[Death due to pulmonary tuberculosis--a comparison between 1984-88 and 1989-93]

Pulmonary tuberculosis (TB) remains the single leading cause of death from any single infectious agent in the world. We reviewed the case records and chest radiographs of patients with pulmonary tuberculosis who died between 1984 and 1993. Of 2333 patients discharged from National Nishi-Niigata Hospital, 86 (3.7%) died during that period. Comparison between the data for 1984-88 and for 1989-93 showed an increase in the number of elderly patients, TB-related deaths, and complication of TB by malignancy. Thirty-nine of the 86 patients died within 2 months of admission: a spread of TB over a wide region and low performance scores were noted in these patients. Multiple-drug-resistant Mycobacterium tuberculosis was often the cause of death. These results encourage us to pursue early detection in elderly people, to improve management during initial treatment such as with steroids, and to develop new and more effective drugs to treat TB.

Increased plasma level of platelet-activating factor (PAF) and decreased serum PAF acetylhydrolase (PAFAH) activity in adults with bronchial asthma

We evaluated the plasma level of platelet-activating factor (PAF), a chemical mediator that induces various symptoms of bronchial asthma, and the activity of serum PAF acetylhydrolase (PAFAH), an enzyme that specifically inactivates PAF, in adults with bronchial asthma. Measurements were made by radioimmunoassay of samples obtained from 137 adult asthmatic patients (137 cases examined in remission and from among these 41 cases were also measured at the time of an asthmatic attack) 59 adult patients with untreated pulmonary tuberculosis and 106 healthy adult volunteers. It was demonstrated that the plasma PAF level was markedly higher and the serum PAFAH activity markedly lower in the asthmatic patients, both in remission and at the time of asthmatic attack, than in the healthy volunteers. The plasma PAF level was more closely associated with asthma both in remission and at the time of asthmatic attack than with pulmonary tuberculosis, whereas there was no significant difference in the serum PAFAH activity between the two diseases. The low serum PAFAH activity in the asthmatic patients may have been due to saturation as a result of continuous reaction to the increased plasma PAF level in those patients.

[Questionnaire survey on "The guidelines on diagnosis and treatment of asthma" edited by the Japanese Society of Allergology (1993)]

A questionnaire on the evaluation of "The Guidelines on Diagnosis and Management of Asthma" edited by the Japanese Society of Allergology in 1993 was sent to 586 physicians consisting of specialists authorized by the Japanese Society of Allergology and the board members of this Society, who treated patients with bronchial asthma. Of total 306 (52.2%) who responded, 177 (57.8%) answered the questions on adult asthma only, 65 (21.2%) on childhood asthma only and 52 (17.9%) on both adult and childhood asthma. In total, we had 229 respondents on adult asthma and 117 on childhood asthma. As a result, on drug therapy for chronic asthma, it was pointed out that the use of oral anti-allergics, oral steroids and inhaled beta-stimulants was excessive whereas the use of DSCG, inhaled steroids and long acting theophylline was slightly insufficient in both adults and children. On the management of acute episodes, the excessive use of beta-stimulants (inhaled, oral and injections) and the lack of the use of parenteral steroids and oxygen inhalation were pointed out in adults. The lack of oxygen inhalation also got a higher percent in children. Nevertheless, the guidelines were found to be highly regarded as a whole: "Very good" was 6.1% in adults (6.8% in children). "Appropriate" 38.0% (33.3%), "Almost appropriate" 52.0% (52.1%) and "Inappropriate" 3.9% (3.4%).

[Identification of Mycobacterium avium and Mycobacterium intracellulare using DNA probe test, and their ratio in Niigata area]

Using Gen-Probe test, both the Mycobacterium avium and Mycobacterium intracellulare strains were identified in the 76 disease-associated Mycobacterium-avium complex (MAC) strains isolated in the NIIGATA area. The following results were obtained: 1) Fifty-four MAC strains (71.1%) reacted with M. avium-probe and 22 strains (28.9%) reacted with M. intracellulare-probe. 2) There were no significant differences between the ratio of two strains before and after 1991. 3) The ratio of female cases with M. avium was significantly higher (22/32) in the later period (after 1991) than in the former period (9/22).

Spontaneous hemopneumothorax with aberrant vessels found to be the source of bleeding: report of two cases

We report herein our experience of two cases of spontaneous hemopneumothorax in which the source of bleeding was found to be aberrant vessels. Both patients were successfully treated by early thoracotomy. Case 1 was a 23-year-old female in whom chest X-ray revealed an air-fluid line and a bulla with a narrow restiform shadow connecting the pleural cupola. Angiography clearly visualized aberrant vessels branching from the costocervical trunk, distributed in and around the bulla in the apex of the lung, being the possible source of bleeding. These aberrant vessels were confirmed at surgery and resected. Case 2 was a 56-year-old male who underwent thoracotomy for persistent bleeding. At surgery, a continuously bleeding vessel from the pleural cupola was seen and ligated. The remnant of the vessel was located in the apex of the lung, and resected with the bulla. Thus, the rare entity of a congenital aberrant vessel lying concealed as a possible source of bleeding should be borne in mind.

[Increased plasma levels of platelet-activating factor (PAF) and low serum PAF acetylhydrolase (PAFAH) activity in adult patients with bronchial asthma]

We studied the relationship between the blood levels of platelet-activating factor (PAF) and the activity of serum PAF acetylhydrolase (PAFAH), an enzyme that inactivates PAF, in adult patients with bronchial asthma. The PAF levels in the blood and the PAFAH activity in the serum obtained from adult patients with bronchial asthma in remission (137 cases) and from healthy adult controls (106 cases) were determined by radioimmunoassay (RIA) and compared. The following results were obtained. 1. The plasma levels of PAF were significantly higher in the patients with bronchial asthma in all severity groups (mild, moderate, and severe) and all asthma types (atopic, mixed, and infectious) than in the healthy controls (p < 0.001). However, no significant differences associated with the severity and type of asthma were noted. 2. Serum PAFAH activity was significantly lower in the patients with bronchial asthma in all severity groups (mild, moderate, and severe) and asthma types (atopic, mixed, and infectious) than in the healthy controls (p < 0.001). However, no significant differences associated with the severity and type of asthma were noted. 3. PAF/PAFAH in the patients with bronchial asthma showed no significant difference associated with the severity and type of asthma. 4. There was not a significant correlation between plasma levels of PAF and serum PAFAH activity in the patients with bronchial asthma. It was, therefore, suggested that the significantly high plasma PAF levels and the significantly low serum PAFAH activity in asthmatic adults compared to the respective values in healthy controls may explain one of the mechanisms of the development and persistency of adult bronchial asthma.

[Studies on HLA typing in a family line with spontaneous pneumothorax]

Our patient with spontaneous pneumothorax is the oldest brother of 3 siblings. Pneumothorax had occurred in his younger sister and in 3 of his mother's 4 siblings also. Namely, pneumothorax had occurred in 5 (including our patient) of 7 persons, family line on mother's side, and thoracotomy had been performed in 3 of them. Two cases in which operative findings were obtained were introduced. Next, HLA and alpha 1-antitrypsin (alpha 1-AT) were determined in this family line. As the result, the alpha 1-AT all remained in the normal range and HLA typing was not in a special relation to the occurrence of pneumothorax in this family line.

[The influence of serum theophylline concentration on the bronchodilating effect of salbutamol inhalation for bronchial asthma]

To examine the effects of serum theophylline concentration on the bronchodilating effect of beta 2-stimulant inhalated by patients with bronchial asthma, 200 micrograms-Salbutamol inhalation test was performed on 30 patients with bronchial asthma (from 17 to 71 years old, averaging 49.7; 3 mild, 15 moderate, 12 severe), who had taken theophylline at various oral doses up to 6 hours before the test. Measurements of respiratory function, serum theophylline concentration, blood pressure, pulse rate and the plasma c-AMP and c-GMP concentrations before and one hour after inhalation revealed that inhalation of 200 micrograms salbutamol significantly increased FVC, FEV1.0, PEF and plasma c-AMP (p less than 0.001). No significant change was noted in plasma c-GMP, diastolic pressure or pulse rate. Systolic pressure significantly decreased (p less than 0.05). Furthermore, no significant correlation was noted between the rates of increase (%) in FVC, FEV1.0 and PEF and those in plasma c-AMP, c-GMP and c-AMP/c-GMP in one hour after inhalation. Inaddlition no significant correlation was noted between the rates of increase in FVC, FEV1.0 and PEF one hour after inhalation and serum theophylline concentrations (0-19.3 and 0-21.5 micrograms/ml before and one hour after inhalation, respectively). The above results suggest that the bronchodilating effect of salbutamol inhalated at dose of 200 micrograms is not influenced by the serum theophylline concentration both before and at one hour after inhalation of salbutamol. The bronchodilating effect of salbutamol seems to be ascribable to an increase of intracellular c-AMP level of bronchial smooth muscle.

[Chondrosarcoma of the ribs: report of two cases]

Chondrosarcoma of rib origin is relatively rare in Japan. Two patients with chondrosarcoma of rib origin were treated surgically. Case 1: A 79-year-old male, 4 years ago, he noticed a tumor in the left anteroinferior part of the chest. The histological examination of the specimen obtained by incisional biopsy showed osteochondroma in another hospital and he had been under observation. Since the tumor has recently increased in size, he was referred to our department. Radical resection of the chest wall was performed. As expected, the tumor was found to be a secondary chondrosarcoma by postoperative histological examination. Case 2: A 49-year-old female. In the follow up studies after radical nephrectomy, Tc-MDP scintigram revealed an accumulation in the left second rib. Under the diagnosis of rib metastasis, radical resection was performed. The histological examination showed chondrosarcoma of rib origin postoperatively. This lesion was a primary central type, and is considered to have been resected in the earliest stage of all cases we have found in the Japanese literature.

[Angiographic findings in a patient with spontaneous hemopneumothorax]

We experienced one patient with spontaneous hemopneumothorax in whom angiography was performed preoperatively. The patient was a 23-year-old female and her plain chest X-ray revealed an index-finger-tip-sized bulla at the left apex and a narrow restiform shadow connecting the pleural cupola with the bulla. Left subclavian arteriography revealed preoperatively that the restiform shadow consisted of aberrant vessels branched from the left costocervical trunk and distributed in and around the bulla at the apex. In the present study very rare angiographic findings and excised specimens obtained from the patient are shown, with reference to surgical indication of spontaneous pneumothorax.

[Traumatic diaphragmatic hernia]

Five cases of traumatic diaphragmatic hernia were reported and 495 cases reported in Japan were reviewed. Analysis of cases of hernia following blunt trauma in the present study provided a simple classification of fissure of the diaphragm, i.e., "tension type (indirect type)" and "impact type (direct type)". In the former type, the fissure occurs in the central tendon or its vicinity in the diaphragm as a result of distortion of the bony thorax without direct force on the diaphragm, while in the latter type, the fissure occurs in the diaphragm close to the struck bony thorax as a result of blunt force on the bony thorax to which the diaphragm is attached.