The role of platelet factor 4 in local and remote tissue damage in a mouse model of mesenteric ischemia/reperfusion injury

The robust inflammatory response that occurs during ischemia reperfusion (IR) injury recruits factors from both the innate and adaptive immune systems. However the contribution of platelets and their products such as Platelet Factor 4 (PF4; CXCL4), during the pathogenesis of IR injury has not been thoroughly investigated. We show that a deficiency in PF4 protects mice from local and remote tissue damage after 30 minutes of mesenteric ischemia and 3 hours of reperfusion in PF4-/- mice compared to control B6 mice. This protection was independent from Ig or complement deposition in the tissues. However, neutrophil and monocyte infiltration were decreased in the lungs of PF4-/- mice compared with B6 control mice. Platelet-depleted B6 mice transfused with platelets from PF4-/- mice displayed reduced tissue damage compared with controls. In contrast, transfusion of B6 platelets into platelet depleted PF4-/- mice reconstituted damage in both intestine and lung tissues. We also show that PF4 may modulate the release of IgA. Interestingly, we show that PF4 expression on intestinal epithelial cells is increased after IR at both the mRNA and protein levels. In conclusion, these findings demonstrate that may PF4 represent an important mediator of local and remote tissue damage.

The role of Platelet Factor 4 in local and remote tissue damage in a mouse model of mesenteric ischemia/reperfusion injury (120.18)

The robust inflammatory response that takes place during ischemia reperfusion injury (IR/I) recruits factors from both the innate and adaptive immune system. However the contribution of platelets and their products such as Platelet Factor 4 (PF4; CXCL4), during the pathogenesis of IR/I has not been thoroughly investigated. We show that a deficiency in PF4 protects mice from local and remote tissue damage after 30 minutes of mesenteric ischemia and 3 hours of reperfusion in PF4-/- mice compared to control B6 mice. This protection was independent from Ig or complement deposition in the tissues. However, neutrophil and monocyte infiltration was decreased in the lungs of PF4-/- mice compared with B6 control mice. Platelet-depleted B6 mice transfused with platelets from PF4-/- mice displayed reduced tissue damage compared with controls. In contrast, transfusion of B6 platelets into platelet depleted PF4-/- mice reconstituted damage in both intestine and lung tissue. We also show that PF4 may modulate the release of IgA. Interestingly, we show that PF4 expression on intestinal epithelial cells is increased after ischemia/reperfusion at both the mRNA and protein levels. In conclusion, these findings demonstrate that PF4 represents an important mediator of local and remote tissue damage.

Protective role of R-spondin3 in mesenteric ischemia/reperfusion induced tissue injury (54.11)

Ischemia reperfusion (I/R) injury represents a leading cause of morbidity and mortality. R-spondins, acknowledged as ligands of Wnt pathways, demonstrate their physiological role as mitogens, morphogens, stem cell factors, and wound healing agents in various development and disease models. We asked whether these proteins could prevent inflammation-associated tissue damage in ischemic disorders. C57BL/6J mice were pretreated with vehicle or R-spondin3 (R-spo3) before inducing mesenteric I/R for 30/180 min. At the end of reperfusion, intestinal tissues were harvested for different experimental analysis. Treatment with R-spo3 significantly decreased local intestinal injury. mRNA and protein analyses revealed that this effect was achieved through the modulation of the expression of pro-inflammatory cytokines (IL-6, TNFα and COX2) and deposition of IgM and complement. The decreased levels of IgM on tissues correlated with the reduced vascular leakage in the intestine of R-spo3 treated mice. Further we determined the effect of R-spo3 on endothelial barrier function in vitro using HUVECs and FITC-dextran (500kDa). R-spo3 pretreated groups showed significant reduction in histamine-enhanced FITC-dextran permeability of endothelial monolayer. Our results demonstrate that R-spo3 mitigates I/R-induced local tissue injury by preventing vascular leakage and decreasing the local inflammatory response. These findings confer the protective effects of R-spondin3 in I/R-related tissue damage.

Depletion of gut commensal bacteria attenuates intestinal ischemia/reperfusion injury

Gut commensal bacteria play important roles in the development and homeostasis of intestinal immunity. However, the role of gut commensals in intestinal ischemia/reperfusion (I/R) injury is unclear. To determine the roles of gut commensal bacteria in intestinal IR injury, we depleted gut microbiota with a broad-spectrum antibiotic cocktail and performed mesenteric I/R (M I/R). First, we confirmed that antibiotic treatment completely depleted gut commensal bacteria and diminished the size of secondary lymphoid tissues such as the Peyer's patches. We next found that antibiotic treatment attenuated intestinal injury following M I/R. Depletion of gut commensal bacteria reduced the expression of Toll-like receptor (TLR)2 and TLR4 in the intestine. Both are well-known receptors for gram-positive and -negative bacteria. Decreased expression of TLR2 and TLR4 led to the reduction of inflammatory mediators, such as TNF, IL-6, and cyclooxygenase-2. Intestinal I/R injury is initiated when natural antibodies recognize neo-antigens that are revealed on ischemic cells and activate the complement pathway. Thus we evaluated complement and immunoglobulin (Ig) deposition in the damaged intestine and found that antibiotic treatment decreased the deposition of both C3 and IgM. Interestingly, we also found that the deposition of IgA also increased in the intestine following M I/R compared with control mice and that antibiotic treatment decreased the deposition of IgA in the damaged intestine. These results suggest that depletion of gut commensal bacteria decreases B cells, Igs, and TLR expression in the intestine, inhibits complement activation, and attenuates intestinal inflammation and injury following M I/R.

R-spondins protect from ischemia/reperfusion-induced tissue damage (112.25)

Local and systemic inflammatory responses triggered by ischemia/reperfusion (IR) represent a leading cause of morbidity and mortality in a number of clinical settings including shock and transplantation. R-Spondins play a key role in wound healing and tissue regeneration through the modulation of the wnt pathway. We hypothesized that R-Spondins could prevent tissue injury caused by mesenteric IR by decreasing the local inflammatory response to ischemia. C57BL/6J mice were pretreated with vehicle or R-Spondins before inducing intestinal IR by clamping the superior mesenteric artery for 30 min. After this period of occlusion, the clamps were removed and the intestine was reperfused for 180 min. Intestinal injury was quantified by histologic scoring. Treatment with R-Spondins significantly decreased local intestinal injury. mRNA and protein analyses revealed that this effect was achieved through the modulation of the expression of inflammatory cytokines. Specifically, R-Spondins suppressed the levels of the IR-enhanced IL-6, IL-1β, TNFα, IL-10/CCL2 and CXCL5 cytokines/chemokines. Our results demonstrate that R-Spondins can mitigate the IR-induced local tissue damage induced by decreasing the local inflammatory cytokine response to ischemia and imply that they may be useful in the prevention of IR-related tissue damage.

[Single-stage operation for synchronous bilateral multiple lung cancer through median sternotomy]

An asymptomatic 65-year-old woman was incidentally found to have abnormal shadows on a chest X-ray during a medical examination. A chest computed tomography (CT) scan showed a pulmonary nodule in both right and left lung. Those were diagnosed as synchronous cStage IA bilateral lung cancer, and right upper lobectomy and segmentectomy of the left lung with lymphoadenectomy were sequentially performed through median sternotomy. The patient showed a favorable course after surgery, and was discharged on postoperative day 12. The pathological diagnosis was synchronous lung cancer and both were adenocarcinoma. The pathological stage was IA on the right side and IB on the left. A single-stage operation through median sternotomy was a useful surgical procedure for treating this case of synchronous bilateral lung cancer.

[Bronchoplastic procedures for lung cancer]

Bronchoplastic procedures for patients with lung cancer are designed to achieve radical cure with preservation of functioning lung parenchyma. The operative results of 139 cases of lung cancer who underwent bronchoplasty between 1963 through 2007 were reviewed. The mean age of the patients was 62.5 years (range, 20 to 78 years). Sleeve lobectomy (SL) was performed in 119 cases, wedge lobectomy (WL) in 10 cases, sleeve segmentectomy (SS) in 5 cases, wedge segmentectomy (WS) in 2 cases, sleeve resection (SR) in 2 cases, and wedge resection (WR) in 1 case. Squamous cell carcinoma was the most frequently encountered histological type of disease (78%), followed by adenocarcinoma (12%) and other histological types (10%). The tumor was central in 125 patients (90%) and peripheral with nodal involvement in 14 patients (10%). Vascular resection and reconstruction was performed in 16 patients. Early major bronchial anastomotic complications occurred in 6 patients (4.3%). The 5-year survival rate in the patients with squamous cell carcinoma was 63.2%, and in patients with adenocarcinoma was 26.3%. SS for patients with early-stage squamous cell carcinoma of the segmental bronchus is a curative operation with preservation of the pulmonary function. Bronchoplasty without lung resection (SR, WR) is a reliable method for patients with low-grade malignant polypoid tumors arising from the bronchus. Patients with adenocarcinoma, N2 disease or major bronchial anastomotic complication show a worse prognosis.

Spontaneous occlusion of splenic and renal pseudoaneurysm after blunt abdominal trauma: a case report and literature review

Pseudoaneurysms caused by blunt abdominal trauma are rarely observed in solid organs. The preferred therapy for pseudoaneurysm after blunt abdominal trauma is often angiography and embolization. Here, we report a case of a spontaneous occlusion of splenic pseudoaneurysm and renal pseudoaneurysm after blunt abdominal trauma. Angiography and embolization were not required, and contrast-enhanced multi-detector computed tomography was used to monitor the patient. This case shows that spontaneous occlusion can be one of the possible outcomes of intraparenchymal splenic pseudoaneurysm and renal pseudoaneurysm after blunt abdominal trauma.

Acute Cerebral Blood Flow Variations after Human Cardiac Arrest Assessed by Stable Xenon Enhanced Computed Tomography

In this study, changes in cerebral blood flow (CBF) during acute phase after cardiopulmonary arrest (CPA) were examined in patients using stable Xenon enhanced computed tomography (Xe-CT). All patients (8) were stabilized hemodynamically within 4 hours after admission, and Xe-CT was performed immediately after restoration of spontaneous circulation (ROSC) at 8, 24, 48, 96 and 168 hours after ROSC. The progress of patients was monitored in other hospitals and clinics after discharge. Neurological outcomes were evaluated using the Glasgow outcome scale (GOS) 6 months after admission, and scores were compared against changes in CBF. Patients were grouped by prognosis. Four patients belonged to Group A (good recovery) and Group B (2 severely disabled, 2 in persistent vegetative state). The pattern of change in CBF after ROSC was found to be significantly different between Groups A and B (p <0.05). The CBF ratio relative to normal controls was higher in Group B than Group A within 48 hours after ROSC. However, at 48, 96, and 168 hours after ROSC, the opposite was observed: The CBF ratio was significantly higher in Group A than Group B (p<0.05). Based on these results, we concluded that CBF in the patients who survived after CPA changed remarkable especially within the first week. Furthermore, patients with abnormally low CBF that returns to supernormal within the first 48 hours following CPA can be expected to recover well neurologically.

Enhanced expression of intracellular heme oxygenase-1 in deactivated monocytes from patients with severe systemic inflammatory response syndrome

BACKGROUND

Monocyte deactivation is an important contributor to infectious susceptibility in critically ill patients. However, the mechanism of monocyte deactivation has not been fully elucidated. Recently, intracellular heme oxygenese-1 (HO-1), an anti-inflammatory heat-shock protein, was reported to be activated by Toll-like receptors (TLRs), and to inhibit inflammatory cytokine production such as that of TNF-alpha. In the present study, we evaluated the expression of intracellular HO-1 and TLRs in monocytes from patients with severe systemic inflammatory response syndrome (SIRS) and examined the role of HO-1 in monocyte deactivation.

PATIENTS

Twenty-seven patients who fulfilled the criteria for severe SIRS and had a serum C-reactive protein (CRP) level >10 mg/dL were included in this study. The cause of SIRS was sepsis in 16 patients, trauma in 7, and other in 4. Expression of intracellular HO-1, surface TLR2 and TLR4, and intracellular cytokines (TNF-alpha, Interleukin-6) stimulated via TLR activation were measured in circulating monocytes by flow cytometry. Intracellular HO-1 expression was evaluated in normal monocytes stimulated with patient serum. Serum cytokine levels were also measured. Patient data were compared with data from healthy volunteers (n = 16).

RESULTS

Cytoplasmic HO-1 was clearly detected by fluorescence microscopy. Expression of HO-1, TLR2, and TLR4 in monocytes was significantly enhanced in patients with severe SIRS compared with that in healthy volunteers, whereas intracellular TNF-alpha expression with peptidoglycan was significantly decreased (p < 0.05) in patients compared with that in healthy volunteers. HO-1 expression was significantly enhanced in normal monocytes stimulated with patient serum. Intracellular HO-1 levels were positively related to serum TNF-alpha levels in patients (r = 0.46).

CONCLUSIONS

Expression of intracellular HO-1 and of TLRs was enhanced in deactivated monocytes from patients with SIRS. Increased production of intracellular HO-1 in response to serum factors may play a role in monocyte deactivation after systemic inflammation.

Altered gut flora and environment in patients with severe SIRS

BACKGROUND

The gut is considered an important target organ of injury after severe insult such as sepsis, trauma, and shock. The impact of bacterial translocation or mesenteric lymph on systemic inflammatory response and multiple organ damage has been investigated in animals, but dynamic changes in the gut flora and environment have not been fully clarified in critically ill patients. In the present study, we quantitatively evaluated changes in the gut microflora and environment in patients with severe systemic inflammatory response syndrome (SIRS).

METHODS

Twenty-five patients with severe SIRS, who fulfilled the criteria for SIRS, had a serum CRP level >10 mg/dL, and were treated in the intensive care unit for more than 2 days, were included in our study. SIRS was a result of sepsis in 18 patients, trauma in 6, and burn in 1. A fecal sample was used for quantitative evaluation of microflora (bacterial counts of 10 key groups including Bifidobacterium and Lactobacillus) by plate or tube technique and of the gut environment (pH and 9 organic acids by high speed liquid chromatography). Data obtained from patients were compared with corresponding data from healthy volunteers.

RESULTS

Analysis of fecal flora confirmed that patients with severe SIRS had significantly lower total anaerobic bacterial counts (especially 2-4 log fewer "beneficial" Bifidobacterium and Lactobacillus) and 2 log higher "pathogenic" Staphylococcus and Pseudomonas group counts than those of healthy volunteers. Concentrations of total organic acids (especially "beneficial" short-chain fatty acids such as acetic acid, propionic acid, and butyric acid) in the feces were significantly decreased in the patients, whereas pH was markedly increased.

CONCLUSIONS

The gut flora and environment are significantly altered in patients with severe SIRS. Abnormal gut flora and environment may affect systemic inflammatory response after severe insult.

Changes in Cerebral Blood Flow from the Acute to the Chronic Phase of Severe Head Injury

We studied cerebral blood flow (CBF) in the transition from the acute to the chronic phase of severe head injury in order to determine patterns of change in relation to neurological outcome. We measured CBF with stable xenon-enhanced computed tomography (Xe-CT) in 20 consecutive patients at 1, 2, 3, 4, and 6 weeks after severe head injury, and analyzed the relation between the pattern of change in CBF and neurological outcome at 6 months after injury. CBF values were significantly lower in the brain-injured patients than in 14 healthy volunteers, except at 3 weeks after injury, when CBF increased in the patients to a value that did not differ significantly from that in the normal volunteers. We therefore focused on the change in CBF at 3 weeks after injury. We separated the 20 brain-injured patients into two subgroups, of which the first (subgroup A) consisted of nine patients whose CBF had returned to normal by week 3 post-injury, while the second (subgroup B) consisted of 11 patients whose CBF was subnormal at week 3 post-injury. CBF was significantly higher in subgroup A than in subgroup B at 2 weeks post-injury (p < 0.05). CBF in subgroup B remained significantly lower than that in subgroup A throughout the study period. At 6 months post-injury, subgroup A had a significantly better neurological outcome than did subgroup B (p < 0.05). We conclude that patients whose CBF returns to normal at 2-3 weeks following severe traumatic brain injury after being abnormally low in the acute phase of injury can be expected to achieve a good neurological outcome.

The Balance Between Expression of Intranuclear NF-κB and Glucocorticoid Receptor in Polymorphonuclear Leukocytes in SIRS Patients

BACKGROUND

We previously reported enhanced expression of nuclear factor kappa B (NF-kappaB) in activated polymorphonuclear leukocytes (PMNLs) from patients with systemic inflammatory response syndrome (SIRS). Inflammatory response, however, is not regulated only by stimulatory transcription factors. Glucocorticoid receptor (GR) has been recently reported to play an important role in anti-inflammatory signal transduction. The objective of our study was to evaluate the balance between expression of intranuclear NF-kappaB and GR in PMNLs from SIRS patients.

METHODS

In study 1, 29 patients with severe SIRS, who fulfilled the criteria for SIRS and had a serum C-reactive protein level of more than 10 mg/dL, were included. Expression of intranuclear NF-kappaB and GR in PMNLs was measured by flow cytometry with antibodies specific for NF-kappaB subunit p65 and GR. PMNL oxidative activity and serum cytokine levels were also measured. Study 2 included 13 patients with severe trauma (Injury Severity Score 24.6 +/- 12.2). We measured serial changes in expression of intranuclear NF-kappaB and GR in days 0 to 2, 3 to 6, and 7 to 14 after injury.

RESULTS

In study 1, expression of both intranuclear NF-kappaB and GR in PMNLs was significantly higher in SIRS patients than in healthy controls. There was a strong correlation between expression of these two transcription factors (r = 0.78). Positive correlations were also found between PMNL oxidative activity and both transcription factors. In study 2, expression of both NF-kappaB and GR in PMNLs was markedly elevated on days 3 to 6 after injury and changed serially with strong mutual correlation.

CONCLUSIONS

In activated PMNLs from SIRS patients, levels of both intranuclear NF-kappaB and GR were elevated and strongly correlated. In trauma patients, NF-kappaB and GR in PMNLs changed serially with strong mutual correlation. Further studies are needed to clarify the effect of the balance of NF-kappaB and GR on PMNL activation and systemic inflammatory process.

Early activation of gammadelta T lymphocytes in patients with severe systemic inflammatory response syndrome

Innate immunity plays an important role in host defense after severe insult. gammadelta T lymphocytes are recognized as the first line of defense against microbial invasion. In this study, we evaluated gammadelta T lymphocytes in the peripheral blood of patients with severe systemic inflammatory response syndrome (SIRS), and examined on role of these cells. Thirty-seven patients with severe SIRS (SIRS criteria and serum C-reactive protein > or = 10 mg/dL) and 27 healthy volunteers were studied. Severe SIRS was caused by trauma in 14 patients (Injury Severity Score of 30.1 +/- 10.8) and by sepsis in 23 patients. The counts of gammadelta and alphabeta T lymphocytes were determined by flow cytometry of cells stained with monoclonal antibodies to gammadelta and alphabeta T lymphocyte receptors. The activation of these cells was evaluated by flow cytometry of cells stained with monoclonal antibodies to CD69 and HLA-DR. Serial counts and activation of gammadelta and alphabeta T lymphocytes were also determined in eight trauma patients (Injury Severity Score of 31.0 +/- 13.5) during a 2-week observation period. The count of gammadelta T lymphocytes in the peripheral blood of SIRS patients (30.1 +/- 6.0/microL) was significantly lower (P < 0.05) than that of the healthy volunteers (104.3 +/- 10.9/microL). The expression of CD69, an index of early activation of T lymphocytes, was significantly greater on gammadelta T lymphocytes from SIRS patients (patients 23.9% +/- 3.4%, healthy controls 4.8% +/- 0.6%, P < 0.05). In trauma patients, the expression of CD69 on gammadelta T lymphocytes increased rapidly within 48 h after injuries. In conclusion, gammadelta T lymphocytes are activated and decreased in the peripheral blood of severe SIRS patients. In trauma patients, the activation of gammadelta T lymphocytes occurs in the fairly acute phase after injuries. These results suggest a significant role for gammadelta T lymphocytes as early responders after severe insult.

New Experimental Model of Crush Injury of the Hindlimbs in Rats

BACKGROUND

Crush injury (CI) remains a life-threatening condition. Because there is a shortage of animal models of CI, we purposed to develop a reproducible model of CI of hindlimbs in rats and to evaluate correlation between the volume of muscles traumatized and the severity of CI.

METHODS

The right or both hindlimbs of anesthetized rats were compressed for 6 hours under blocks weighing 3 kg. This was followed by 3 hours of reperfusion. Serum lactate, base excess (BE), and potassium (K) were measured at 10 minutes after cannulaton (baseline), immediately before release (compression), and 3 hours after release (reperfusion). Serum creatine phosphokinase (CK), lactate dehydrogenase (LDH), aspartate transferase (AST) and alanine transferase (ALT) were measured at baseline and reperfusion. Muscles and kidneys were evaluated morphologically. In a separate group of animals treated in the same way, survival rate was monitored for 168 hours.

RESULTS

Unilateral CI did not induce serious systemic impairment. Bilateral CI resulted in severe lactic acidosis. Serum K levels increased similarly and significantly in both groups. Serum CK levels correlated strongly with the volume of muscles traumatized. Bilateral CI produced a sharp increase in serum LDH, AST and ALT levels by the end of experiment. Signs of direct cellular damage and ischemia-reperfusion injury were found in histology specimens. In bilaterally crushed rats there were patent signs of acute tubular necrosis at 24 hours after insult. All rats with unilateral CI survived, whereas mortality rate reached 58.3% in rats with bilateral CI. The majority of these animals died within 24 hours after compression.

CONCLUSIONS

We developed a valid experimental model of severe CI of the hindlimbs in rats. Systemic responses to CI and the severity of CI appeared to correlate strongly with the volume of muscle traumatized.

Hepatocyte Growth Factor in Polymorphonuclear Leukocytes Is Increased in Patients with Systemic Inflammatory Response Syndrome

BACKGROUND

Hepatocyte growth factor (HGF) has a significant effect on the regeneration of epithelial and endothelial cells. Studies have also shown an important role of HGF in wound healing and organ regeneration. Because recent studies indicate that polymorphonuclear leukocytes (PMNLs) store HGF in their specific granules and that HGF can be degranulated in the inflammatory tissue in which activated PMNLs migrate, we evaluated the storage and release of HGF in PMNLs from patients with systemic inflammatory response syndrome (SIRS) and attempted to examine the role of HGF from PMNLs in the systemic inflammatory process.

METHODS

Twenty-four patients with SIRS (serum C-reactive protein, 20.2 +/- 12.4 mg/dL [mean +/- SD]) and 18 healthy volunteers were studied. HGF in PMNLs was measured by flow cytometry by using a monoclonal antibody to HGF. The oxidative activity in PMNLs was also measured by flow cytometry. Serum HGF, interleukin (IL)-6, and IL-8 levels in each patient were measured by enzyme-linked immunosorbent assay. HGF degranulation from PMNLs was evaluated in 10 patients.

RESULTS

Immunocytochemistry under fluorescence microscopy revealed enhanced expression of HGF in the granules of PMNLs. HGF in PMNLs significantly increased in patients with SIRS compared with PMNLs from healthy volunteers (SIRS, 171.0 +/- 6.6 fluorescence/cell; control, 130.7 +/- 3.8 fluorescence/cell). N-formylmethionyl-leucyl-phenylalanine and lipopolysaccharide stimulation induced further increase of HGF fluorescence in PMNLs from patients. HGF degranulation from PMNLs was also significantly enhanced in patients. Moreover, oxidative activity in PMNLs was significantly enhanced in patients with SIRS. Plasma HGF (pHGF) correlated positively with IL-6 and IL-8 levels in patients (pHGF and IL-6, gamma = 0.635, p < 0.05; pHGF and IL-8, gamma = 0.827, p < 0.01), but these values did not correlate with HGF in PMNLs.

CONCLUSION

Activated PMNLs in SIRS patients increased HGF in their granules and demonstrate enhanced degranulation of HGF. The release of HGF from migrated PMNLs in the inflammatory tissue may play an important role in wound healing and organ regeneration under those conditions.

Profile of gene expression in the subventricular zone after traumatic brain injury

Neural stem cells, which reside in the subventricular zone (SVZ) and dentate gyrus (DG) of adult mammals, give rise to new neurons throughout life. However, these neural stem cells do not appear to contribute to regeneration in the damaged central nervous system. Following traumatic brain injury (TBI) in adult rats, the number of proliferating cells labeled with bromodeoxyuridine (BrdU) is significantly increased in the bilateral SVZ and DG; however, these proliferating cells do not contribute to effective regeneration in the damaged area. To gain insight into the molecular mechanisms of these biological actions, changes in gene expression in the SVZ after brain trauma were examined by cDNA microarray. Of 9,596 genes screened, 97 were upregulated and 204 were downregulated. Classifying these genes according to their function suggests that TBI affects a broad range of cellular functions. The validity of the data was confirmed by RT-PCR. The expression of some genes localized in the SVZ was confirmed by in situ hybridization. This combined strategy is effective for comprehensive analysis of the pathophysiological changes in the SVZ after brain injury and should contribute to the understanding of the molecular events that occur after injury. In the future, this may enable regeneration of the damaged central nervous system.

Induction of mRNAs and proteins for Na/K ATPase alpha1 and beta1 subunits following hypoxia/reoxygenation in astrocytes

Characteristics of the cellular response to oxygen deprivation and subsequent reoxygenation (hypoxia/reoxygenation) include redirection of energy metabolism, increased glucose utilization and expression of oxygen-regulated proteins. Inhibition of protein synthesis during early reoxygenation period prevented effective astrocyte adaptation to hypoxia/reoxygenation, resulting in eventual cell death. To elucidate the role of astrocytes in the central nervous system in response to hypoxia/reoxygenation, we analyzed the cDNA library derived from the cultured rat astrocytes subjected to 24 h of hypoxia followed by reoxygenation by differential display, and isolated a cDNA corresponding to Na/K ATPase alpha1 subunit. The expression of Na/K ATPase alpha1 subunit mRNA as well as beta1subunit mRNA was transiently increased after reoxygenation, whereas hypoxia itself did not induce any gene expression change. Na/K ATPase alpha1 subunit protein was transiently increased, whereas the protein expression for Na/K ATPase beta1 subunit showed sustained induction after reoxygenation. Overexpression of beta1 subunit in HEK 293 cells subjected to hypoxia/reoxygenation promoted survival of the cells. These findings suggest that Na/K ATPases may contribute to maintain the cellular environment of astrocytes subjected to hypoxia/reoxygenation.

Successful surgical treatment of a ruptured abdominal aortic aneurysm without homologous blood transfusion in a Jehovah's Witness: report of a case

We report herein the case of a 47-year-old woman of the Jehovah's Witness faith in whom Y-grafting for a ruptured abdominal aortic aneurysm was successfully performed without a homologous blood transfusion. We used a Cell Saver (Haemonetics, Braintree, MA. USA) red cell salvaging device and an aortic occlusion balloon catheter, and performed gentle and minimal dissection during the operation. Postoperatively. the patient was kept heavily sedated and required hypothermic therapy for only 14h. We treated her severe anemia using conventional drugs, including iron and folic acid, and her hemoglobin increased smoothly. Although her hemoglobin level decreased to 2.8g/dl during the operation, her postoperative course was uneventful.

[Pulmonary hyalinizing granuloma with massive infiltration of lymphocytes]

A 39-year-old man was admitted to our hospital for examination of multiple nodules and infiltrates on a chest radiograph. His chest HRCT revealed multiple nodules with or without thick- or thin-walled cavities. Specimens obtained by video-assisted thoracoscopic biopsy showed bundles of hyalinized collagen fibers, some of which contained accumulated plasma cells in the center. The nodules were surrounded by massive lymphoid cells which formed germinal centers. These findings are compatible with pulmonary hyalinizing granuloma. The lymphoid cells looked uniform in some areas and had infiltrated along the bronchioles and small vessels and into the intralobular septa in a manner resembling pulmonary lymphoma or pseudolymphoma. The findings suggested that pulmonary hyalinizing granuloma may overlap pulmonary lymphoma. The disease has shown no progression for four years although no treatment has been given.

[Measurements of cerebral blood flow by the noninvasive microsphere method with 123I-IMP and fan beam collimator: comparison with the continuous arterial blood sampling method]

PURPOSE AND METHODS

The noninvasive microsphere (NIMS) method quantifies cerebral blood flow with N-isopropyl-p-[123I]-iodoamphetamine (123I-IMP) without blood sampling of a patient, but when a fan beam collimator is used for collecting raw data in single photon emission computed tomography (SPECT), the procedure is complicated because we have to change the collimator. In phantom and clinical studies we investigated the validity of using a fan beam collimator in collecting planar and SPECT raw data.

RESULTS

The phantom study suggested that using a fan beam collimator for planar imaging was feasible because of the image magnification rate and the count rate. Mean cerebral blood flow (mCBF) values obtained by the NIMS method with the fan beam collimator were compared with mCBF simultaneously estimated from the conventional continuous arterial blood sampling (microsphere: MS) method in twenty patients with ischemic cerebral vascular diseases. There was good correlation (y = 1.033x + 8.004, r2 = 0.729, p < 0.01) in mCBF between the fan beam NIMS method and the MS method.

CONCLUSION

In conclusion, this method for the measurement of CBF was acceptable for routine clinical studies.

[Total arch replacement following partial replacement of the descending aorta for acute type A aortic dissection: report of a case]

A 42-year-old man was admitted to our hospital due to severe back pain. A computed tomographic scan revealed aortic dissection from the ascending aorta to the left common iliac artery. His blood pressure was well controlled untill he went into shock 21 hours after the onset. He was given a diagnosis of aortic rupture to the left pleural cavity by echocardiography and chest X-ray. He underwent emergent left thoracotomy under femoro-femoral bypass. We found a rupture of the descending aorta 3 cm above the diaphragma and replaced the ruptured segment with a woven Dacron graft. On postoperative day 9, we performed total arch replacement utilizing deep hypothermia and selective cerebral perfusion. We located the entrance tear in the aortic arch. His postoperative course was uneventful and he showed no neurological deficit. He was discharged from the hospital on postoperative day 36.

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.

Successful tracheal transplantation using cryopreserved allografts in a rat model

OBJECTIVES

The purpose of this study was to determine the appropriate cryopreservation period of tracheal allografts based on morphological and immunological findings and to test the possibility of tracheal transplantation in rats using cryopreserved allografts without immunosuppression.

METHODS

Morphological and immunological studies were performed to compare the differences between non-cryopreserved grafts and cryopreserved grafts. Orthotopic tracheal transplantation using cryopreserved allografts, non-cryopreserved allografts, and non-cryopreserved autografts was performed and the rejection score of each group was evaluated.

RESULTS

Epithelial cells were lost when the grafts were cryopreserved for more than 20 days. Immunohistochemical staining of the trachea revealed that the MHC classII antigen was expressed on normal epithelium. These findings suggest that cryopreservation for more than 20 days decreased the antigeneicity of allografts because of epithelial desquamation. All rats that received allografts cryopreserved for more than 20 days survived until the scheduled sacrifice day. Microscopically, cryopreserved allografts that had been preserved for more than 20 days had a significantly lower rejection score than that of non-cryopreserved allografts (P < 0.05).

CONCLUSIONS

We conclude that the appropriate period for cryopreservation of allografts would be 20 days or more, because cryopreservation for more than 20 days depleted epithelium, which possessed the MHC classII antigen. Therefore, a longer period of cryopreservation decreases the antigeneicity of allografts. Rat tracheal transplantations using cryopreserved allografts is possible without immunosuppression when the grafts have been cryopreserved for more than 20 days.

Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis

BACKGROUND

The number of elderly patients who are diagnosed as myasthenia gravis (MG) is increasing in Japan. Although several factors affecting thymectomy have been well documented, few studies have focused on the efficacy and safety of thymectomy for elderly patients older than 60 years.

METHODS

We evaluated 94 patients with MG who underwent extended thymectomy, and divided them into two groups: patients younger than 59 years and patients older than 60 years. Preoperative patient data, pathology of the thymus, complications, and clinical outcome were evaluated.

RESULTS

In 69 young patients and 25 elderly patients, we observed no significant differences between the two groups with regard to preoperative data. Thymic hyperplasia was present in 45% of the young group and 16% of the elderly group. Remission and improvement rate were 40% and 57% in the young group and 8% and 75% in the elderly group, respectively. There were no serious complications, except one early death due to gastrointestinal bleeding in the elderly group.

CONCLUSIONS

We conclude that thymectomy is a safe and effective alternative for elderly patients with MG.

[Two cases of descending necrotizing mediastinitis]

Descending necrotizing mediastinitis (DNM) is relatively rare inflammatory lesion with high mortality unless an appropriate surgical treatment is undertaken. Recently we successfully treated two surgical cases of DNM. In both cases, the disease started with pharyngeal abscess, and the mediastinal swelling followed. The surgery consisted with neck drainage and the mediastinal drainage through thoracotomy at the same time. A continuous mediastinal irrigation was performed postoperatively, and both patients recovered well. Immediate drainage of the primary lesion and the mediastinum is important once the diagnosis of DNM is established.

VATS-stepwise resection of a giant bulla in an oxygen-dependent patient

We report a case of a giant bulla in a 16-year-old boy who was oxygen and wheelchair dependent. He had been diagnosed with Marfan's syndrome and had severe kyphoscoliosis. The giant bulla occupying his entire left thoracic cavity compressed the contralateral lung. Until referral to our hospital, a bullectomy had been deferred during the preceding 5 years because of his poor pulmonary function and severe chest wall deformity. The patient was considered a candidate for thoracoscopic bullectomy. A stepwise resection technique was used. First, the bulla should be emptied by aspiration or wall perforation. Second, the redundant wall of the bulla should be resected by a looped ligation without opening the cavity. Third, a stapled resection of the downsized bulla should be performed. After a successful bullectomy, his subjective symptoms and pulmonary function improved. The reduction of the bulla makes bullectomy easily and decreases the number of staplers, and reduces operating time compared with opening the bulla and suturing it. Therefore, when treating a giant bulla, we recommend a stepwise resection technique.

[Results of surgical treatment in patients with T3 non-small cell lung cancer]

To investigate the prognosis of pathological proven T3N0-1M0 non-small cell lung cancer (NSCLC), 73 patients who underwent pulmonary resection between 1975 and 1993 were reviewed. The 5-year survival rate for all patients was 46.3%. The subject included chest wall invasion in 34 (parietal pleura 17, intercostal muscle or ribs 17), invasion to another lobe in 30, main bronchus involvement less than 2 cm distal to the carina in 12, invasion to pericardium in 6 and invasion to diaphragm in 3. The 5-year survival rates was as follows: chest wall invasion 46.7%, invasion to another lobe 51.7%, main bronchus involvement 41.7%, invasion to pericardium and diaphragm 33.3% respectively. The 5-year survival rate was 58.8% when invasion was limited within parietal pleura, whereas 35.3% when invasion extended outside intercostal muscle. Patients invaded within parietal pleura had better prognosis than that of outside intercostal muscle. In conclusion, good outcome would be expected in patients with T3N0-1M0 non-small cell lung cancer when the invasion limited within parietal pleura.

[Quantitative measurements of regional cerebral blood flow using technetium-99m-L,L-ECD SPECT activated with acetazolamide: fundamental study of measurement's accuracy, comparison with 123I-IMP ARG method]

We measured regional cerebral blood flow before and after acetazolamide administration using a serial noninvasive method with 99mTc-ECD developed by Matsuda and Takeuchi et al., and compared the accuracy of measured values with those obtained by the conventional 123I-IMP ARG method. When the regional cerebral blood flow was measured for 80 brain regions in 5 subjects without scatter correction, a differential of 0.5 +/- 8.4% was obtained between values measured before and after physiological saline administration as a placebo. A differential of -0.2 +/- 12.6% was obtained when the same regions were measured with scatter correction. These findings indicated that placebo administration did not affect measured values, regardless of whether scatter correction was performed. When 64 regions in 4 subjects at rest were measured on two successive days, a differential of -1.1 +/- 9.0% was obtained between the values measured on the two days. A differential of -4.0 +/- 11.7% was obtained for the same regions following acetazolamide administration. These findings showed that measurements were reproducible both when subjects were at rest and when they were administered acetazolamide. The above two methods were used for measurement of 80 brain regions in the same 5 subjects for comparison. Measurements of subjects at rest and with acetazolamide administration were performed on separate days. The regression line y = 0.99x + 1.47, r = 0.80, was obtained for the subjects at rest, and y = 0.86x + 7.76, with r = 0.76, for the subjects following acetazolamide administration. These findings demonstrated a good correlation between the values obtained using the two methods. The values obtained using the method of Matsuda and Takeuchi et al., before and after acetazolamide administration were thus consistent with those reported previously using the conventional method, and the former method proved to be both simple and reliable.

[Malignant fibrous histiocytoma of the chest wall: a case report]

A 74-year-old man was admitted to our hospital with a cough. His chest X-ray film, chest CT scan and MRI showed a tumor of the chest wall. Histology of a percutaneous needle biopsy revealed malignant fibrous histiocytoma (MFH). The tumor enlarged rapidly, and the patient underwent resection including the 6th, 7th and 8th ribs and partial resection of the right diaphragm and the right middle and lower lung lobes. Multiple pulmonary metastases were found 40 days after the operation, and the patient died of respiratory failure 4 months after surgery. Although MFH is one of the most common soft tissue sarcomas, lesions arising from the chest wall are uncommon. We stress the need for early diagnosis and aggressive surgical resection in the treatment of MFH arising from the chest wall.

[A clinicopathological study of 90 children with acute renal failure]

Clinical presentation, laboratory findings, renal biopsy findings and subsequent clinical course were studied retrospectively in 90 children with acute renal failure to intrinsic renal damage. The mean age at presentation was 8.1 years. Diagnosis and number of patients were as follows: Hemolytic uremic syndrome (HUS) in 32 patients, tubulo-interstitial nephritis in 19, idiopathic nephrotic syndrome in 10, IgA nephropathy on 9, membranoproliferative glomerulonephritis in 8, lupus in 5, poststreptococcal glomerulonephritis in 4, cortical necrosis in 1, Henoch Schoenlein purpura nephritis in 1 and anti-neutrophil cytoplasmic antibody associated glomerulonephritis in 1. Thirty-nine patients needed dialysis, but 36 of these were able to stop dialysis, 3 patients with HUS without gastrointestinal symptoms needed chronic dialysis. The mean follow-up period was 7.3 years from onset, and the the latest follow-up 82 patients had normal renal function, 3 showed chronic renal failure, 2 had regular dialysis, 2 had successful renal transplantation, an 1 had died due to heart failure. A poor outcome was associated with diffuse crescents and the presence of severe vascular changes. The early biopsy findings were very useful for the management of children with acute renal failure.

Video-assisted thoracoscopic surgery for spontaneous hemopneumothorax

A 19-year-old man with spontaneous hemopneumothorax, a rare condition, underwent video-assisted thoracoscopic surgery (VATS) on the fourth day after presentation. Evacuation of clot, resection of the bullae, and irrigation of the pleural cavity were performed without difficulty. The indications for VATS for spontaneous hemopneumothorax are discussed.

[Surgical treatment of T4 lung cancer: combined resection of lung and heart or great vessels]

From 1980 to 1995, sixteen patients with T4 lung cancer underwent resection of left atrium (LA) or great vessels combined with pulmonary resection. For eight patients with lung cancer invading LA, LA was resected under simple clamp of LA in seven cases, and under extracorporeal circulation in one case. For three patients with lung cancer invading aorta, resection and reconstruction of aorta was performed under femoro-femoral bypass in one case, and under temporary bypass using a heparin-coated tube in two cases. For five patients with lung cancer invading superior vena cava (SVC), SVC was resected under partial clamp or simple clamp of SVC in each case. In remaining three patients, SVC was resected under internal bypass in one case, and under temporary bypass using a heparin-coated tube in two cases. Three were two operative deaths, one (SVC) died of acute heart failure, and the other (LA) died of acute respiratory distress syndrome. Four patients are alive without recurrence and three of them (one LA and two SVC) have been surviving more than five years after operation.

[Intracavity suction and drainage in a patient with giant bulla accompanied by pneumoconiosis and emphysema: a case report]

A 74-year-old man with giant bulla accompanied by pneumoconiosis and emphysema was treated by intracavity suction and drainage procedure using chemical irritant and fibrin glue. About one month later, the bulla disappeared and the patient symptomatically improved on discharge from hospital. Intracavity suction and drainage is safe and effective treatment of emphysematous bulla in patients considered to be a bad risk for formal thoracotomy.

[Serological assay for diagnosis of verotoxin-producing Escherichia coli (VTEC) infection in the patients with diarrhea]

A total of 239 serum samples from 136 persons were used for bacterial agglutination assay (BA) against predominant three O-antigens of VTEC. All VTEC isolates from stools of 30 patients were only O157:H7 serotype (these patients are called group I). The levels of positive BA antibody titers (over 1:160) to O157-antigen were recognized in each patients as follows. The VTEC isolated patients with HUS or without HUS in group I were all of 13 (100%) and 14 (82.4%) in 17 patients, respectively. And 21 (65.6%) patients of group II (HUS patients with stool negative cultures, or stool cultures were not performed in 32 patients), and 6 (15.0%) patients of group III (family members of group I and II; 40 persons), were also recognized. In group IV (patients with diarrhea due to other pathogen than VTEC; 11 patients), and V (clinically healthy persons; 23 persons), none were recognized as positive BA antibody titers. All patients in the group II except one who had a positive BA antibody titer to O111, were not recognized to O111 and O26. A few VTEC-positive patients without gastrointestinal syndrome did not have significant agglutinating titers to O157-antigen on the days after VTEC isolation. However, almost all patients with diarrhea due to VTEC and HUS, and with VTEC but no HUS, had a level of positive BA antibody titer on the 5 day after onset of diarrhea. These results suggest that this serological assay is a very simple and useful tool for diagnosis of VTEC infection when VTEC are not detected by culture method due to antimicrobial treatment, or due to the lapse of many days after onset of diarrhea.

[Thoracoscopic partial lung resection using staplers and polyglycolic acid (PGA) felts in an 85-year-old patient]

An 85-year-old man was admitted to our hospital with complaints of dyspnea and palpitations. His chest roentgenogram and CT scan showed emphysematous lung and a right pneumothorax with bulla. In cases of emphysematous lung disease, it is well-known that postoperative pulmonary leakage tend to be prolonged, and that control of such leakage is often difficult. A felt-like bioabsorbable prosthesis (polyglycolic acid sheet: NEOVEIL) was used for partial lung resection under thoracoscopic guidance. On each side of the stapler, PGA strips (1 cm wide x 3.5 cm long) were fixed with absorbable sutures. We found that it was difficult to cut with the stapler knife and that the second staple line could not easily cut across the first. However, there was no postoperative air-leakage and his postoperative course was uneventful.

[Four cases of hemolytic uremic syndrome (HUS) associated with serotype O165 verotoxin producing Escherichia coli (VTEC) identified by LPS-solid phase enzyme-linked immunosorbent assay (ELISA)]

Enzyme-linked immunosorbent assay using LPS derived from newly recognized serotype O165 verotoxin producing Escherichia coli (VTEC) could identify 4 cases of hemolytic uremic syndrome (HUS) associated with O165 VTEC. All 4 cases showed a typical clinical course seen in VTEC-associated HUS. We screened 33 cases of HUS whose pathogen was not identified by culture of serodiagnosis. The O165 serotype was not thought to be important not only as a VTEC but also as an enteropathogenic E. coli. However, the prevalence, 4 cases, was as high as of O111 serotype, which is the second major serotype of VTEC in Japan. We have to be careful for this serotype when we look for the pathogen of the patients with hemorrhagic colitis or with HUS.

[Thoracoscopic treatment of a giant bulla: a case report]

A 38-year-old man was admitted to our hospital because of left giant bulla and pneumothorax. His chest X-rays and CT scan showed giant bulla of the left upper lobe and left pneumothorax. We performed bullectomy using the ENDOPATH ENDO LINEAR CUTTER 60 mm and 35 mm disporsable surgical stapler under thoracoscopic guidance. Clipping with end-clips and fibrin glue were effective for miner air leakage. There were no complications such as prolonged air leakage or incomplete lung re-expansion. His post operative couse was uneventful and he was discharged from the hospital on the 11th post operative day. When performed along with mini-thoracotomy, thoracoscopic operation is useful in treating patients with giant bulla.

[Reoperation for recurrent or second primary lung cancer]

From 1975 to July 1994, twenty patients underwent second or third pulmonary resections for 7 recurrent lung cancers and 14 second primary lung cancers. The initial surgical procedures were lobectomy in 18, pneumonectomy in 1 and bilateral segmentectomy in 1. The procedures at the second operation were completion pneumonectomy in 4, ipsilateral wedge resection in 3, contralateral lobectomy in 1, contralateral segmentectomy in 4, contralateral wedge resection in 7 and resection of left main bronchus in 1. At the third operation, wedge resection was done in one 28 months after completion pneumonectomy. There was no operative death following second and third operations. Five-year survival rate following second operation in 20 patients was 32.3%, and it was 28.6% for patients with recurrent lung cancers, and 31.2% for multiple primary lung cancers. In conclusion, an aggressive surgical approach for reappearing lung tumor should be performed. At the reoperation, wedge resection for recurrent lung cancers, completion pneumonectomy for ipsilateral primary lung cancers and segmentectomy for contralateral primary lung cancers should be chosen for the standard surgical procedure.

[Completion pneumonectomy for local recurrence of lung cancer]

Completion pneumonectomy refers to an operation intended to remove what is left of a lung partially resected during a previous operation. The procedure is seldom indicated and the risk of operative mortality and morbidity is higher than standard pneumonectomy. Four patients underwent completion pneumonectomy for recurrence of lung cancer. The first patient had metastatic lesion of hilar lymph nodes more than five years after surgery. The second one had received preoperative radiation therapy and the third had very poor pulmonary function. The last one had underwent pulmonary resections twice during twelve years. Each case was relatively uncommon and gave the difficult surgical problem, but all patients survived the operation and are doing well at present.

[Renal ablation by transcatheter renal arterial embolization in the treatment of benign renal disease]

Renal ablation by transcatheter renal arterial embolization (TAE) was performed in 10 patients with benign renal disease (hydronephrosis n = 6; renovascular hypertension n = 3; nephrotic syndrome n = 1). Each affected kidney had little or no renal function. Six patients with hydronephrosis were treated with TAE using absolute ethanol alone in three patients and the combination of absolute ethanol and gelatin sponge in the other three. Each patient was followed by sclerotherapy of the pelvocalyceal system via nephrostomy using absolute ethanol. In four of the six patients, the embolized kidney had no urine, and there was very little urine in the remaining two. The size of the embolized kidney was markedly decreased on CT. The three patients with renovascular hypertension were pre-studied by selective and renal vein sampling for PRA, and the kidney excreting higher renin was embolized by TAE with absolute ethanol. Blood pressure has become manageable without antihypertensive drug in two patients and with a reduced amount of drug in one. The patient with nephrotic syndrome had end stage renal failure and showed significant protein excretion. To prevent further protein loss, both kidneys were embolized with stainless steel coils. Urine output was significantly decreased, and consequently, hypoalbuminemia improved. All patients tolerated the procedure well, and there were no significant complications. Renal ablation by TAE may be an alternative to surgical treatment in selected patients with benign renal disease, particularly in patients with contraindications to surgery and in the elderly. Absolute ethanol and gelatin sponge seem safe and effective for TAE in patients with hydronephrosis and renovascular hypertension. For hydronephrosis, we recommend combining TAE with sclerotherapy of the pelvocalyceal system via nephrostomy using absolute ethanol. Though we successfully applied steel coil for the patient with nephrotic syndrome, absolute ethanol may be equally effective.

[How extensive should lymph node dissection be done for the surgery of the left lung cancer?]

Mediastinal lymph node dissection for cancer of the left lung is more difficult than for cancer of the right lung because of the presence of aorta. Location and frequency of lymph node metastasis were examined for 231 left lung cancer patients who underwent pulmonary resection and mediastinal lymph node dissection, and survival rate of them was evaluated. Subaortic (# 5), paraaortic (#6), subcarinal (#7), tracheobronchial (#4) lymph nodes were the most frequently involved N 2 nodes. 5-year survival rate of the patients who had #4, #5, #6, #7, #8 or #9 lymph node metastasis was 20.7%. #4, #5, #6, #7, #8 and #9 should be dissected for the surgery of the left lung cancer.

[A five-year survivor of small cell lung carcinoma stage IIIB treated with surgical resection and an adjuvant chemoradiotherapy--a case report]

A 56-year-old woman was admitted to our hospital with the complaint of cough. She had a rt. supraclavicular lymph node swelling, and her chest X-ray showed masses at the rt. hilum and the mediastinum. On bronchofiberscopy, a tumor was detected at the orifice of the lt. B3b, and the biopsy revealed small cell lung cancer (SCLC). With the peroperative diagnosis of stage IIIB SCLC, a neoadjuvant chemotherapy followed by surgical resection was performed. Because of the presence of malignant cells in the pericardial effusion, the operation turned out to be an absolutely non-curative one. As the recurrence of mediastinal lymph node swelling occurred after the surgery, an intensive chemoradiotherapy was performed successfully. Then the patient has been free from disease for five years. This case indicates the possibility that some of SCLC patients can be long-term survivors by the treatment of an appropriate adjuvant therapy combined with radical resection, even if the clinical stage is advanced. Therefore an extended operative indication for SCLC should be considered.

[Results of surgery for pT4 lung cancer]

During 1977 and 1991, 54 patients with lung cancer underwent surgery at Niigata University Hospital and were diagnosed with pathological T4. The survival rate of these pT4 patients was 32.5% at 3 years and 24.4% at 5 years. There was no significant difference between the survival rates of those with squamous cell carcinoma and those with adenocarcinoma. 5-year survival rate of 20 patients with N0 disease and 23 patients with N2 disease was 43.0% and 13.0%, respectively (p < 0.05). 5-year survival rate of 21 patients with organ invasion alone, 21 with dissemination or malignant effusion alone, and 12 with organ invasion plus dissemination or malignant effusion was 22.5%, 28.6% and 0%, respectively; there was no significant differences between these rates. Seven patients survived over 5 years; however, there were no obvious common factors. An aggressive surgical approach is indicated for T4 lung cancer, not only in patients with N0 disease but also in those with organ invasion alone or small amounts of malignant effusion alone.

[A case of quadricuspid aortic valve associated with mitral regurgitation]

A case of a 60-year-old man associated with quadricuspid aortic valve and mitral regurgitation is reported. The aortic valve consisted of three larger cusps and a small accessory cusp situated between the right and the non-coronary cusps. The aortic regurgitation resulted from malcoaptation of the four cusps and the mitral regurgitation resulted from annulus dilatation and thickening of the anterior leaflet. The surgical treatment was performed successfully by the aortic and mitral valve replacements with St. Jude Medical valves. The patient is doing well fifteen months postoperatively. Sixteen Japanese cases of quadricuspid aortic valve which were corrected surgically are reviewed.

Incomplete interlobar fissures: bronchovascular analysis with CT

Thin-section computed tomographic scans of both lungs in 154 patients, including seven cadavers, with lung cancer (n = 37), diffuse (n = 32) or inflammatory (n = 30) lung disease, other proved or suspected disease (n = 23), or healthy lungs (n = 32) were analyzed to determine the frequency of incomplete interlobar fissure (IIF). An IIF was defined as a discontinuous linear shadow that remained in contact with the chest wall. An IIF was found in 128 of 154 right lungs (83.1%) and 77 of 154 left lungs (50.0%). Some bronchovascular structures crossed or passed through two contiguous lobes in the fused area. The most common bronchovascular structure associated with an IIF was a pulmonary vein; this association was found in 87 right lungs (56.5%) and 20 left lungs (13.0%). An IIF was traversed by a pulmonary artery in only seven right lungs and 13 left lungs or by a bronchus in only three lungs. It is concluded that recognition of an IIF might improve understanding of the spread of pulmonary disease.