Accidental injury by a grass strimmer: an unusual fatality

The body of a 61-year-old woman was found in the morning lying near a wire fence at her farm where she was cutting grass using a motor-powered strimmer. Autopsy revealed a laceration of the heart apex, haemopericardium and left haemothorax caused by a U-shaped wire projectile which was found lodged in the left thoracic cavity. The mechanistic analysis of the injuries and manner of death, however, were conclusive after a scene visit following the autopsy. The farm was surrounded by a wire fence to prevent wild pigs from entering in. The wire projectile was cut by unshielded blade of the strimmer and struck her chest. This case represents an unusual accidental fatality and indicates the need for improved user education and safety when using such implements. This case also reemphasizes scene investigation as an important part of medicolegal autopsy for proper determination of mechanisms of injuries and precise manner of death. We hope this report will increase awareness and alert the general public to the dangers of the grass strimmer operated without proper safety precautions.

Influence of prolonged corticosteroid therapy on the outcome of steroid-responsive nephrotic syndrome

Eighty-six patients (59 males and 27 females) diagnosed with steroid-responsive nephrotic syndrome during childhood were identified. The patients were 20-40 years of age (mean 27.0 +/- 5.0) with a mean follow-up period of 19.5 +/- 5.9 years. All patients had been treated with a long-term tapering corticosteroid therapy. Thirty patients had also received a course of cyclophosphamide (2 mg/kg/day for 12 weeks). Sixty-six had achieved sustained remission off corticosteroids, while 20 were still receiving corticosteroids to maintain remission. None of the 86 patients had proteinuria or renal insufficiency at the time of the study. Mean final heights in males and females were similar (-0.51 +/- 1.21 and -0.23 +/- 1.16 standard deviation score). Mean final height of 20 steroid-dependent patients was significantly less than that of 66 in remission off corticosteroids (p < 0.005). Ten cyclophosphamide-treated patients got married and 9 had at least 1 healthy child. In children with steroid-responsive nephrotic syndrome, the need for corticosteroid therapy to maintain remission may be associated with decreased adult height. Patients who received a 12-week course of cyclophosphamide are likely to be normally fertile as adults.

Cryoglobulinemia in Japanese patients with chronic hepatitis C virus infection: host genetic and virological study

Essential cryoglobulinemia is associated closely with hepatitis C virus (HCV) infection. The mechanism responsible for occurrence of the disease is unclear. The aim of this study was to investigate pathogenetic roles of HCV in cryoglobulinemia. One hundred sixty-seven consecutive patients with HCV were studied clinically by HCV grouping, HCV RNA levels, GBV-C/HGV, HCV quasispecies (target region was hypervariable region-1) and HLA polymorphism. The quasispecies in cryoprecipitate were compared with those in supernatant. The results of HLA polymorphism of patients with cryoglobulinemia were compared with those without cryoglobulinemia and healthy controls. The frequency of HCV-related cryoglobulinemia was 71 of 167 (42.5%). Patients with cirrhosis (36 of 63, 57.1%) had cryoglobulinemia more frequently than those with chronic hepatitis (35 of 104, 33.7%, P < 0.01). No significant differences were not found between the two groups (patients with and without cryoglobulinemia) in age, gender, HCV grouping, HCV RNA level and frequency of GBV-C/HGV. HCV was found quantitatively and clonally more frequently in the cryoprecipitate than in the supernatant. HLA polymorphism presented no significant differences among three groups. The stage of liver disease is one of pathogenetic factors. The greater the presence of HCV quasispecies in cryoprecipitate than in the supernatant indicates that various antigen presentations play an important role in the formation of cryoglobulin, whereas HLA typing dose not seem to contribute to the development of cryoglobulinemia.

Transforming growth factor-beta1 expression in early biopsy specimen predicts long-term graft function following pediatric renal transplantation

The main cause of late graft loss or declining long-term graft function is chronic allograft nephropathy (CAN), characterized by progressive interstitial fibrosis. Transforming growth factor (TGF)-beta1 plays a key role in fibrogenesis. We immunohistochemically investigated whether the degree of TGF-beta1 expression in early biopsy specimens routinely obtained from stable allografts at 100 d could predict fibrosis and graft dysfunction in the late phase. Patients were children with grafts from related donors. We immunohistochemically determined intracellular and extracellular expression of TGF-beta1 in the graft using LC antibody (LC) for intracellular TGF-beta1 and CC antibody (CC) for extracellular TGF-beta1. The change in creatinine clearance between 100 d and 3 yr after transplantation (DeltaCcr) was used as an index of long-term graft function. We also used image analysis to calculate the relative area involved by interstitial fibrosis in the trichrome-stained section of graft biopsy specimens at 100 d and 3 yr, designating the change as DeltaFI. DeltaCcr was -4.2+/-9.4 mL/min in subjects with minimal early immunoreactivity for CC and -20.5+/-15.9 mL/min in subjects with strong reactivity (p<0.05). DeltaCcr was -14.5+/-18.6 mL/min in subjects with minimal early immunoreactivity for LC and -11.7+/-12.8 mL/min in those with strong reactivity. DeltaFI in subjects with minimal CC reactivity (1.28+/-4.11%) tended to be lower than that in subjects with strong reactivity (8.45+/-15.47%). Neither fibrosis at 100 d nor DeltaFI differed between subjects with minimal and strong LC reactivity. Thus, strong extracellular TGF-beta1 expression in grafts at 100 d after transplantation is associated with a long-term decline in graft function and tends to be associated with increased graft fibrosis at 3 yr.

Assessment of health-related quality of life in renal transplant and hemodialysis patients using the SF-36 health survey

OBJECTIVES

To determine whether the health-related quality of life (HQOL) for renal transplant patients improved using SF-36 survey scores and to examine which clinical measures after renal transplantation are connected to aspects of their HQOL.

METHODS

A total of 117 renal transplant patients and 114 hemodialysis patients, including 49 awaiting transplantation and 65 not awaiting transplantation, were included in this study. The scale scores of the SF-36 survey concerning HQOL were compared between the two groups of patients. The relationships of the clinical episode and complications with the scale scores were examined.

RESULTS

The renal transplant patients had significantly higher scores in the physical functioning, bodily pain, general health, and social functioning scales than did the hemodialysis patients. The role-physical functioning, bodily pain, and social functioning scales of the transplant patients were significantly higher than those of the hemodialysis patients not awaiting transplantation. In contrast, the scores, except for that of general health, of the transplant patients were not significantly different from those of the hemodialysis patients awaiting transplantation. Multiple regression analysis demonstrated that the scale scores of physical functioning, general health, and vitality were significantly dependent on the serum level of creatinine in the renal transplant patients (P <0.05). The scores of physical functioning and general health of the patients with a creatinine level >2 mg/dL were significantly lower than those of the patients with 1 mg/dL < creatinine level </=1.5 mg/dL or a creatinine level </=1 mg/dL (P <0.05). An episode of hospitalization was not related to the scale scores, but an instance of rejection had an effect on the scores of social functioning and role-emotional functioning.

CONCLUSIONS

The SF-36 health survey is a short but comprehensive scale for evaluating a patient's HQOL. The renal transplant patients' HQOL improved compared with that of the hemodialysis patients. The most important factor affecting HQOL was the serum creatinine level at the time of testing with the SF-36 survey.

Growth of L929 cells on polymeric films prepared by Langmuir-Blodgett and casting methods

The growth and spreading of fibroblast, L929 cells, on various polymeric films prepared by the Langmuir-Blodgett (LB) and casting methods were investigated. L929 cells, which were cultivated on collagen and synthetic polymeric films prepared by the LB method, adhered and spread much more than those on synthetic films prepared by the casting method. This is explained by the fact that cell growth and cell spreading are suitable for L929 cells on the films having serum proteins that contain a high alpha-helix content, because LB films adsorbed those serum proteins estimated from the circular dichroism measurements of the films immersed in cell culture medium. An exponential relationship was observed from the plot of the cell density vs root mean square of roughness of the films, which is estimated by atomic force microscopy, whereas a linear relationship was observed from the plot of the spreading ratio vs the root mean square of roughness. It is suggested that the correlation between the cell growth or spreading ratio and surface roughness of the films where L929 cells were cultivated is considered to be more important than the correlation between the cell growth or spreading ratio and the contact angle of the films.

Thymidylate synthase levels as a therapeutic and prognostic predictor in breast cancer

5-Fluorouracil (5-FU) is a commonly used adjuvant therapeutic drug in treating breast cancer. 5-FU is metabolically converted to 5-fluorouracil-2'-deoxyuridine-5'-monophosphate-(FdUMP) which is believed to inhibit DNA synthesis in neoplastic cells by forming a tightly bound ternary complex with thymidylate synthase (TS). In the present study, we examined the possible relationship between TS levels and clinico-pathologic and prognostic features in breast disease. Mean TS levels of 2.9 pmol/g, 6.1 pmol/g, and 23.1 pmol/g were obtained in cases of benign breast disease (3 cases), primary breast cancer (115 cases), and recurrent tumors (4 cases), respectively. In breast cancer, mean TS levels significantly correlated with S-phase fraction (SPF), DNA polymerase a and lymphatic invasion. Thus, TS levels in breast cancer significantly reflected cell proliferation and malignancy. Regarding the survival rate, patients with TS values above 10 pmol/g showed an unfavorable prognosis. The effectiveness of adjuvant 5-FU derivatives chemotherapy was reflected in a higher disease-free survival rate in node (+) cases showing TS levels between 5 and 10 pmol/g (p < 0.1), but not in node (-) cases. In conclusion, TS levels in neoplastic tissues of the breast were highest in recurrent tumors, followed by those in primary cancer, benign breast disease and in breast cancer which reflected proliferative activity. Breast cancers with extremely high TS levels were accompanied by an unfavorable prognosis; however, those with moderately high TS levels tended to respond to adjuvant chemotherapy with 5-FU derivatives.

Apoptosis in breast cancer and its relationship to clinicopathological characteristics and prognosis

BACKGROUND AND OBJECTIVES

Apoptosis is essential to maintain homeostasis in living organisms and occurs in a variety of tissues in response to both physiological and pathological stimuli. In breast cancer, most cytotoxic drugs and hormonal treatments induce apoptosis. We studied the relationships between apoptosis and clinicopathological variables or prognosis in 143 patients with operable breast cancer.

METHODS

Apoptosis was numerically graded in 5 consecutive 40x high-power fields (HPF) of hematoxylin-eosin (H&E) stained sections, since we showed that there was a significant correlation of H&E staining with terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining.

RESULTS

The average number of apoptotic cells was 19.9 (0 approximately 168)/5 HPF, and cases were classified into 3 groups based on the number of apoptotic cells/5HPF: 0 to 10, 11 to 30, and 31+. The level of apoptosis increased with increasing size of the tumor, and apoptosis was rarely seen in tumors with positive ER or lower proliferative activity, as assessed by DNA polymerase alpha. As shown by DNA content analysis, apoptotic cells were observed more frequently in tumors with low G1 and high S-phase fractions. In addition, apoptosis was correlated with overexpression of p53 and poor prognosis. Although apoptosis did not correlate with EIC (extensive intraductal component) status, tumors with comedo component had higher values of apoptosis than those without comedo component.

CONCLUSIONS

In breast cancer, apoptosis might reflect biological behavior, namely a higher degree of biological aggressiveness and unfavorable prognosis.

[The efficiency of magnetic resonance angiography (MRA) in the diagnosis and vertigo--prediction of vertebrobasilar insufficiency (VBI) and atherosclerosis]

Major causes of vertigo in patients who attend Otolaryngology clinics are peripheral vestibular disorders (PVD) and vertebrobasilar insufficiency (VBI). The purpose of this study was to see whether MRA findings can distinguish VBI from PVD to evaluate the efficiency of MRA in the diagnosis of vertigo. A total of 185 vertigo patients were examined by MRA with the 3D-Phase Contrast method. Three kinds of abnormalities of vessels, that is, (a) disappearance, (b) meandering, and (c) stoppage were found in MRA imaging. Therefore, we classified the MRA patterns into four types with two subtypes: type I; normal, type II-R; right hypoform of the vertebral artery, II-L; left hypoform of the vertebral artery, III; meandering form of the vertebrobasilar artery, IV-1; stoppage form of the basilar artery, IV-2; hypoform of the bilateral vertebral and basilar arteries. Diagnosis of the MRA patterns in each patient was camed out by a radiologist and neurosurgeon with the cooperation of an otolaryngologist. In 185 vertigo patients, 139 patients were clinically diagnosed as having PVD, 41 patients as having VBI, and 5 patients as having cerebellar and brainstem infarctions. The numbers of patients in MRA patterns I, II-R, II-L, III and IV were 140, 17, 12, 8, and 8 cases, respectively. The total number of VBI patients who demonstrated type III or IV patterns in MRA was significantly higher than that of type I, II-R and II-L (P < 0.005). All of the 8 cases with cerebellar and brainstem infarction belonged to type IV. Cerebral angiography was performed in nine cases with type II-R, II-L, III or IV-1, and the number of patients in each group was 3, 3, 1 and 2 cases, respectively. All of the type II-R and II-L cases revealed hypoform of the vertebral artery. The appearance of type III was restricted to type III's view was only meandering and type IV-1 showed severe stenotic changes in the union area. These data show that MRA findings in the diagnosis of vertigo patients are very effective in distinguishing VBI and cerebellar and brainstem infarction from PVD and that some pattern of MRA may correspond to atherosclerosis of the vertebrobasilar artery. We think MRA examination of vertigo patients is useful not only to assist in the diagnosis of the etiology but also to predict the stage of atherosclerosis in each patient.

Covering the head and face maintains intraoperative core temperature

PURPOSE

To determine the effect of covering the patient's head and face on the prevention of intraoperative hypothermia (<35.5 degrees C).

METHODS

This randomized, prospective trial included 44 adults undergoing elective abdominal surgery. After the induction of anesthesia with thiopental, in 44 patients their extremities and trunk were covered with towels and sheets. In addition, 22 patients (covered group) had their face and head fully covered. Anesthesia was maintained with N2O 50-66% (2-3 L x min(-1)) and isoflurane (<IMAC) in oxygen combined with thoracic epidural anesthesia. Core temperature was measured at the tympanic membrane continuously and was recorded at 15 min intervals from the induction of anesthesia. Heat and moisture exchangers were used in their anesthetic circuit. Ambient temperature was maintained near 25 degrees C.

RESULTS

Neither group demonstrated intraoperative hypothermia. However, tympanic membrane temperature at 75, 90, 105 min in the covered group were higher than those of control group (36.7+/-0.4 degrees C vs. 36.5+/-0.4 degrees C, 36.8+/-0.5 degrees C vs. 36.4+/-0.5 degrees C, 36.8+/-0.5 degrees C vs. 36.4+/-0.5 degrees C, respectively, P<0.05).

CONCLUSION

Covering the patient's head and face maintains intraoperative core temperature.

Detection of cerebroside sulfotransferase mRNA in human gastric mucosa and adenocarcinoma

Sulfatide is a major acidic glycolipid in human gastric mucosa, and its sulfation is catalyzed by cerebroside sulfotransferase (CST). To investigate the expression of the CST gene in human gastric cancer, a reverse transcription PCR method was developed with the use of endoscopic bioptic specimens. By this method, we examined the CST mRNA expression in 11 cases of gastric cancer, and in all the cases we detected various levels of the expression both in cancer tissues and in uninvolved adjacent tissues. The present assay method was suggested to be useful in the detection of CST mRNA from a limited amount of bioptic samples.

Outcome of precise vesicourethral anastomosis following retropubic radical prostatectomy using a Foley catheter

PURPOSE

In order to evaluate precise anastomosis using a Foley catheter, complications following radical retropubic prostatectomy were examined.

METHODS

Twenty-one patients underwent radical retropubic prostatectomy. Precise vesicourethral anastomosis was performed, visualizing the urethral stump by raising up the urogenital diaphragm using a Foley catheter. Complications, such as prolonged urinary extravasation and temporary urinary retention, were checked when the catheter was removed. Incontinence was evaluated both within 6 weeks and more than 6 weeks after operation. Anastomotic and urethral strictures were also checked during follow up.

RESULTS

The follow-up period ranged from 4 to 47 months (mean (+/- SD) 22.0 +/- 12.1 months). Eighteen of 21 patients (85.7%) achieved continence after the operation. However, two patients still had stress incontinence and one patient had mild incontinence. Neither prolonged urinary extravasation nor temporally urinary retention were observed. Anastomotic and urethral stricture were not experienced during follow up.

CONCLUSIONS

Precise anastomosis using a Foley catheter is technically easy and useful, even for relatively inexperienced urologists, to perform. Patients can often achieve continence following this procedure.

Subclinical Sjögren's syndrome: a significant 67gallium accumulation in the orbits and parotid glands

An 8-year-old girl with hypergammaglobulinemia showed an abnormal 67gallium accumulation in the orbits and parotid glands. Although she did not have any subjective siccant complaints, reported typical histopathological and sialographic changes suggesting Sjögren's syndrome (SjS) were observed in the salivary glands. Gallium scintigram might be a valuable and non-invasive diagnostic tool in the diagnosis of children with SjS without sicca symptoms.

[Two cases of spontaneous hemopeumothorax]

We experienced two cases of spontaneous hemopeumothorax. One case was a 17-year-old male with a complaint of back pain. A chest tube for rapid pleural evacuation disclosed hemorrhage as much as 3,000 ml, with drainage volume being gradually decreased. He needed about two month's admission because of complication of pyothorax. The other case was a 46-year-old male with a complaint of chest pain. Chest X-P gave the diagnosis of right hemopeumothorax. Thirty minutes later, he became shock, and five hours later, we performed an emergency intervention of video-assisted thoracoscopic surgery (VATS). Bleeding site of a funicular structure from the parietal pleura was stopped by clipping, with excellent postoperative results. Spontaneous hemopeumothorax is often indicated for early surgical intervention because of association with a high risk of hemorrhagic shock. In such a case, VATS is very helpful.

[The evaluation of the pre-operative interviews using information sheets]

This investigation deals with patients of more than 15 years of age and family members of children younger than 12 years of age to evaluate the pre-operative interviews using information sheets. The information sheets describe the anesthetic management and complications in a simple style. Sixty% of the patients and 75% of the children's family felt anxiety about the anesthesia and/or the operation (P < 0.05). More than a half of the patients did not want to receive informations about the anesthetic management and the risk of anesthesia. On the other hand, 9% of children's family did not want to know informations about the risk (P < 0.05). More than 80% of patients read the information sheets after the pre-operative interviews and about a half of patients answered that their anxiety before the surgery decreased. In this investigation, the children's family wanted to have information about the anesthesia or the operation more than patients themselves. The pre-anesthetic interviews using information sheets is useful to give information about anesthesia and to relieve anxiety of the patients and the children's family.

Binswanger's disease. A rare cause of dementia in elderly persons

A 80-year-old in-patient with abnormal behaviors was strangulated in a hospital bed by another in-patient while he could not escape from the violence because of being restrained to the bed with safety belts. Neuropathological examination of the victim's brain showed characteristic pathological changes of Binswanger's disease (BD), a rare cause of dementia inducing abnormal behaviors. The authors methodically documented BD of the victim and at least justified the restraint as a preventive measure of his abnormal behaviors. Although the etiology of BD is unknown, immunostaining for glial fibrillary acidic protein of the white matter lesions showed neither hyperplasia nor hypertrophy of astrocytes. This result suggested that astrocytes may play an important role in the pathogenesis of BD.

[Prognostic effect of PyNPase (pyrimidine nucleoside phosphorylase) activity in breast cancer]

To clarify the clinical significance of PyNPase (Pyrimidine Nucleoside Phosphorylase)/ PD-ECGF activity in breast cancer, we examined the possible correlation of PyNPase activity to clinicopathological features and prognosis in 195 patients with primary breast cancer between January 1992 through December 1993. The mean PyNPase activity of primary breast cancer, assayed by ELISA method, was 140.6 U/ml, which was between that of benign breast disease (18.2) and recurrent tumors (270.9). In histological type of breast cancer, tumors with solid-tubular carcinoma had significantly higher levels of PyNPase activity. The activity of ER negative or aneuploid tumors was higher than that of ER positive or diploid tumors, respectively. And there was a significant relationship between PyNPase activity and proliferative activity determined by S-phase fraction (SPF) or DNA polymerase alpha. These findings suggested that PyNPase activity was associated with the degree of malignancy. As regards prognosis, in lower SPF (< 16%) group, patients with higher PyNPase activity had significantly lower disease--free survival rates, whereas those with higher activity had a favorable prognosis in the higher SPF (> or = 16%) group. The contradiction might be explained by the possibility that 5-FU derivatives were effective only in patients with high SPF and PyNPase activity, as all patients were treated by a regimen containing 5-FU derivatives. We suggest that PyNPase activity is associated with progression and proliferation of breast cancer, and that it may be useful for prediction of prognosis and therapeutic efficacy of 5-FU derivatives.

[Neuropathological diagnosis of senile dementia of Alzheimer's type in forensic autopsy cases]

Senile dementia of Alzheimer's type is frequently an underlying cause of accidental death of elderly persons. Neuropathological diagnosis of dementia is therefore crucial to assess the contribution of dementia to the cause of accident. The authors applied two conventional neuropathological criteria described by Khachaturian and Mirra, et al. to three forensic autopsy cases of dementia-related accidental death. In all cases, the number of neocortical senile plaque, a hallmark of dementia, could not fulfill both criteria. This result indicates that foregoing neuropathological criteria derived from fully developed dementia are hardly applicable to elderly persons who died in an early stage of dementia in forensic settings. Further investigation will be required to establish a diagnostic criterion of early stage of dementia.

Predictive value of serum medroxyprogesterone acetate concentration for response in advanced or recurrent breast cancer

Medroxyprogesterone acetate (MPA) is one of the most commonly prescribed drugs for endocrine therapy of metastatic breast cancer. In this study, the serum MPA concentration was measured by high-performance liquid chromatography (HPLC) and evaluated for its usefulness in predicting the response in 79 cases of advanced or recurrent breast cancers. Overall, 29 patients (37%) achieved an objective response. The response rate correlated significantly with the oestrogen receptor (ER) status (P = 0.03), proliferative activity determined by DNA polymerase alpha (P = 0.04), the disease-free interval (DFI) (P = 0.05) and the serum MPA concentration (P < 0.001). Patients with ER-positive tumours, lower proliferative activity, a longer (DFI) or a higher serum MPA concentration responded more frequently. The mean serum MPA concentration in the responders with ER-positive tumours (P = 0.01) or tumours with a lower proliferative activity (P = 0.008) were significantly lower than in cases with ER-negative tumours or tumours with a higher proliferative activity, respectively. Cases with soft tissue metastases showed responses at significantly lower MPA concentrations (P = 0.003) than those with bone or visceral metastases. Furthermore, there was a dramatic decrease in the MPA concentration when a responder with a high concentration became unresponsive to the therapy. Thus, the serum MPA concentration is a determining factor for the response to treatment.

[An operative case of suture-granuloma which resulted from an intra-pulmonary treatment 10 years ago and manifested hemoptysis]

We experienced a 27-year-old male patient with recurrent hemoptysis manifested by granuloma which resulted from surgical repair that was performed for right pneumothorax using unabsorbable sutures (braided silk) before 10 years. The patient had been suffering from fever and cough for three months before hemoptysis. Chest X-ray and CT scan films showed a mass shadow in the lateral side of the right lung field. Furthermore, bronchoscopy revealed bleeding in B3 of the right lung. The patient underwent right upper lobectomy, which disclosed that hemoptysis was due to a granuloma (2.3 x 3.2 cm in size) formed around sutures. The granuloma was caused not only by foreign body reaction but also by transbronchial infection.

[Intermittent hydronephrosis. A clinical study in 23 pediatric patients]

BACKGROUND

It is difficult to diagnose intermittent hydronephrosis and to decide the indication of surgical intervention. We investigated 23 cases of intermittent hydronephrosis.

METHODS

From 1978 to 1995, a total of 23 patients were diagnosed as intermittent hydronephrosis in our institution. We inspected their clinical features and treatment which had been performed to them.

RESULTS

Our study comprised 21 boys and 2 girls, whose mean age was 6 year old. Their chief complaint was intermittent flank pain (left: 21, right: 1, bilateral: 1) accompanied with gross hematuria (30%) and vomiting (39%). When they were asymptomatic, an excretory urogram revealed only mild pelvic dilatation without calyceal distension and kinking of ureteropelvic junction. Split renal function study by RI showed no difference between the affected side and the normal side except one case. When pelvic or calyceal enlargement was confirmed on ultrasonography while they were symptomatic, surgery was indicated. Surgery was performed in 17 cases (74%) including dismembered pyeloplasty in 14 cases, resection of aberrant vessel in 1, relocation of lower pole renal vessel in 1 and nephrectomy in 1. In surgical and histological view points, intrinsic stenosis was seen in 10 cases, extrinsic obstruction caused by aberrant vessels was seen in 4 and ureteral polyp was seen in 3 (bilateral polyp in 1 case).

CONCLUSION

They had no more symptoms after operation. Of 23 among followed up cases without surgery, we experienced 2 cases unexpectedly advancing irreversible hydronephrotic change after the last attack, 1 case of gradually progressing hydronephrotic change and 1 case of severe renal dysfunction after many attacks. Therefore intermittent hydronephrosis should be followed up carefully.

[Effects of propofol on contractility and electrophysiological properties of canine single cardiomyocytes]

We assessed the effects of propofol on contraction, action potentials and Ca2+ currents (Ica) in single ventricular cells in dog. Low concentrations of propofol 10(-5)M had no effects on contractile responses, but high doses above 10(-4)M of propofol decreased contractions. Propofol 10(-3)M reduced the duration of action potentials (time to 90% repolarization). Ica was decreased by propofol 10(-4)M without accompanying use-dependent manner. The present study indicates that clinical concentrations of propofol do not exert direct negative inotropic effects, but at supratherapeutic concentrations it inhibits cardiac contractility.

Infective endocarditis caused by an unusual gram-negative rod, Rahnella aquatilis

An 11-month-old girl with congenital heart disease developed infective endocarditis. Blood cultures revealed an unusual gram-negative rod, Rahnella aquatilis. The patient was successfully treated with a combination of netilmicin and ceftazidime. This is the first case report of infective endocarditis caused by this organism. R. aquatilis should be recognized as a clinical pathogen capable of causing life-threatening infection in children and adults.

Benefits of Medroxyprogesterone Acetate (MPA) in Advanced or Recurrent Breast Cancer with Higher Serum Concertration

The efficacy of medroxyprogesterone acetate (MPA) therapy in controlling progressive measurable metastatic breast cancer was assessed in 61 patients. In addition serum MPA concentrations were measured by high performance liquid chromatography (HPLC) and subjective effects of treatment were monitored. Overall 24 patients (39.3%) achieved an objective response(2 complete responses [ CR ] and 22 partial responses [ PR ]). There was no significant relationships between response to therapy and menopausal status, metastatic sites, previous therapy, histological type, or disease-free interval. Patients with estrogen (ER) and progesterone (PgR) receptor-positive tumors responded more frequently. Significant differences in serum MPA concentrations were seen between responders and non-responders, objective tumor shrinkage being seen in patients with serum levels in excess of 55 ng/ml. There were few cases responding to the therapy with serum MPA concentrations lower than 25 ng/ml. The serum MPA levels significantly correlated with an improvement in the performance status and survival. Patients with serum MPA concentrations lower than 25 ng/ml had significantly poorer survival. There was a significant relationship between MPA level and dose per area of boby surface (mg/ m(2)) in cases with CR or PR or no change (NC). However, the serum levels of patients with progressive disease despite therapy were lower than the expected levels based on the body surface area. This study demonstrated that serum MPA concentration is a determining factor for therapeutic benefit in advanced or recurrent breast cancer.

[The significance of bone mineral density measurement of premenopausal women]

We examined the starting age for measuring bone mineral density (BMD) in premenopausal women to detect osteopenia as soon as possible. BMD of the second to fourth lumbar spine vertebrae was measured by dual-energy X-ray absorptiometry to determine normal values for 500 healthy premenopausal women (aged from 17 to 55). We found the rate for low BMD premenopausal women, whose BMD was under the peak bone mass-2SD. And we compared normal BMD women with low BMD women with reference to menstrual history, obstetrical history, and life style, by means of a questionnaire. The peak bone mass of premenopausal women was reached between 35 and 39 years of age (1.059 +/- 0.097g/cm2). The low BMD rate was 7% in all premenopausal women, and increased to 13.5% at from 45 to 49 years. On the other hand, it was only from 5.7 to 7.4% even at from 20 to 29 years. There was the positive correlation between BMD and the body mass index (BMI). There was no statistically significant difference between the low BMD women and the normal BMD women in menstrual history, obstetrical history or life style (parity was 1.7 +/- 1.6 and 1.1 +/- 1.2, respectively, p < 0.05). We concluded that premenopausal women should have their BMD measured after aged 45, and be measured once from 20 to 40 years of age if possible.

[Double uterus and double vagina with unilateral imperforate vagina associated with ipsilateral renal agenesis: an infant case report]

Duplicated uterus associated with unilateral imperforate vagina and ipsilateral renal agenesis is a very rare anomaly. We report a case of a 10-month-old female infant presenting with pus discharge from vagina, and discussed the embryologic and clinical features relevant to this interesting disease complex with a review of the past literature. Echographic and CT examinations demonstrated a right-sided cystic pelvic mass. IVP revealed a left slight hydronephrosis and non-visualizing right kidney. No right ureteral orifice was found at cystoscopy. Under anesthesia the mass and pus was aspirated. Under the diagnosis of Gartner's cystic duct and a right renal agenesis or dysplasia with or without ectopic ureter, we subsequently performed laparotomy. Surgical exploration revealed a duplicated uterus with a normal ovary, and the mass was an imperforate right-sided vagina which communicated through the uterus. The diagnosis was changed to a double uterus with right-sided imperforate vagina, then the vaginal septum was excised. The post-operative course was uneventful, and pus discharge and the left hydronephrosis have disappeared.

[Scrotal calcification associated with hydrocele testis in a child: a case report]

Scrotal calcification is a rare complication of childhood hydrocele testis. Herein, a 12-year-old boy who suffered from left hydrocele testis with intrascrotal calcification is reported. The boy had experienced scrotal pain about 6 months prior to the first visit to our hospital, and gradually noted scrotal swelling. Physical examination revealed left scrotal enlargement with transillumination. Sonographic examination revealed a left hydrocele testis, and a 1.5 cm discrete focus of calcification was found immediate cranio-lateral to the left testis, contour, size and consistency of which were palpated normally. In left hydrocelectomy, no appendix epididymidis was found. A smooth, white, spherical, firm body connecting to the head of the epididymidis was removed. A microscopic examination revealed multiple layers of collagenous tissue with the necrotic tissue in the core. We concluded that this case presented with hydrocele testis secondary to a growing calcification reacting to the infarction due to the repeated torsion of the appendix epididymidis.

[Anesthesia for modified radical mastectomy with breast reconstruction]

We investigated the factors influencing the amount of intraoperative bleeding, the factors influencing postoperative blood transfusion and the effect of postoperative analgesia retrospectively in 71 patients who underwent modified radical mastectomy with breast reconstruction. The amount of intraoperative bleeding decreased significantly in hypotensive anesthesia using epidural anesthesia compared with that with prostaglandin E1. Patient's weight and body surface area are the factors which influenced the amount of intraoperative bleeding. No patient received intraoperative blood transfusion. The amount of postoperative bleeding was significantly greater in 14 cases with blood transfusion and the amount of intraoperative bleeding was not significantly greater in blood transfusion cases. Fifty-one patients received epidural morphine intraoperatively. The dosage of postoperative analgesic was significantly less in these patients.

Application of 13C NMR spectroscopy to paratope mapping for larger antigen-Fab complexes

For the purpose of engineering the antibody combining site, mapping residues that are involved in antigen binding provide us with valuable information. By use of 13C NMR spectroscopy with selectively 13C-labeled Fv fragments, we have established a general strategy to identify the residues that are perturbed upon binding of small antigen (hapten) molecules [(1990) Biochemistry 30, 6604-6610]. In the present paper, we demonstrate that this strategy can be extended to molecular structural analyses of the complexes of an Fab fragment and a larger antigen molecule such as Pseudomonas aeruginosa exotoxin A with a molecular mass of 67 kDa.

[Analgesic effects of the lumbar epidural block with the catheter placed caudad]

In 31 cases of trans-urethral resection of the prostate (TUR-P), the lumbar epidural block was carried out with the catheter placed caudad. In 23 of 31 cases, it was found that the catheters were inserted caudad with coiling, but not so distant from the puncture site. In 3 cases, the catheters were placed caudad beyond a vertebral segment, in 2 cases cephalad, in another 2 cases passed through the intervertebral foramen, and in the other case the position undetectable. However, in 24 of 31 cases, adequate analgesia was obtained by epidural block only. Hypotension during the operation was seen only in 4 cases. In 3 cases, the catheters were successfully placed caudad beyond a vertebral segment and the levels of analgesia 10 minutes after the injection were T11-T10 to S3-S5. In the anesthetic management of TUR-P, it is necessary to obtain complete analgesia in sacral segments and to avoid high thoracic epidural block. We concluded that this method was useful for the anesthetic management of TUR-P.

A case of papillary renal cell carcinoma suggestive of Bellini duct origin

A case of Bellini duct carcinoma is reported. A left renal tumor was detected by abdominal computerized tomography in a 76-year-old male, although he had no symptoms, such as hematuria, weight loss or flank pain. Radical nephrectomy was performed under the diagnosis of renal cell carcinoma in the left kidney. Macroscopic examination of the resected kidney revealed a tumor 2.0 cm in diameter, with a yellow-brown cut surface, located in the renal medulla. Histological examinations showed malignant tumor cells with eosinophilic cytoplasm with a papillary growth pattern. Immunohistostaining examinations using Lectin and two kinds of monoclonal antibodies demonstrated no significant staining with soybean agglutinin, peanut agglutinin, Dolichos biflorus agglutinin, Lotus tetragonolobus agglutinin or cytokeratin, and negative staining with Tamm-Horsfall protein. Although the results of immunohistostaining did not provide support, both macroscopic and microscopic findings strongly suggested that this tumor originated from Bellini duct epithelium (Bellini duct carcinoma). The patient is alive with no evidence of disease 1 year after surgery. Bellini duct carcinoma is a rare malignant condition and the prognosis is usually poor. Differential diagnosis from other renal or pelvic tumors is difficult and long-term careful follow-up is necessary.

[Effects of sevoflurane on contraction, membrane ionic currents and intracellular cyclic AMP concentration in canine single ventricular cells]

The effects of sevoflurane (SV) on contraction, membrane ionic currents and intracellular cAMP concentration were studied in single canine ventricular cells. The authors demonstrated first that SV depressed contractile response of single ventricular cells in a dose-dependent manner. In electrophysiological studies, SV depressed the plateau height and duration of action potentials. Whole-cell voltage clamp experiments revealed that SV depressed voltage-dependent Ca2+ currents in a dose-dependent manner but SV (1%, 2%) did not change Na+ currents. Further, SV (1%, 2%) did not reduce intracellular cAMP concentrations. We conclude that the decrease of myocardial contractile response in single canine cardiac cells by SV is mainly due to the inhibition of voltage-dependent L-type of Ca2+ channels at the sarcolemma and not through changes in intracellular cAMP levels.

[Anesthetic management of a patient with a cryptophthalmos syndactyly syndrome and subglottic stenosis]

We experienced five episodes of anesthesia for a girl with dryptophthalmos syndactyly syndrome and congenital subglottic stenosis from the age of 1.3 year to 4 years. A girl was born at 34 weeks of gestation. The birth weight was 1360 g. The Apgar score was 8 at one minute and there was a hoarseness. She had right cryptophthalmos, syndactyly of hands and left foot, left polydactyly, anomalies of ear and nose, and agenesis of right kidney. The operation was scheduled for syndactyly under general anesthesia when she was 17 days and 5 months. As intubation was unsuccessful in both occasions, the operation was cancelled and subglottic stenosis was pointed out. We decided to postpone the operation until she could cry fully without cyanosis. We evaluated her respiratory ability from the time she became able to cry fully without cyanosis. As a result, we could manage her without any complications such as hypoxia or hypercapnea except mild wheezing.

Malignant gonadal stromal tumor

A case of malignant gonadal stromal tumor is reported, and the 24 cases reported in the English and Japanese literature are reviewed. A thirty-four-year-old male visited our hospital with a painless tumor in the left scrotum. Left high orchiectomy was performed under a diagnosis of testicular tumor, and histologic examination of the resected specimen demonstrated that it was a malignant gonadal stromal tumor. There has been no evidence of disease for forty-one months following surgery. Of the 15 cases reported in the English literature, retroperitoneal lymph node dissection was performed in 3 cases, and metastasis was present in the resected lymph nodes in 2 of the cases. These 3 patients survived with no evidence of disease for follow-up periods ranging between six months and five years. However, lymph node metastasis was observed in 5 of 6 patients who underwent orchiectomy alone or in combination with radiation to the retroperitoneal lymph nodes. The 3 patients described in the Japanese literature who had received high orchiectomy and retroperitoneal lymph node dissection survived with no evidence of disease for follow-up periods ranging from eighteen months to forty-one months following surgery. These findings indicate that retroperitoneal lymph node dissection is useful as a treatment for malignant gonadal stromal tumor. However, the prognosis for patients with advanced disease is very poor, because neither chemotherapy nor radiotherapy is effective. Corroborative study of many patients is necessary to understand the pathophysiology of malignant gonadal stromal tumor and to develop useful treatments.

Adjuvant chemotherapy for invasive urothelial cancer: experience with a methotrexate, vincristine, cisplatin, cyclophosphamide, adriamycin and bleomycin (MVP-CAB) regimen: a preliminary report

MVP-CAB chemotherapy (methotrexate, vincristine, cisplatin, cyclophosphamide, adriamycin and bleomycin) was administered to 28 patients with high grade, locally-invasive or regional lymph node-involved urothelial cancer as an adjuvant therapy after radical surgery. The median follow-up period of all the evaluated patients was 24 (range, 5-62) months. The median disease-free durations in patients with pT1b+2+3 bladder and upper urothelial cancer were 26 and 22 months, respectively. In contrast, all patients with pT4 disease or lymph node metastases had a recurrence within 24 months of surgery. The median disease-free durations in patients with pure transitional cell carcinoma (grade 3) of the bladder and upper urothelial cancer were 19 and 18 months, respectively. The median disease-free duration in patients with grade 3 pT1b+2+3 pure transitional cell carcinoma was 19 months. In contrast, the median disease-free duration in bladder cancer patients with pT1b+2+3 squamous cell carcinoma components was 35 months. The three-year actuarial survival rates were 79 and 89% for pT1b+2+3 bladder and upper urothelial cancer, respectively, while the three-year actuarial survival rates of patients with pT4 bladder cancer and pT4 upper urothelial cancer were 0 and 100%, respectively. The two-year actuarial survivals in the bladder cancer and upper urothelial cancer patients with lymph node involvement were 0 and 100%, respectively. The three-year actuarial survivals of patients with pure transitional cell carcinoma (grade 3) were 53 and 80% in bladder cancer and upper urothelial cancer patients, respectively. The three-year actuarial survival rate in patients with squamous cell carcinoma or adenocarcinoma components which did not recur was, however, 100%. Although randomized studies comparing MVP-CAB and M-VAC (methotrexate, vinblastin, adriamycin and cisplatin) or other chemotherapeutic regimens will be necessary, we believe our results indicate that MVP-CAB chemotherapy may be useful as an adjuvant therapy for patients with urothelial cancer, including those with squamous cell carcinoma and adenocarcinoma components. More intensive MVP-CAB chemotherapy, i.e., increasing the dose of cisplatin and giving at least five courses, as well as the use of granulocyte colony stimulating factor and a new antiemetic drug (granisetron), will, however, be necessary for patients with pT4 or lymph node-involved disease.

[A case of asynchronous renal cell carcinoma and urothelial cancer of the urinary bladder and left ureter]

A 49-year-old male with left renal cell carcinoma and urothelial cancer (bladder and residual left ureter), which asynchronously occurred, was reported. He had received radical nephrectomy due to renal cell carcinoma 12 years earlier. He was followed up by his local physician for 7 years postoperatively, during which time no metastatic lesion was detected. However, he presented with macroscopic hematuria on January 7, 1992, and a diagnosis of urinary bladder cancer was made at our hospital. Computerized tomography demonstrated a non-papillary, broad-based tumor on the left wall of the urinary bladder, which histologically was transitional cell carcinoma (grade 3). Radical cystectomy, ureterectomy of the left residual ureter and ileal conduit were performed. Histological examinations showed that the urinary bladder tumor was transitional cell carcinoma, grade 3, pT-3b, and CIS (transitional cell carcinoma, grade 3) was found in the residual left ureter. Chemotherapy containing cis-platinum was performed as an adjuvant therapy, but multiple lung metastatic lesions appeared 2 months postoperatively, the histology of which was transitional cell carcinoma, suggesting metastasis from the urothelial cancer. Chemotherapy was ineffective, and he died of the disease 9 months after the operation. If this patient had been under long-term follow-up, the urothelial cancer may have been resected completely by transurethral resection. Our report indicated the importance of examination of the urinary tract in patients with such cancers, as well as the necessity of long-term follow-up.