time after injection (P<0.001). In the second set of experiments, 7-NI (50, 100 mg/kg) or an equal volume of vehicle was administered after unilateral carotid artery ligation, but 30 min before hypoxia in PND 7 rats. 7-NI (100 mg/kg) significantly protected against cerebral hypoxic-ischemic injury (100 mg/kg of 7-NI, 1.7+/-1.0% damage; control, 8.7+/-1.6%,P<0.05). 7-NI administered 15 min after cerebral hypoxia-ischemia was not neuroprotective. The data suggest that the protective effect of 7-NI is dose dependent, and is related to the duration of suppressed NOS activity.

[Immunohistochemical study of KL-6 in pulmonary tuberculosis]

KL-6 is a glycoprotein antigen derived from the cell line of human lung adenocarcinoma. Although KL-6 is known to be a serum marker of interstitial pneumonia, elevated KL-6 serum levels have also been reported in some cases of pulmonary tuberculosis. To elucidate the mechanism of KL-6 elevation in pulmonary tuberculosis, we stained pulmonary tissue samples from five clinical cases for immunohistochemical analyses. In the two cases showing productive changes, KL-6 immunoreactivity was localized in the area of type II pneumocytes showing strong interstitial changes surrounding caseous necrosis. In the two cases showing exudative changes, KL-6 immunoreaction was observed not only to surround caseous necrosis but also to appear within it, particularly in the remaining alveolar lumen septa. On the other hand, the one patient with old pulmonary tuberculosis that showed slight interstitial changes presented with weak KL-6 immunoreactivity on the surface of the alveolar lumen surrounding the tuberculotic region. These results suggest that serum elevation of KL-6 in pulmonary tuberculosis originates from the proliferation of type II pneumocytes along with interstitial changes that surround the tuberculous region.

Neurobiology of hypoxic-ischemic injury in the developing brain

Hypoxic ischemia is a common cause of damage to the fetal and neonatal brain. Although systemic and cerebrovascular physiologic factors play an important role in the initial phases of hypoxic-ischemic injuries, the intrinsic vulnerability of specific cell types and systems in the developing brain may be more important in determining the final pattern of damage and functional disability. Excitotoxicity, a term applied to the death of neurons and certain other cells caused by overstimulation of excitatory, mainly glutamate, neurotransmitter receptors, plays a critical role in these processes. Selected neuronal circuits as well as certain populations of glia such as immature periventricular oligodendroglia may die from excitotoxicity triggered by hypoxic ischemia. These patterns of neuropathologic vulnerability are associated with clinical syndromes of neurologic disability such as the extrapyramidal and spastic diplegia forms of cerebral palsy. The cascade of biochemical and histopathologic events triggered by hypoxic ischemia can extend for days to weeks after the insult is triggered, creating the potential for therapeutic interventions.

Characteristics of somatosensory feedback in postural control during standing

In the present study, the function of the somatosensory feedback system in postural control was investigated. For the sake of simplicity, the present study considered only balancing in the anteroposterior direction using the ankle strategy, in which the ankle moment is mainly used to maintain balance. To suppress the vestibular and visual feedback paths, a subject stood on a force-measuring platform with a fixed back support. Because the subject's body was immovable under these conditions, the subject controlled a computer model that simulated the subject's load at the ankles. Information about the sway angle of the model was fed through the somatosensory feedback path. Frequency response functions of the ankle moment in response to the sway angle were calculated. The experimental results suggest that the human somatosensory feedback system has derivative characteristics and, consequently, can maintain an upright posture by itself. The results were compared with those of previous studies on vestibular and visual feedback systems. The comparison reveals that subject-to-subject variance in the somatosensory system is significantly smaller than that in the other systems. This may indicate that the somatosensory feedback is the most automatic of the systems and plays a dominant role when a subject maintains an upright posture using the ankle strategy.

Substrate specificity of Ca(2+)/calmodulin-dependent protein kinase phosphatase: kinetic studies using synthetic phosphopeptides as model substrates

Ca(2+)/calmodulin-dependent protein kinase phosphatase (CaMKPase) dephosphorylates and regulates multifunctional Ca(2+)/calmodulin-dependent protein kinases. In order to elucidate the mechanism of substrate recognition by CaMKPase, we chemically synthesized a variety of phosphopeptide analogs and carried out kinetic analysis using them as CaMKPase substrates. This is the first report using systematically synthesized phosphopeptides as substrates for kinetic studies on substrate specificities of protein Ser/Thr phosphatases. CaMKPase was shown to be a protein Ser/Thr phosphatase having a strong preference for a phospho-Thr residue. A Pro residue adjacent to the dephosphorylation site on the C-terminal side and acidic clusters around the dephosphorylation site had detrimental effects on dephosphorylation by CaMKPase. Deletion analysis of a model substrate peptide revealed that the minimal length of the substrate peptide was only 2 to 3 amino acid residues including the dephosphorylation site. The residues on the C-terminal side of the dephosphorylation site were not essential for dephosphorylation, whereas the residue adjacent to the dephosphorylation site on the N-terminal side was essential. Ala-scanning analysis suggested that CaMKPase did not recognize a specific motif around the dephosphorylation site. Myosin light chain phosphorylated by protein kinase C and Erk2 phosphorylated by MEK1 were poor substrates for CaMKPase, while a synthetic phosphopeptide corresponding to the sequence around the phosphorylation site of the former was not dephosphorylated by CaMKPase but that of the latter was fairly good substrate. These data suggest that substrate specificity of CaMKPase is determined by higher-order structure of the substrate protein rather than by the primary structure around its dephosphorylation site. Use of phosphopeptide substrates also revealed that poly-L-lysine, an activator for CaMKPase, activated the enzyme mainly through increase in the V(max) values.

Light-use properties in two sun-adapted shrubs with contrasting canopy structures

We investigated the impact of high solar irradiance and elevated temperature on carbon gain by two, co-occurring, sun-adapted, dwarf shrub species, Planchonella obovata var. dubia (Koidz.) Hatusima and Hibiscus glaber Matsumura, growing on sun-exposed ridges in the Bonin Islands, in the subtropical Pacific Ocean. Planchonella had steeply inclined, longer lived, sclerophyllous leaves, whereas Hibiscus has thinner, more horizontally oriented, and shorter lived leaves. We tested the hypothesis that leaf physiological tolerance to high light is lower in Planchonella than in Hibiscus. Under relatively high irradiances (photosynthetic photon flux density, PPFD, > 500 micromol m(-2) s(-1)), net photosynthetic rate (P(n)) was about 8.0 and 0.4 micromol m(-2) s(-1) in mature and young leaves of Planchonella, and about 12.4 and 10.3 micromol m(-2) s(-1) in mature and young leaves of Hibiscus, respectively. Both P(n) and photosystem II (PSII) quantum yield at a given PPFD were lower in Planchonella than in Hibiscus, whereas non-photochemical quenching (NPQ) at a given PPFD was higher in Planchonella. When leaf discs were exposed to high light (1900 micromol m(-2) s(-1) PPFD) at 37, 40 or 43 degrees C for 3 h, the recovery of PSII quantum yield (F(v)/F(m)) in the following 60-min dark period was slower in Planchonella than in Hibiscus, indicating that the ability of PSII to tolerate high light and high temperature was less in Planchonella than in Hibiscus. We postulate that there is a linkage between leaf display and leaf photochemical ability in sun-adapted shrub species.

Delayed increase in neuronal nitric oxide synthase immunoreactivity in thalamus and other brain regions after hypoxic-ischemic injury in neonatal rats

We examined the response of neuronal nitric oxide synthase (nNOS)-containing CNS neurons in rats exposed to a unilateral hypoxic-ischemic insult at 7 days of age. Animals were sacrificed at several time points after the injury, up to and including 7 days (Postnatal Day 14). Brain regions ipsilateral to the injury (including cerebral cortex, caudate-putamen, and thalamus) exhibited delayed, focal increases in nNOS immunoreactivity. The increase in nNOS immunoreactive fiber staining was prominent in areas adjacent to severe neuronal damage, especially in the cortex and the thalamus, regions that are also heavily and focally injured in term human neonates with hypoxic-ischemic encephalopathy. In cerebral cortex, these increases occurred despite modest declines in nNOS catalytic activity and protein levels. Proliferation of surviving nNOS immunoreactive fibers highlights regions of selective vulnerability to hypoxic-ischemic insult in the neonatal brain and may also contribute to plasticity of neuronal circuitry during recovery.

Analysis of pharyngeal swallowing in healthy subjects

The Biomechanics of pharyngeal swallowing was investigated by videofluorography in 10 healthy subjects (9 men and 1 woman) during swallowing of 3 ml of fluid contrast medium and a small spoonful of jelly contrast medium. The items measured were the sequential movement of the hyoid bone: hyoid bone angle; epiglottis angle: antero-posterior diameters of the thyroid cartilage, larynx, hypopharynx, and pharyngoesophageal junction: and transport time of the swallowed bolus. It was concluded that the movement of the hyoid bone and thyroid cartilage and the angle of the epiglottis were important for evaluation of pharyngeal swallowing, and that the antero-posterior and vertical movement of the hyoid bone showed a significant relationship to transport time of the swallowed bolus as far as the esophagus, which was within 400 msec on average.

Oncostatin M promotes biphasic tissue factor expression in smooth muscle cells: evidence for Erk-1/2 activation

Tissue factor (TF), a transmembrane glycoprotein, initiates the extrinsic coagulation cascade. TF is known to play a major role in mediating thrombosis and thrombotic episodes associated with the progression of atherosclerosis. Macrophages at inflammatory sites, such as atherosclerotic lesions, release numerous cytokines that are capable of modulating TF expression. This study examined the role of oncostatin M (OSM), a macrophage/ T-lymphocyte-restricted cytokine, in the expression of TF in vascular smooth muscle cells (SMCs). It is reported here that OSM stimulated a biphasic and sustained pattern of TF messenger RNA (mRNA). The effect of OSM on TF mRNA expression was regulated at the transcriptional level as determined by nuclear run-offs and transient transfection of a TF promoter-reporter gene construct. OSM-induced TF expression was regulated primarily by the transcription factor NF-kappaB. Activation of NF-kappaB by OSM did not require IkappaB-alpha degradation. Inhibition of MEK activity by U0126 prevented OSM-induced TF expression by suppressing NF-kappaB DNA binding activity as determined by gel-shift analysis. Further, inhibition of Erk-1/2 protein by antisense treatment resulted in suppression of TF mRNA expression, indicating a role for Erk-1/2 in modulating NF-kappaB DNA binding activity. These studies suggest that the induced expression of TF by OSM is primarily through the activation of NF-kappaB and that activation of NF-kappaB is regulated in part by the MEK/Erk-1/2 signal transduction pathway. This study indicates that OSM may play a key role in promoting TF expression in SMCs within atherosclerotic lesions.

Memory rehabilitation of an amnesic patient following limbic encephalitis and a role of family members: a case report

We describe problems in daily living that arose in a 46-year-old man with severe amnesia following limbic encephalitis. Amnesic symptoms changed from stage I (difficulty in memory retention) to stage II (loss of continuity of memory) and finally to stage III (paramnesia and confused sequence of events), significantly affecting his ability to function. Questionnaire response assessment, directly observed behavior, neuropsychological testing, and especially interviewing permitted qualitative assessment of clinical changes, promoted patient insight into the memory disturbance, and enhanced motivation to use a memory notebook. Additionally, the family gained a better understanding of the disorder, made appropriate environmental modifications, and provided other necessary assistance. Episodic memory improved, and the memory notebook served as an effective compensatory tool. However, disturbance in prospective memory did not improve, and was not compensated adequately by use of the notebook. Anxiety and significant impairment of everyday functioning resulted. Long-term supportive intervention at home was necessary. The patient's wife in particular needed to make environmental adjustments and aid him in use of the notebook.

Changes in patterns of left ventricular hypertrophy after aortic valve replacement for aortic stenosis and regurgitation with St. Jude Medical cardiac valves

In this study, we analyzed the extent and pattern of regression of left ventricular (LV) hypertrophy after aortic valve replacement in patients with aortic stenosis (AS) and compared the results with those of another group of patients with aortic regurgitation (AR). Seventy patients who underwent isolated aortic valve replacement were divided into 2 groups. Group 1 was comprised of 29 patients who underwent aortic valve replacement for aortic stenosis, and Group 2 of 41 patients who underwent aortic valve replacement for aortic regurgitation. A third group of 10 healthy subjects served as a healthy control group. Echocardiographic studies were done before the operation and 5 years postoperatively. At follow-up, a significant reduction in the left ventricular mass was found in both groups, but it remained significantly greater than in the healthy control group. The ratio of LV wall thickness to radius (th/r) in Group 1 decreased significantly, and at follow-up it was within the normal value. In Group 2, the th/r ratio increased, and at follow-up it was within the normal value. After aortic valve replacement, the wall thickness remained significantly greater than normal for patients with AS, and the chamber radius remained significantly greater than normal for patients with AR. For these reasons, LV hypertrophy still existed in both groups at postoperative follow-up. The actuarial survival rate was 85.3% at 16 years for Group 1 and 83.4% at 18 years for Group 2. There was no significant difference in the long-term survival rates between the 2 groups. Actuarial freedom from valve-related events was 91.9% at 16 years for Group 1 and 82% at 18 years for Group 2. There was no significant difference in the valve-related event free curves between groups. After 5 years of follow-up, th/r reached normal for both groups, indicating remodeling of the LV geometry after aortic valve replacement.

Apoptosis has a prolonged role in the neurodegeneration after hypoxic ischemia in the newborn rat

Birth asphyxia can cause moderate to severe brain injury. It is unclear to what degree apoptotic or necrotic mechanisms of cell death account for damage after neonatal hypoxia-ischemia (HI). In a 7-d-old rat HI model, we determined the contributions of apoptosis and necrosis to neuronal injury in adjacent Nissl-stained, hematoxylin and eosin-stained, and terminal deoxynucleotidyl transferase-mediated UTP nick end-labeled sections. We found an apoptotic-necrotic continuum in the morphology of injured neurons in all regions examined. Eosinophilic necrotic neurons, typical in adult models, were rarely observed in neonatal HI. Electron microscopic analysis showed "classic" apoptotic and necrotic neurons and "hybrid" cells with intermediate characteristics. The time course of apoptotic injury varied regionally. In CA3, dentate gyrus, medial habenula, and laterodorsal thalamus, the density of apoptotic cells was highest at 24-72 hr after HI and then declined. In contrast, densities remained elevated from 12 hr to 7 d after HI in most cortical areas and in the basal ganglia. Temporal and regional patterns of neuronal death were compared with expression of caspase-3, a cysteine protease involved in the execution phase of apoptosis. Immunocytochemical and Western blot analyses showed increased caspase-3 expression in damaged hemispheres 24 hr to 7 d after HI. A p17 peptide fragment, which results from the proteolytic activation of the caspase-3 precursor, was detected in hippocampus, thalamus, and striatum but not in cerebral cortex. The continued expression of activated caspase-3 and the persistence of cells with an apoptotic morphology for days after HI suggests a prolonged role for apoptosis in neonatal hypoxic ischemic brain injury.

Primary malignant lymphoma of the uterine corpus diagnosed by endometrial cytology. A case report

BACKGROUND

A relatively small number of cases of primary malignant lymphoma of the uterine corpus have been reported, and it is rare for cases to be preoperatively diagnosed by cytology.

CASE

A 59-year-old female experienced abnormal uterine bleeding of two months' duration. Preoperative evaluation of endometrial cytology revealed malignant cells. These cells demonstrated a rather round or oval configuration, with a markedly increased nuclear/cytoplasmic ratio, and were isolated and scattered in an inflammatory background. The nuclei were round or oval, and macronucleoli were marked. The cytologic diagnosis was malignant lymphoma. Postoperative histologic evaluation verified the presence of a primary malignant lymphoma in the uterine corpus, with a B-cell phenotype.

CONCLUSION

Preoperative endometrial cytology correctly demonstrated malignant lymphoma of the uterine corpus.

15-Deoxy-Delta(12,14)-prostaglandin J(2) induces G(1) arrest and differentiation marker expression in vascular smooth muscle cells

In search of substances useful for the treatment of atherosclerotic vascular diseases, we studied the effects of 15-deoxy-Delta(12, 14)-prostaglandin J(2) (15d-PGJ(2)), a natural ligand for peroxisome proliferator-activated receptor gamma, on the proliferation and differentiation of vascular smooth muscle cells (VSMCs). 15d-PGJ(2) but not WY14643, an agonist for peroxisome proliferator-activated receptor alpha, dose-dependently inhibited VSMC proliferation; the effect was maximal at 12 microM. This compound strongly suppressed the activities of cyclin-dependent kinases (Cdk) 4, 6, and 2, thereby preventing the phosphorylation of the retinoblastoma protein. These Cdks seemed to be inhibited through two mechanisms: the down-regulation of cyclin D1 and the up-regulation of Cdk inhibitor p21(Cip1/Waf1/Sdi1). 15d-PGJ(2) was found to inhibit the phosphatidylinositol 3-kinase/protein kinase B signaling pathway, which mediates cyclin D1 expression. Mitogenic stimulation of quiescent cells decreased the level of mRNA for the smooth muscle-specific myosin heavy-chain SM1, whereas this reduction was prevented by 15d-PGJ(2). A long-term treatment of exponentially growing VSMCs with 15d-PGJ(2) markedly elevated the mRNA level of SM1 and, moreover, induced SM2, another isoform expressed exclusively in mature VSMCs. 15d-PGJ(2) also increased the expression levels of calponin-h1 and smooth muscle alpha-actin. These results suggest that 15d-PGJ(2) induces G(1) arrest by two distinct mechanisms and promotes VSMC differentiation.

Microvascular anastomoses using an Nd-YAG laser

The authors performed anastomoses of small vessels with the Nd-YAG laser, comparing these with conventional suture anastomoses. Some arteries were sutured with 10-0 nylon with about eight suture sites, and others were held by stay sutures at three points with laser irradiation performed between them. Two surgeons performed the anastomoses in the same way. The first was well-trained and experienced, and the second was technically inexperienced. The authors evaluated clamping time, patency rate, and endoscopic and histologic findings. The patency rate of the first surgeon was 100 percent (30/30) in the suture anastomoses and was 97 percent (29/30) in the laser anastomoses. For the second surgeon, the rates were 60 percent (18/30) in the suture group and 80 percent (24/30) in the laser group. On histologic examination, the suture group showed inflammatory cells around the suture site at the fourth week after the operation. In the laser group, an inflammatory reaction around the suture material was observed, but the other areas recovered. For the experienced surgeon, the patency rate and clamping time of the laser anastomosis provided no statistically significant difference to those of the suture anastomosis. On the other hand, for the inexperienced surgeon, the patency rate of the laser anastomosis was superior to that of the suture anastomosis, and the clamping time of the laser anastomosis was shorter than that of the suture anastomosis. Therefore, the authors concluded that the Nd-YAG laser anastomosis is useful for small vessels.