[Emphysematous pyelonephritis and cystitis concurrence; A case report]

We report a case of emphysematous pyelonephritis coexisting with emphysematous cystitis. A 57-year-old woman seen for abdominal pain, diarrhea, and high fever had been referred after computed tomography (CT) elsewhere had shown an air density mass in the left kidney and pelvis. Abdominal CT on admission showed emphysematous change in the left renal parenchyma and intramural bladder. Serum analysis results showed disseminated intravascular coagulation (DIC) and uncontrolled diabetes. Klebsiella pneumoniae was isolated in the blood. She was diagnosed with sepsis based on these findings due to concurrent emphysematous pyelonephritis and cystitis caused by K. pneumoniae. She was treated conservatively with meropenem, intravenous immunoglobulin, and gabexate mesilate and cured. Concurrent emphysematous cystitis and pyelonephritis is rare., with ours only the fourth case reported in Japan.

[Resistance to vecuronium induced muscle relaxation in a patient with mental retardation receiving phenytoin for chronic anticonvulsant therapy]

A 36-year-old woman weighing 31.7 kg with mental retardation was scheduled for dental treatment under general anesthesia. She had undergone anticonvulsant therapy (phenytoin, clonazepam, zonisamide) for years. Standard monitors and bispectral index (BIS) monitor were applied except for an accelomyography. Anesthesia was induced with propofol and vecuronium, and maintained with nitrous oxide in oxygen, with 1.5-2.0% end-tidal concentration of sevoflurane. Forty minutes after induction of anesthesia, spontaneous respiration (SR) started suddenly despite adequate depth of anesthesia (BIS value 35-40). Vecuronium 1 mg was administered and SR stopped immediately. After the event, however, SR started repeatedly and then additional vecuronium was administered every 30-40 minutes to stop SR until the end of the treatment. During the treatment, no factors (hypercapnia, hypoxemia, hyperthermia and so on) to shorten the muscle relaxation were observed. The treatment finished uneventfully She became awake rapidly and extubated. Post-extubation period was also uneventful. In this case, chronic phenytoin therapy induced resistance to vecuronium was highly suspected; however, since clonazepam and zonisamide have elevation effects on blood concentration of phenytoin, they might be also cofactors in resistance to vecuronium. Therefore, patients undergoing chronic anticonvulsant therapy should be paid more attention because they have resistance to neuromuscular blocking drugs.

[One-week effects of Tamsulosin on benign prostatic hyperplasia assessed with a daily symptom score]

The early effects of Tamsulosin within one week of administration on lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH) were investigated. Patients with newly diagnosed BPH were randomized into a Tamsulosin group and a Eviprostat group. Changes in subjective symptoms daily for 7 days after the start of administration and in the 4th week (8 times in total) were evaluated using seven symptoms in the International Prostate Symptom Score (IPSS) and the quality of life (QOL) index entered in a self-scoring diary kept by the patients daily. In the Tamsulosin group, the IPSS total score showed significant improvements. Significant improvements were observed in the incomplete emptying and frequency scores from the day after the start of administration, in the intermittence and straining scores from day 2, in the urgency and weak stream scores from day 3 and in the nocturia score from day 5. The QOL index significantly improved on day 7. In comparison with Eviprostat, Tamsulosin showed a stronger improvement tendency in the total IPSS, voiding symptoms score and incomplete emptying score and the difference was significant. The difference between the two groups was especially marked for the intermittence and weak stream scores and Tamsulosin showed significantly better early effects. Tamsulosin also showed significantly better early effects than Eviprostat in the QOL index. In conclusion, it was clear that Tamsulosin caused significant improvement in lower urinary tract symptoms associated with BPH as a whole from a very early stage within one week after administration.

Novel cardiac precursor-like cells from human menstrual blood-derived mesenchymal cells

Stem cell therapy can help repair damaged heart tissue. Yet many of the suitable cells currently identified for human use are difficult to obtain and involve invasive procedures. In our search for novel stem cells with a higher cardiomyogenic potential than those available from bone marrow, we discovered that potent cardiac precursor-like cells can be harvested from human menstrual blood. This represents a new, noninvasive, and potent source of cardiac stem cell therapeutic material. We demonstrate that menstrual blood-derived mesenchymal cells (MMCs) began beating spontaneously after induction, exhibiting cardiomyocyte-specific action potentials. Cardiac troponin-I-positive cardiomyocytes accounted for 27%-32% of the MMCs in vitro. The MMCs proliferated, on average, 28 generations without affecting cardiomyogenic transdifferentiation ability, and expressed mRNA of GATA-4 before cardiomyogenic induction. Hypothesizing that the majority of cardiomyogenic cells in MMCs originated from detached uterine endometrial glands, we established monoclonal endometrial gland-derived mesenchymal cells (EMCs), 76%-97% of which transdifferentiated into cardiac cells in vitro. Both EMCs and MMCs were positive for CD29, CD105 and negative for CD34, CD45. EMCs engrafted onto a recipient's heart using a novel 3-dimensional EMC cell sheet manipulation transdifferentiated into cardiac tissue layer in vivo. Transplanted MMCs also significantly restored impaired cardiac function, decreasing the myocardial infarction (MI) area in the nude rat model, with tissue of MMC-derived cardiomyocytes observed in the MI area in vivo. Thus, MMCs appear to be a potential novel, easily accessible source of material for cardiac stem cell-based therapy.

[Airway access using an endotracheal tube changer for safe extubation in an infant with a difficult airway]

We present a case where airway access was maintained using an endotracheal tube changer (ETC) after extubation in an infant with a difficult airway. A 4-month-old male infant with bilateral cleft lip and palate, micrognathia, schizencephaly, undescended testis, and abnormality of chromosomes 10 was scheduled for bilateral cleft lip repair. After anesthesia induction with thiamylal and vecuronium, we found that laryngoscopy was difficult (Cormack and Lehane grade III) despite external laryngeal compression. Since there was no fiberoptic bronchoscopy for an infant in our department, and the fact that epiglottis could be visualized with external laryngeal compression, three anesthesiologists attempted tracheal intubation in turn and intubation was successful at last. The surgery was concluded uneventfully; but since endotracheal intubation had been difficult, special care was taken for extubation. We used an ETC for tracheal tube passing into the endotracheal tube at the time of extubation. Although using the ETC in infant with difficult airway for extubation remains controversial, we believe that for a difficult airway, even in an infant, a flexible ETC is a useful device for temporal airway access after extubation.

[Resistance to vecuronium bromide induced muscle relaxation in a patient with chronic renal failure and secondary hyperparathyroidism]

We report resistance to vecuronium bromide (Vb) induced muscle relaxation for general anesthesia in a patient with chronic renal failure (CRF) and secondary hyperparathyroidism (HPT). An 81-year-old man (body weight : 52 kg) diagnosed with bladder carcinoma was scheduled for a total cystectomy. In the operating room, standard monitors were applied except for a nerve stimulator. After epidural catheter had been secured, anesthesia was induced with propofol 80 mg and Vb 5 mg. In spite of administration of these drugs and supplying 5% sevoflurane for 4 minutes, spontaneous respiration was observed. Then, propofol 50 mg and Vb 3 mg were added and lidocaine aerosol 8% was sprayed topically to oropharyngolaryngeal structures. No movement of the vocal cord was observed through the laryngoscope and the patient was intubated smoothly, but the patient did cough and move a little. The surgery was concluded uneventfully. Although the total amount of Vb administration was 14 mg in 3 hr anesthesia time, he was awake rapidly and extubated sooner than expected. We suspect that resistance to Vb has been caused in part by secondary HPT and it appears necessary to take care when administering Vb in CRF patients with secondary HPT, especially at the induction of general anesthesia.

Anesthetic management of laparoscopic adjustable gastric banding in Japanese patients with morbid obesity

Laparoscopic adjustable gastric banding (LAGB) is a common type of bariatric surgery worldwide, though not so in Japan. Here we report the anesthetic management of LAGB in ten Japanese patients with morbid obesity. General anesthesia was induced with propofol, fentanyl, and vecuronium bromide and maintained with sevoflurane in oxygen and air (or nitrous oxide in some cases). In a limited number of patients, perioperative epidural analgesia was performed, with fentanyl injected intravenously for analgesia in the remaining patients. Although some special considerations were needed, in perioperative management, including thromboprophylaxis, there were no severe complications in any of the patients.

Effects of high peak airway pressure on the expression of heat shock protein 70 in rat lungs: a preliminary study

BACKGROUND

Heat shock protein 70 (HSP70) is induced by a wide variety of stresses in addition to hyperthermia. Recent studies have clarified that mechanical stretching and pressure overload can induce HSP70 in some tissues and cells. However, it remains unclear whether HSP70 is induced in stretch-subjected lungs, such as those under mechanical ventilation. This study was designed to investigate the effects of high peak airway pressure (PAP) ventilation on HSP70 expression in intact rat lungs.

METHODS

Male Sprague-Dawley rats were randomly allocated to one of three groups: non-ventilated (anesthesia alone) control group; PAP 15 cm H(2)O group (P15); and PAP 30 cm H(2)O group (P30). The rats in the PAP groups were subjected to pressure-controlled assisted ventilation at the appropriate PAP for 30 min. Rats were killed at 12, 24 and 48 h after ventilation or anesthesia alone, and the lungs were removed. The lung tissues were processed for immunohistochemical and Western blotting analyses of HSP70.

RESULTS

Following 30 min of pressure-controlled assisted ventilation, HSP70 expression in the P30 group was significantly up-regulated in bronchiolar cells and subepithelial tissues at 12 h, and this up-regulation continued throughout the observation period. In contrast, there were no significant differences between the control and P15 groups, although the expression of HSP70 was higher in the P15 group than in the control group at all time points.

CONCLUSIONS

HSP70 was induced by high PAP ventilation, but its specific role and induction mechanism remain unclear. Therefore, further investigations should be encouraged.

Pulsatile cardiac tissue grafts using a novel three-dimensional cell sheet manipulation technique functionally integrates with the host heart, in vivo

We devised a method of fabricating easily transplantable scaffoldless 3D heart tissue, made with a novel cell-sheet (CS) technology from cultured cardiomyocytes using a fibrin polymer coated dish. In the present study, we tested in vivo electrical communication which is essential for improving heart function between the host heart and the grafted CS. The epicardial surface of the ventricle of an anesthetized open-chest nude rat was ablated by applying a heated metal. Bilayered CS was obtained from neonatal rat primary culture. CS was transplanted onto the injured myocardial surface (sMI) (sMI+sheet group). The rats were allowed to recover for 1 to 4 weeks, to stabilize the grafts. Action potentials (APs) from the excised perfused heart were monitored by the fluorescence signal of di-4ANEPPS with a high speed charge-coupled device camera. The APs were observed under epicardial pacing of the host heart or the CS grafts. The pacing threshold of the current output was measured in the sMI+sheet group and in the nongrafted sMI group at the center of the sMI and in the normal zone (Nz). Bidirectional AP propagation between the sMI and Nz was observed in the sMI+sheet group (n=14), but was blocked at the marginal area of the sMI in the sMI group (n=9). The ratio of the pacing threshold (sMI/Nz) was significantly lower in the sMI+sheet than in the sMI group (3.0+/-0.7, 19.0+/-6.1 respectively P<0.05). There were neither spontaneous nor pacing-induced arrhythmias in these two groups. Bidirectional smooth AP propagation between the host heart and the grafted CS was observed. This finding suggested functional integration of this CS graft with the host heart without serious arrhythmia.

Mild hypothermia reduces expression of intercellular adhesion molecule-1 (ICAM-1) and the accumulation of neutrophils after acid-induced lung injury in the rat

BACKGROUND

The pathophysiology of the acute phase of acid-induced lung injury (AILI) has been elucidated. However, once acute respiratory distress syndrome (ARDS) develops, the mortality rate remains high and there is, as yet, no effective therapy. There are reports that application of mild hypothermia is an effective treatment for ARDS. In this study, we hypothesize that mild hypothermia inhibits activation of neutrophils and expression of intercellular adhesion molecule-1 (ICAM-1) in an injured lung. We studied the effects of mild hypothermia on the expression of ICAM-1 and the accumulation of neutrophils after AILI in the rat.

METHODS

Male Sprague-Dawley rats were randomly allocated to one of the four groups: control normothermic group, induced mild hypothermia group, acid-instilled normothermic group, and acid-instilled group with mild hypothermia. At 6 h after instillation of acid, lungs were removed to measure neutrophil activity and to detect the expression of ICAM-1 in each group.

RESULTS

Oxygenation in acid-instilled rats was significantly impaired as compared to that in non-instilled groups, but induction of mild hypothermia gradually improved oxygenation. Expression of ICAM-1 was enhanced in the acid-instilled normothermic group. By contrast, no overexpression of ICAM-1 and its mRNA was detected in the acid-instilled hypothermic group. In addition, accumulation of neutrophils was markedly inhibited after exposure to mild hypothermia irrespective of the instillation of acid.

CONCLUSION

Our data suggest mild hypothermia can inhibit the adhesion, activation, and accumulation of neutrophils during the acute phase of AILI in the rat and may have the potential to reduce ongoing inflammation of ALI or ARDS.

Effects of acute moderate exercise on the phagocytosis of Kupffer cells in rats

AIM

This study investigated the function of Kupffer cells, and particularly their role as immunocompetent cells that come into contact with gut-derived endotoxin, in the acute exercise of rats.

METHODS

Female Fischer 344 rats were run on a treadmill at 21 m min(-1) for 60 min on a 15% grade.

RESULTS

Afterwards, the number of latex particles in the liver was higher in the exercising rats than that in resting rats and an increase in the number of latex particles phagocytosed by each Kupffer cell was noted. The plasma endotoxin concentration was significantly higher in the exercise group than in the resting rats, and the small intestine was damaged by the exercise. Plasma corticosterone and thyroxine 4 levels were unchanged. Although the number of Kupffer cells was unchanged by acute exercise, the number of CD14-positive Kupffer cells increased. Plasma liver enzyme activities were slightly increased by acute exercise, whereas plasma tumour necrosis factor-alpha was not detected.

CONCLUSION

These results suggest that moderately intense exercise increases the phagocytosis of Kupffer cells, and that it might be induced by endotoxemia of portal blood caused by intestinal mucosal lesions resulting from acute exercise.

Changes in serum leptin concentrations in overweight Japanese men after exercise

AIM

To investigate the link between serum leptin concentrations and exercise.

DESIGN

Cross-sectional and longitudinal studies of an exercise intervention.

SUBJECTS

110 Japanese overweight men aged 32-59 years were recruited. At baseline, the average body mass index (BMI) was 28.5 +/- 2.5 kg/m2. From this group, we used data of 36 overweight men (BMI, 28.9 +/- 2.3) for a 1-year exercise programme.

MEASUREMENTS

Leptin was measured at baseline and after 1 year. Fat distribution was evaluated by visceral fat (V) and subcutaneous fat (S) areas measured with computed tomography (CT) scanning at umbilical levels. Anthropometric parameters, aerobic exercise level, muscle strength and flexibility were also investigated at baseline and after 1 year.

RESULTS

In the first analysis, using cross-sectional data, leptin was significantly correlated with total body fat (r = 0.760, p < 0.01), V (r = 0.383, p < 0.01) and S (r = 0.617, p < 0.01) areas. In the second analysis, using longitudinal data, leptin was significantly reduced after 1 year (pre 6.7 +/- 4.0 ng/ml vs. post 5.1 +/- 3.1 ng/ml, p < 0.01). Results showed that steps per day were increased, and aerobic exercise level, weight-bearing index (WBI) and insulin resistance were significantly improved. Although, there was a positive correlation between Delta leptin(positive changes in leptin after 1 year) and anthropometric measurements such as Delta body weight, Delta BMI and Delta body fat, leptin/body weight, leptin/BMI and leptin/body fat ratios were significantly reduced during exercise intervention.

CONCLUSION

The present study indicated exercise significantly lowers serum leptin concentrations, and thus it may improve the leptin resistance observed in overweight Japanese men.

Olprinone improves diaphragmatic contractility and fatigability during abdominal sepsis in a rat model

BACKGROUND

Respiratory failure with diaphragmatic fatigability is common in patients suffering sepsis or septic shock. However, the development and progress of diaphragmatic fatigability remains poorly understood, and no method has been established to treat fatigability. In this study, we hypothesize that neutrophil activation contributes to the development of diaphragmatic fatigability. We also sought to investigate whether a phosphodiesterase inhibitor, olprinone, improves diaphragmatic fatigability associated with abdominal sepsis and inhibits an increase in myeloperoxidase activity in diaphragmatic muscle.

METHODS

Male Wistar rats were randomly assigned to a sham group, coecal legation perforation group (CLP), and a phosphodiesterase inhibitor (PDE) pretreated group. At 16 h after surgical procedure, the left hemidiaphragm was removed for the measurement of diaphragmatic contractility and fatigability. In addition, for the measurement of serial changes in myeloperoxidase activity, the right hemidiaphragm was also removed at 4, 8 or 16 h after the surgical procedure in each group.

RESULTS

In a septic model involving rats, we observed that diaphragmatic muscles were fatigable and myeloperoxidase activity increased. We also demonstrated that intraperitoneal administration of olprinone improves diaphragmatic fatigability and inhibits an increase in myeloperoxidase activity induced by abdominal sepsis.

CONCLUSION

Olprinone represents a potential therapy for cases of respiratory failure with diaphragmatic fatigability resulting from inhibition of neutrophil activation.

Serum bFGF levels are reduced in Japanese overweight men and restored by a 6-month exercise education

OBJECTIVE

To investigate whether the changes in vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) concentrations before and after weight reduction in Japanese overweight men are associated with changes in body mass index (BMI), visceral, subcutaneous fat, VO(2) and work rate (WR) at ventilatory threshold (VT).

DESIGN

Cross-sectional and longitudinal clinical intervention study with exercise education.

SUBJECTS

In total, 30 Japanese overweight men (BMI, 29.0+/-2.2 kg/m(2)) and 31 normal-weight men (BMI, 22.5+/-1.6 kg/m(2)) at baseline were enrolled: 30 overweight men (BMI, 29.0+/-2.2 kg/m(2)) were further enrolled into a 6-month exercise program.

MEASUREMENTS

Fat distribution evaluated by visceral fat (V) and subcutaneous fat (S) areas measured with computed tomography scanning at umbilical levels, angiogenic peptides including VEGF and bFGF, exercise tests at baseline and after 6 months.

RESULTS

In normal-weight and overweight subjects at baseline, VEGF positively correlated with S area (r=0.350, P=0.007) but not with V area. In contrast, bFGF negatively correlated with BMI (r=-0.619, P<0.001), S (r=-0.457, P<0.001) and V areas (r=-0.466, P<0.001). By intervention with exercise education, 30 overweight subjects showed reduction in BMI (29.0+/-2.2 to 28.0+/-2.0, P<0.001), V and S areas, increase in VO(2) and WR at VT, increase in bFGF (9.21+/-5.82-21.2+/-7.04 ng/ml, P<0.001), and no change in VEGF (1.45+/-0.72-1.88+/-0.52 ng/ml, P=0.016). The stepwise multiple regression analysis revealed that DeltaBMI (beta=-6.052) and DeltaVO(2) (beta=2.806) were independently related to DeltabFGF (P<0.001) and all other variables including DeltaS area, and DeltaV area, and DeltaWR did not enter the equation at significant levels.

CONCLUSION

The present study indicated a negative correlation between serum bFGF levels and BMI at baseline as well as an association of DeltaBMI and DeltaVO(2) with DeltabFGF after exercise intervention. The exercise-induced elevation of bFGF may be beneficial in the prevention of the atherosclerosis in overweight subjects.

Relationship between reduced serum IGF-I levels and accumulation of visceral fat in Japanese men

OBJECTIVE

To investigate whether the changes in IGF-I concentrations after weight reduction in Japanese overweight men are associated with changes in visceral and subcutaneous fat.

DESIGN

Cross-sectional and longitudinal clinical intervention study with exercise education.

SUBJECTS

One-hundred and twelve Japanese overweight men aged 30-59 y (body mass index (BMI) 28.4+/-2.5 kg/m(2)) and 33 normal-weight men aged 30-39 y (BMI 22.1+/-1.5 kg/m(2)) at baseline. From the participants, 56 randomly selected overweight men (BMI 28.8+/-2.8) were further enrolled into a 1 y exercise program.

MEASUREMENTS

Fat distribution was evaluated by visceral fat (V) and subcutaneous fat (S) areas measured with computed tomography scanning at umbilical levels, metabolic parameters and hormones including insulin, leptin and IGF-I at baseline and after 1 y.

RESULTS

In 112 overweight subjects at baseline, insulin (10.5+/-5.0 microU/ml) and leptin (6.4+/-3.7 ng/ml) significantly correlated with both V (r=0.260, P=0.0073; r=0.410, P<0.0001) and S areas (r=0.377, P<0.0001; r=0.613, P<0.0001), respectively. IGF-I (156.8+/-48.7 microU/ml) significantly and negatively correlated with V area (r=-0.242, P=0.0125) and age (r=-0.192, P=0.0480). In normal-weight men aged 30-39 y (n=33) and age-matched subjects (n=30) selected from the 112 overweight men, the serum IGF-I further tightly correlated with V area (r=-0.467, P<0.0001). Visceral fat area and age were independently related to serum IGF-I levels by multiple regression analysis. By intervention with exercise education, 56 overweight subjects showed an increase in daily steps (6224+/-2781 to 7898+/-4141 steps/day) and reduction of BMI (28.8+/-2.8 to 27.7+/-2.9). deltaIGF-I significantly correlated with deltaV area (r=-0.432, P=0.0009) but not with DeltaS area or deltaBMI.

CONCLUSION

The present study indicated a negative correlation between IGF-I levels and visceral fat at baseline as well as an association between the reduction in visceral fat and increase in IGF-I levels after an exercise intervention.

cDNA cloning and expression of mutant catalase from the hypocatalasemic mouse: comparison with the acatalasemic mutant

Mutant catalase cDNAs from the hypocatalasemic and acatalasemic mice were cloned and expressed in bacteria. A novel missense mutation, Asp (AAT) to Ser (AGT), was identified at amino acid position 439 of the hypocatalasemic catalase. Analysis of recombinant catalase mutants revealed that the mutation is responsible for the reduced activity of hypocatalasemic catalase and the unstable tetrameric structure of acatalasemic catalase was also suggested.

Lead content of brain tissue in diffuse neurofibrillary tangles with calcification (DNTC): the possibility of lead neurotoxicity

Diffuse neurofibrillary tangles with calcification (DNTC) is a form of presenile dementia, characterized pathologically by fronto-temporal atrophy with neurofibrillary tangles (NFTs), neuropil threads and Fahr-type calcification, in which no senile plaques are observed. As already noted, chronic exposure to lead (Pb) might be one of the etiological factors of Fahr-type calcification. Until now, there have been no reports in which Pb concentration has been quantified in DNTC brains. We examined the concentration of Pb in fresh-frozen brain tissue and in 10% formalin-fixed brain tissue from six cases of DNTC, four cases of Alzheimer's disease, and in nine non-demented elderly controls by flameless atomic absorption spectrometry, and demonstrated a high concentration of Pb in DNTC brains. Although it remains unclear how these findings are related to the formation of NFTs, they suggest that Pb neurotoxicity may be involved in the pathogenesis of DNTC.

Longitudinal follow-up study of 11 patients with pulmonary lymphangioleiomyomatosis: diverse clinical courses of LAM allow some patients to be treated without anti-hormone therapy

OBJECTIVE

The purpose of this study is to clarify the existing issues on the clinical diversity, natural history, and mode of disease progression of pulmonary lymphangioleiomyomatosis (LAM).

METHODOLOGY

Eleven patients with LAM were reviewed retrospectively with special reference to serial changes in pulmonary function and radiological findings during the course of their disease, treatment, and outcome. All patients were female with a mean age of 33.8 years at presentation and the observation period ranged from 2.1 to 20.8 years (mean 7.4 years).

RESULTS

Four of six patients, treated with anti-hormone therapy, presented with exertional dyspnoea, marked airflow limitation (forced expiratory volume in 1 s/forced vital capacity, 23-38%), and severely impaired diffusing capacity (%DLCO, 21.4-36% of the predicted). The remaining two patients showed only a decreased diffusing capacity (70.6% and 59.4% of the predicted) which rapidly deteriorated with subsequent development of airflow limitation. Repeated chest computed tomographic (CT) examinations revealed increasing numbers of cysts with simultaneous loss of normal lung parenchyma in these two patients. In contrast, the five patients who received no anti-hormone therapy had no respiratory symptoms aside from pneumothorax at onset. Remarkable differences were noted, with pulmonary function being well maintained and slow progression of cystic changes on CT being observed in the latter group.

CONCLUSIONS

Diverse clinical courses observed in patients with pulmonary LAM can be well delineated and assessed by periodic examinations including pulmonary function tests and chest CT imaging. Anti-hormone therapy is not always necessary for a certain group of LAM patients and they appear to have a stable course and favourable outcomes without anti-hormone treatment.