A case of Guillain-Barré syndrome developed minimal change nephrotic syndrome simultaneously

A case who developed Guillain-Barré syndrome (GBS) and nephrotic syndrome (NS) simultaneously is reported. In this case, the onset of nephrotic change of proteinuria coincided with the development of the neurological disturbance. Analysis of renal biopsy by light, immunofluorescent and electron microscopy showed minor glomerular abnormalities. The occurrence of GBS in association with NS is rare, and moreover most cases in the previous reports had membranous nephropathy. Only 1 case had minimal change nephrotic syndrome (MCNS). To our knowledge, this is the first report of a case beneficially treated with glucocorticoids, suggesting that immune disorder may play an important role in the association between MCNS and GBS.

Circulating interleukin-6 significantly correlates to thyroid hormone in acute myocardial infarction but not in chronic heart failure

To investigate relationships between thyroid states and the cardiac endocrine system, we analyzed thyrotropin (TSH), thyroid hormone, plasma levels of interleukin-6 (IL-6) and brain natriuretic peptide (BNP) in 50 patients with chronic heart failure (CHF), in 30 patients with heart failure from acute myocardial infarction (AMI), and in 15 controls. Plasma levels of IL-6 and BNP in both CHF and AMI were significantly elevated, while free triiodothyronine (FT3) was significantly decreased compared to controls. FT3/free thyroxine (FT4) ratio was significantly decreased in CHF but not in AMI compared to controls. In CHF, diuretic treatment diminished circulating BNP but not IL-6, while diuretic treatment increased FT3/FT4 ratio. In AMI, FT3/FT4 ratio was significantly decreased 72 h compared to 12 h after the onset of AMI, while BNP and IL-6 were significantly increased 72 h compared to 12 h after the onset of AMI. In both CHF and AMI, BNP significantly correlated with FT4. On the other hand, significant correlations between IL-6 and FT3, and between IL-6 and FT3/FT4 ratio were detected in AMI but not in CHF. This preliminary study suggests that IL-6, BNP and thyroid hormone reflect ventricular dysfunction in both acute and chronic heart failure, and that IL-6 significantly relates to circulating thyroid hormone in AMI but not in CHF.

Moderate-intensity regular exercise decreases serum tumor necrosis factor-alpha and HbA1c levels in healthy women

OBJECTIVE

To evaluate the effects of moderate-intensity regular exercise on serum levels of tumor necrosis factor-alpha (TNF-alpha) and glucose and lipid metabolism parameters.

DESIGN

Longitudinal intervention study of a 5 month exercise training program (30-45 min/day, 4-5 days/week).

SUBJECTS

Forty-one healthy Japanese women aged 41-69 y at baseline; 27 participants in the exercise program.

MEASUREMENTS

Body mass index (BMI), waist-to-hip ratio (WHR), percentage body fat, and fasting levels for serum TNF-alpha, serum soluble TNF receptor p55 (TNF-RI) and TNF receptor p75 (TNF-RII), serum lipids, HbA1c, and serum insulin before and after exercise.

RESULTS

In overweight to obese subjects, serum levels of TNF-alpha, TNF-RI and TNF-RII were significantly higher than those in lean subjects. There were significant correlations between log serum TNF-alpha and BMI, percentage body fat, WHR, HbA1c and log insulin. TNF-RI was significantly correlated with BMI, percentage body fat, WHR and HbA1c. TNF-RII was also associated with BMI, percentage body fat and WHR. However, the correlation between TNF-RII and HbA1c did not reach statistical significance. Neither TNF-RI nor TNF-RII was correlated with log insulin. In contrast, TNF-alpha, TNF-RI and TNF-RII were negatively correlated with HDL cholesterol. Regular exercise decreased BMI, percentage body fat, HbA1c, serum TNF-alpha, TNF-RI and TNF-RII and increased HDL cholesterol levels. In addition, exercise-induced change in serum TNF-alpha was independently correlated with changes in HbA1c and serum insulin, after being adjusted for the change in fat-free mass.

CONCLUSION

Changes in serum TNF-alpha that occur with exercise may play an important role in improving glucose metabolism parameters.

Apoptotic cell death in steroid induced osteonecrosis: an experimental study in rabbits

OBJECTIVE

We investigated apoptosis, i.e., programmed cell death, in steroid induced osteonecrosis in a rabbit model.

METHODS

Forty-four adult Japanese White rabbits were divided into 3 groups: Group A were untreated controls and had a subsequent 8 week no-treatment period; Group B received intramuscular injection of methylprednisolone 4 mg/kg once weekly for 4 weeks; and Group C received the same treatment and had a subsequent 8 week no-treatment period. At the end of each period, all animals were sacrificed and tissue samples were obtained from the femur and humerus for histopathologic examination. Terminal deoxynucleotidyl transferase (TdT) mediated deoxyuridine triphosphate (dUTP) biotin nick end labeling (TUNEL) was used to detect fragmented DNA known to be associated with apoptotic cell death.

RESULTS

Group A rabbits did not develop osteonecrosis-like lesions (ONL) in the femur and humerus, and few TUNEL positive cells were observed in bone marrow cells. In Group B, ONL developed in 11/15 rabbits, and many TUNEL positive cells were found in the area surrounding ONL. In Group C, ONL were found in 6/10 rabbits, but only a few TUNEL positive cells were present around the lesion.

CONCLUSION

These findings revealed that apoptosis occurs in the early stage of steroid induced osteonecrosis.

Autoantigen-specific CD4+CD28low T cell subset prevents autoimmune exocrinopathy in murine Sjögren's syndrome

Organ-specific autoimmune exocrinopathy resembling Sjögren's syndrome (SS) that spontaneously develops in NFS/sld mutant mice thymectomized 3 day after birth is dependent on Th1-type CD4+ T cells. We previously reported that a cleavage product of 120-kDa alpha-fodrin may be an important autoantigen in the pathogenesis of SS in both an animal model and the patients. We demonstrate that in an animal model of SS with overt exocrinopathy, a unique CD4+ T cell subset expressing CD28low is dramatically increased in spleen cells before the disease onset, but that the CD4+ T cells of diseased mice were virtually all CD28high. We found that the spleen cells in these mice before the disease onset showed a significant increase in autoantigen-specific T cell proliferation. Analysis of in vitro cytokine production by spleen cells indicated, before the disease onset, severely impaired production of IL-2 and IFN-gamma in the animal model, whereas high levels of IL-4 were observed. Expression of cytokine genes, including IL-4, IL-10, and TGF-beta, was detected in FACS-sorted CD4+CD28low T cells by RT-PCR analysis. Transfer of CD4+CD28low T cells into the animal model actually prevented the development of autoimmune lesions including autoantibody production. These results suggest that a CD4+CD28low T cell subset that is continuously activated by an organ-specific autoantigen may play a regulatory role in the development of organ-specific autoimmune disease in an animal model of SS.

Interleukin-1beta alters the oxygen delivery-oxygen consumption relationship in rabbits by increasing the slope of the supply-independent line

When systemic oxygen delivery (DO2) is reduced, oxygen consumption (VO2) is maintained until a critical level is reached (DO2crit). Sepsis is thought to shift DO2crit to the right and lengthen the supply-dependent portion. We tested the effect of interleukin (IL)-1beta, which is one of the key cytokines related to sepsis, on the DO2-VO2 relationship. Fifteen rabbits were subjected to stepwise cardiac tamponade to reduce DO2 to 10% by inflating a handmade balloon placed into the pericardial sac. Seven rabbits were given 10 microg/kg of IL-1beta intravenously (IL-1beta group) prior to the graded cardiac tamponade. The remainder received saline alone (control group). The DO2-VO2 relationship was analyzed by the dual-line method. IL-1beta significantly decreased mean arterial pressure (65 +/- 11 mmHg from baseline 85 +/- 7 mmHg) without altering cardiac output. The IL-1beta group showed significantly steeper supply-independent line slopes than did the control group (0.19 +/- 0.02 vs. 0.11 +/- 0.02, respectively), which resulted in a DO2crit shift to the left (IL-1beta group, 8.7 +/- 1.7 ml/kg x min vs. control, 11.7 +/- 0.7 ml/kg x min). The IL-1beta group also showed greater PO2 and plasma lactate levels in the portal vein than did the control group. These results indicate that IL-1beta impairs systemic oxygen uptake even before VO2 becomes supply-dependent, presumably due to maldistribution of the blood flow including the splanchnic circulation.

4-(3-Chloro-4-methoxybenzyl)aminophthalazines: synthesis and inhibitory activity toward phosphodiesterase 5

We synthesized various 4-(3-chloro-4-methoxybenzyl)aminophthalazines substituted at the 1- and 6-positions and evaluated their inhibitory activity toward phosphodiesterase 5 (PDE5) and their vasorelaxant activity in isolated porcine coronary arteries precontracted with prostaglandin F2alpha (10(-5) M). The preferred substituents at the 1-position of the phthalazine were 4-hydroxypiperidino, 4-hydroxymethylpiperidino, 4-(2-hydroxyethyl)piperidino, and 4-oxopiperidino. Among these compounds, [4-(3-chloro-4-methoxybenzyl)amino-1-(4-hydroxy)piperidino]-6-phthala zinecarbonitrile monohydrochloride (13) exhibited potent PDE5 inhibitory activity (IC(50) = 0.56 nM) with >1700-fold high selectivity over other PDE isozymes (PDE1-4). Compound 13 exhibited the most potent vasorelaxant action (EC(50) = 13 nM) in this series of compounds. Compound 13 reduced mean pulmonary arterial pressure by 29.9 +/- 3.1% when administered intravenously at 30 microg/kg to the chronically hypoxic rats and had an apparent oral bioavailability of about 19.5% in rats and was selected for further biological evaluation.

Time to recover from atrial hormonal, mechanical, and electrical dysfunction after successful electrical cardioversion of persistent atrial fibrillation

Although transient atrial dysfunction has been reported after electrical cardioversion of atrial fibrillation (AF), the difference in the time to recover from the atrial hormonal, mechanical, and electrical dysfunction has not been described. Thus, we evaluated the time course of recovery from atrial hormonal, mechanical, and electrical dysfunction after cardioversion in patients with nonvalvular AF. We attempted electrical cardioversion in 87 consecutive patients with nonvalvular AF that had persisted for > or =6 months, and in 24 patients (28%) with maintained sinus rhythm for > or =6 months. To evaluate atrial hormonal, mechanical, and electrical dysfunction in these 24 patients, we measured plasma concentration of atrial natriuretic peptide, the atrial peak velocity in transmitral flow, and the ratio of peak systolic-to-diastolic pulmonary venous flow (S/D ratio) using echocardiography, and the duration and the root mean voltage for the terminal 20 ms (LP20) of the filtered P wave using P-wave signal-averaged electrocardiography. Atrial natriuretic peptide rapidly returned to baseline within 1 day after cardioversion, and maintained these levels for 6 months. Atrial peak velocity in transmitral flow and S/D ratio were significantly increased at 2 weeks, and continued to increase until 1 month, and then reached a plateau. The duration and LP20 began to recover only 6 months after cardioversion. One to 3 years after conversion, the duration and LP20 had nearly reached a plateau, but the latter value remained below normal. In patients with nonvalvular AF of prolonged duration, recovery from atrial electrical dysfunction after sinus conversion took much longer than that from either atrial hormonal or mechanical dysfunction.

Age-related association of MHC class I chain-related gene A (MICA) with type 1 (insulin-dependent) diabetes mellitus

To assess the contribution of the HLA class I region to susceptibility to and heterogeneity of type 1 diabetes, we investigated the association of polymorphism of MHC class I chain-related gene A (MICA) with age-at-onset as well as susceptibility to type 1 diabetes. One hundred one Japanese patients and 110 healthy control subjects were studied. The frequency of A4 allele was significantly higher and that of A6 allele was significantly lower in patients than in control subjects. The frequency of A5.1 allele was highest in early-onset patients (23.0%), intermediate in intermediate-onset patients (9.2%) and lowest in late-onset patients (7.7%) (trend chi-squared test, p = 0.0098). A5. 1 allele was strongly associated with HLA-B7 and Cw7, suggesting that MICA*A5.1-B7-Cw7 haplotype contains a gene responsible for age-at-onset. A4 allele was associated with a susceptible haplotype, DR4-DQB1*0401, and A6 allele was associated with a protective haplotype, DR2-DQB1*0601, suggesting that the association of MICA with type 1 diabetes susceptibility may be due to linkage disequilibrium with class II haplotypes. These data suggest that MICA gene is associated with age-at-onset and that a gene (or genes) responsible for age-at-onset of type 1 diabetes is located in the HLA class I region, probably near the region of MICA-B-C.

Cerebral blood flow during plateau waves in a patient with benign intracranial hypertension--case report

A 50-year-old male presented with benign intracranial hypertension (BIH). He was admitted to our hospital for headache and papilledema. The diagnosis was BIH as continuous monitoring of lumbar cerebrospinal fluid pressure (CSFP) showed high basal pressure with intermittent plateau waves. Ten months after successful ventriculoperitoneal shunting, he presented with headache again due to shunt malfunction. CSFP monitoring showed the same findings as before. Regional cerebral blood flow (rCBF) was measured by positron emission tomography (PET) using the 15O-labeled water autoradiographic method with simultaneous recording of lumbar CSFP. The rCBF values of the cerebral cortex, white matter, thalamus, cerebellar cortex, and pons were evaluated during both the plateau waves and the intervals. In spite of severely reduced cerebral perfusion pressure, rCBF during the plateau waves was not reduced when compared with the rCBF of normal volunteers in all regions. This result might explain why patients with BIH show no impairment of consciousness or focal signs during the plateau waves.

Fusion of the nucleoporin gene, NUP98, and the putative RNA helicase gene, DDX10, by inversion 11 (p15q22) chromosome translocation in a patient with etoposide-related myelodysplastic syndrome

We report a 50-year-old man who developed therapy-related myelodysplastic syndrome after treatment with etoposide-including chemotherapy for extratesticular germ cell tumor. Chromosomal analysis showed inversion 11 (p15q22) translocation. Reverse transcriptase-polymerase chain reaction amplification of patient RNA showed a fusion transcript of nucleoporin gene NUP98, and putative DEAD-box RNA helicase gene DDX10. NUP98 is implicated in the transformation through aberrant nucleocytoplasmic transport. DDX10 is suggested to be involved in ribosome assembly. The NUP98-DDX10 fusion transcript may promote the development of secondary hematological malignancies caused by DNA-topoisomerase II inhibitors through aberrant nucleocytoplasmic transport and/or alteration in ribosome assembly.

Difference in the responses after administration of granulocyte colony-stimulating factor in septic patients with relative neutropenia

OBJECTIVE

The objective of this study was to classify the clinical responses after administration of granulocyte colony-stimulating factor (G-CSF) in septic patients with relative neutropenia.

PATIENTS AND METHODS

We administered recombinant human G-CSF (2 microg/kg) subcutaneously once a day for 5 days to 30 septic patients with white cell counts below 5,000 cells/mm3. Absolute neutrophil count (ANC), neutrophil differentiation, and serum concentration of G-CSF were determined serially. Bone marrow also was analyzed before and after treatment.

RESULTS

Neutrophil responses to G-CSF varied from good (ANC > 10,000/mm3, group G, n = 20) to moderate (ANC < 10,000/mm3, group M, n = 5) to poor (no increase in ANC, group P, n = 5). Before G-CSF administration, the three groups showed no differences in ANC but did show significant differences in serum concentration of G-CSF. G-CSF concentration was 0.16 +/- 0.03 ng/mL in group G, 7.0 +/- 3.0 ng/mL in group M, and 270 +/- 90 ng/mL in group P. Immature neutrophils accounted for 35.0 +/- 3.7% of peripheral leukocytes in group P but only 5.1 +/- 0.6% in group G. Although bone marrow was depressed in all groups before G-CSF treatment, nucleated cell count increased significantly after rhG-CSF treatment in groups G and M. Survival rate after 4 weeks was 90% in group G and 100% in group M; no patient in group P survived.

CONCLUSION

G-CSF administration was effective in septic patients with a low percentage of immature neutrophils and insufficient endogenous G-CSF. It had little effect on patients with a high percentage of immature neutrophils whose G-CSF production was up-regulated and whose bone marrow was severely depressed.

Long-term estrogen replacement therapy is associated with improved exercise capacity in postmenopausal women without known coronary artery disease

BACKGROUND

Short-term estrogen administration improves vasodilation and has been shown to improve exercise capacity. However, it is unknown whether long-term estrogen replacement therapy is associated with improved exercise capacity in postmenopausal women without known coronary artery disease.

METHODS AND RESULTS

We studied 248 postmenopausal women without known coronary artery disease (mean age 63.5 years); 158 (64%) were current or past hormone replacement therapy (HRT) users and 108 (44%) were current users of HRT. Attributes potentially affecting exercise capacity and cardiac risk factors were carefully measured. These included duration of estrogen replacement therapy, all variables in the Framingham risk index, physical activity level, body mass index, waist-to-hip ratio, presence of osteoporosis, and family history of heart disease. We measured maximal oxygen uptake (MVO (2)) and anaerobic threshold as objective markers of exercise capacity. The relation between exercise capacity and use of HRT was analyzed with the use of logistic regression, controlling for confounding variables. We found that fitness, as measured by MVO (2) and anaerobic threshold, was significantly greater in women who had used HRT currently or in the past compared with women who had never used HRT. This difference in fitness was not confounded by age or physical activity level.

CONCLUSIONS

Estrogen replacement therapy is associated with increased exercise capacity as measured by MVO (2) and anaerobic threshold in postmenopausal women without coronary artery disease. This finding is consistent with the beneficial effect of short-term estrogen administration on improved endothelium-dependent and endothelium-independent vasodilation.

Treatment with anti-CD86 costimulatory molecule prevents the autoimmune lesions in murine Sjögren's syndrome (SS) through up-regulated Th2 response

Intraperitoneal administration with anti-CD86 (B7.2) MoAb into the murine model for primary SS in NFS/sld mutant mice resulted in dramatically inhibitory effects on the development of autoimmune lesions, while no significant effects were observed when the mice were administered with anti-CD80 (B7.1) MoAb. We found that spleen cells in the murine SS model treated with anti-CD86 MoAb showed a significant impairment of autoantigen-specific T cell proliferation. T cell activation markers (CD44high, CD45RBlow, Mel-14low) were significantly down-regulated in the spleen cells gated on CD4 in anti-CD86-treated mice. We detected a higher level of cytokine production of IL-4 from splenic T cells in anti-CD86-treated mice, but not of IL-2, and interferon-gamma (IFN-gamma), compared with those in the anti-CD80- and PBS-treated SS model. Moreover, serum autoantibody production against alpha-fodrin autoantigen was almost entirely suppressed in anti-CD86-treated mice. These data provide strong evidence that in autoimmune exocrinopathy resembling SS in NFS/sld mutant mice, the CD86 costimulatory molecule plays a crucial role in the initiation and subsequent progression of Th1-mediated autoimmunity in the salivary and lacrimal glands.

Lack of association of lipoprotein(a) levels with coronary calcium deposits in asymptomatic postmenopausal women

OBJECTIVES

This study sought to determine the relationship of lipoprotein(a) (Lp(a)) and other cardiac risk factors to coronary atherosclerosis as measured by calcification of coronary arteries in asymptomatic postmenopausal women.

BACKGROUND

Lipoprotein(a) is considered a risk factor for coronary heart disease. Coronary calcium deposition is believed to be a useful noninvasive marker of coronary atherosclerosis in women. However, to our knowledge, there are no reports of the relationship of Lp(a) to coronary calcium in postmenopausal women.

METHODS

In 178 asymptomatic postmenopausal women (64 +/- 8 years), we measured Lp(a) and other cardiac risk factors: age, hypertension, diabetes, low-density lipoprotein cholesterol, smoking status, body mass index, physical activity level and duration of hormone replacement therapy. Electron-beam computed tomography was done to measure coronary calcium (calcium score). We analyzed the relationship between calcium score and cardiac risk factors using multivariate analysis.

RESULTS

Although calcium score correlated with traditional risk factors of age, diabetes, hypertension and smoking, it did not correlate with Lp(a) in the asymptomatic postmenopausal women. Similar multivariate analyses were done in the subjects age >60 years and in the subjects with significant coronary calcium deposit (calcium score > or =50). These analyses also have failed to show an association of levels of Lp(a) with coronary calcium deposits.

CONCLUSIONS

We conclude that in asymptomatic postmenopausal women, Lp(a) levels do not correlate with coronary atherosclerosis as measured by coronary calcium deposits.

Cystic lymphangioma: its orofacial manifestations

A patient age five years, nine months with cystic lymphangioma was studied to determine the causes of malocclusion and the optimum time for its treatment. The main findings were unilateral anterior and posterior crossbite and displacement of the mandibular midline due to maxillary deformity and mandibular rotation. The force of the cystic lymphangioma mass caused deformity of the maxilla and rotation of the mandible. The patient had no functional impairment of speech or mastication. A decision was made to defer treatment of malocclusion until complete surgical excision of the cystic lymphangioma can be undertaken, thereby minimizing the chance of malocclusion re-occurrence.

E-4010, a selective phosphodiesterase 5 inhibitor, attenuates hypoxic pulmonary hypertension in rats

The purpose of this study was to determine whether E-4010, a newly synthesized potent and selective orally active phosphodiesterase (PDE) 5 inhibitor, would prevent the development of chronic hypoxia-induced pulmonary hypertension in rats. In conscious, pulmonary hypertensive rats, a single oral administration of E-4010 (1.0 mg/kg) caused an acute, long-lasting reduction in mean pulmonary arterial pressure (PAP), with no significant effects on systemic arterial pressure, cardiac output, and heart rate. In rats that received food containing 0.01 or 0.1% E-4010 during the 3-wk exposure to hypoxia, mean PAP was significantly decreased (mean PAP 24.0 +/- 0.9, 16.2 +/- 0.8, and 12.8 +/- 0.5 mmHg in rats treated with 0, 0.01, and 0.1% E-4010-containing food, respectively), whereas mean systemic arterial pressure was unchanged and cardiac output was slightly increased compared with chronically hypoxic control rats. Right ventricular hypertrophy, medial wall thickness in pulmonary arteries corresponding to the respiratory and terminal bronchioles, and the degree of muscularization of more distal arteries were less severe in E-4010-treated rats. Long-term treatment with E-4010 caused an increase in cGMP levels in lung tissue and plasma but not in aortic tissue and no significant change in cAMP levels in either lung, aorta, or plasma. These results suggest that long-term oral treatment with E-4010 reduced the increase in PAP, right ventricular hypertrophy, and pulmonary arterial remodeling induced by exposure to chronic hypoxia, probably through increasing cGMP levels in the pulmonary vascular smooth muscle.

Evaluation of contrast agents for delineation of vessel wall boundary by intracoronary ultrasound after coronary angioplasty in human

We evaluated the potential for improving visualization at intervention sites using contrast-enhanced intracoronary ultrasound (ICUS) and the suitable contrast agents for this procedure in humans. In 37 patients, ICUS (30 MHz) was performed with intracoronary bolus injection (3 mL) of seven different contrast preparations and without the contrast agents (control) after coronary intervention. The contrast agents used were as follows: saline solution, standard iomeprol, standard ioxaglate, sonicated iomeprol, sonicated ioxaglate, 50% Albunex, and 100% Albunex. Homogeneous and complete opacification of the vessel lumen and false lumen was observed with sonicated ioxaglate, 50% and 100% Albunex. Shadowing was not observed at all with sonicated ioxaglate and was uncommon with 50% Albunex, whereas 100% Albunex caused shadowing in all cases. The coronary delineation rate with the other contrast agents was only 60%-70%, and the homogeneity and peak intensity were relatively low. Thus, sonicated ioxaglate and 50% Albunex both achieved good visualization, but the latter is more expensive, more difficult to handle, and takes longer to prepare. Of the agents we studied, sonicated ioxaglate appears to be best suited for contrast-enhanced ICUS. ICUS using suitable contrast agents could only visualize the large dissections and the strategy was changed according to the contrast-enhanced ICUS results in five cases. Thus, suitable contrast agents, e.g., sonicated ioxaglate, should be used during ICUS after intracoronary intervention.

Interactive fusion of three-dimensional images of upper abdominal CT and FDG PET with no body surface markers

The aim of this study was to propose and validate a new method of making fused images from CT and FDG PET images for the upper abdominal area with no body surface marker. PET and CT were carried out in patients with pancreatic cancer (N = 5) and mass-forming pancreatitis (N = 2). First, we determined the midsagittal plane from PET and CT data. From the difference in location of the midsagittal planes, rotations of Y (from back to front) and Z axes (from foot to head) and X translation (from right to left) were calculated. An upper pole of the kidney was determined from PET and CT data. It showed Y and Z translations. The images of the three-dimensional data sets were fused on a workstation. Reproducibility was assessed with randomly misaligned PET and CT data sets. Pancreatic cancer and its lymph node metastases were identified easily on fused images. In reproducibility assessment, the average error of rotation was 0.77 degree. The average errors of translation were 3.43, 4.70, and 9.23 mm on the X, Y, and Z axes, respectively. In conclusion, this PET/CT image registration technique is feasible and practical. It allows precise anatomical assessment of normal and abnormal FDG accumulation.

A new technique for morphologic measurement of the femur. Its application for Japanese patients with osteoarthrosis of the hip

The cementless femoral prostheses developed in Western countries have commonly been used for Japanese patients, but it has been noted that it is difficult to achieve a good fit between the cementless femoral prostheses and some femora. In Japan, there are many patients with secondary osteoarthrosis (OA) of the hip, but Western designed femoral prostheses seem to be mainly for use with primary OA of the hip. To design femoral prostheses better suited to Japanese patients, a new method to study the morphometry of the femur is required--one which can determine the particular features of the femur in Japanese patients. In this study, a new morphologic measurement technique of the femur is proposed and applied to a number of Japanese OA patients in order to demonstrate its efficacy. In this technique, a three-dimensional solid model based on the outer and inner borders of the femoral cortex is constructed from 3-D CT images and computer-aided design (CAD) software. The bone axis is defined as the line of best fit to the centers of gravity of the femur cross sections in each CT plane by using the least square method. A new femur coordinate system is considered based on this bone axis. The corrected outer borders of the cortex are reconstructed in sections perpendicular to the bone axis. The angle between the principal axis of inertia of the sections and a plane defined by the femur coordinate system is selected as providing a good measurement of the torsion value to characterize the femur morphology. The angles of principal axis were measured in 110 OA and 36 normal hips, and then compared with each other. A significant difference between the OA and normal group was observed especially in the proximal region above the section 6 mm below the level of the lesser trochanter. It is suggested that the anteversion of the femoral neck influences the torsion of the parts below the lesser trochanter. From the results, it is demonstrated that the proposed measurement technique is a reliable and efficient means of determining femur morphology.

Dobutamine stress echocardiography at 7.5 mg/kg/min using color tissue Doppler imaging M-mode safely predicts reversible dysfunction early after reperfusion in patients with acute myocardial infarction

Dobutamine stress echocardiography (DSE) is widely used to predict reversible left ventricular dysfunction, but evaluation by this method is subjective. The recently developed color tissue Doppler imaging (TDI) M-mode may permit objective and quantitative assessment of changes in wall motion induced by DSE. We tested the hypothesis that this new method can detect sensitively reversible dysfunction in the post-myocardial infarction setting. DSE with color TDI M-mode and conventional DSE were performed to predict reversible dysfunction in 53 patients at a mean of 3 days after infarction using 7.5 and 10 microg/kg/min of dobutamine. Follow-up regular echocardiography (4 weeks later) was used as the reference technique to define reversible dysfunction segments. To predict reversible dysfunction segments, the standard segmental wall motion score change on conventional DSE and the ratio of the segmental wall velocity difference at rest versus stress (7.5 and 10 microg/kg/ min) on DSE with color TDI M-mode (7.5-TDI-M and 10-TDI-M, respectively) were used. With 7.5 microg/kg/min of dobutamine, the sensitivity for predicting reversible dysfunction using color TDI M-mode (7.5-TDI-M) was significantly higher than that of conventional DSE (89% vs 73%, p <0.05) whereas specificities and predictive values were almost identical. With a 10-microg/kg/min dose, color TDI-M mode (10-TDI-M) and conventional DSE were not significantly different in predicting reversible dysfunction. With use of color TDI-M mode, regional wall motion during DSE was analyzed objectively and quantitatively. Moreover, combined TDI-M and conventional data were slightly superior to either mode alone. There were no arrhythmias during 7.5 microg/kg/min of dobutamine, but 9 arrhythmias occurred during the 10-microg/kg/min dose in patients with acute myocardial infarction. In conclusion, color TDI M-mode permits objective and quantitative assessment of regional ventricular wall motion and gives additional information for detecting reversible dysfunction in DSE. Improvement of sensitivity at a lower dose of dobutamine with color TDI-M mode may increase the safety of DSE in the post-myocardial infarction setting.

Idiopathic CD4+ T lymphocytopenia disclosed by the onset of empyema thoracis

A 56-year-old man was admitted to our hospital in December 1996 due to empyema thoracis. A laboratory examination revealed lymphocytopenia and CD4+ T lymphocytopenia (<300 cells/ microl). No evidence for a human immunodeficiency virus (HIV) infection was found. No malignant, hematological or autoimmune disease was detected. We thus diagnosed this case as being idiopathic CD4+ T lymphocytopenia (ICL). During his hospital treatment, he was affected with cytomegaloviral retinitis and cured by therapy. His subsequent treatment went well without a recurrence of severe infection although a low CD4+ T lymphocyte count continued after the recovery from empyema thoracis.

Ganciclovir chemoablation of herpes thymidine kinase suicide gene-modified tumors produces tumor necrosis and induces systemic immune responses

The goal of this work was to identify potential host immune responses to thymidine kinase (TK) suicide gene-modified tumors undergoing chemoablation induced by the prodrug ganciclovir (GCV). The aims were to measure the efficacy and specificity of immunity induced against unmodified tumor, to identify qualitative or quantitative changes in the host response to TK+ tumors undergoing chemoablation that may contribute to the induction of antitumor immunity, and to compare critically the induction of immunity by chemoablation of TK-modified tumors with that of other methods of immunization in this tumor model and in response to other well-defined model antigens. Animals treated with TK+ tumors and GCV developed specific resistance to rechallenge with unmodified tumor. GCV induced significant tumor necrosis, which was associated with a pronounced host cell infiltrate composed of polymorphonuclear cells, both CD4+ and CD8+ T lymphocytes, and increased intratumoral IL-12. Cyclophosphamide-treated mice exhibited no such host response despite the induction of tumor necrosis. CTL responses to defined antigens in TK+ cells were greater in animals treated with prodrug than were those in animals not treated with prodrug but harboring live TK+ cells. Similar degrees of immunity were produced by immunization with irradiated cells.

Neural activation of the brain with hemodynamic insufficiency

Little is known about how ischemia affects hemodynamic responses to neural activation in the brain. We compare the effects of a motor activation task and a cerebral vasodilating agent, acetazolamide (ACZ), on regional cerebral blood flow (rCBF) in primary sensorimotor cortex (PSM) in six patients with major cerebral artery steno-occlusive lesions without paresis of the upper extremities. Quantitative rCBF was measured in all patients using H2(15)O autoradiographic method and positron emission tomography. The CBF was determined at rest, during a bimanual motor activation task, and 10 minutes after ACZ administration. With bimanual motor activation, rCBF increased significantly in both PSM compared with at rest (P < 0.01 on lesion side, and P < 0.02 on contralateral side). However, rCBF did not increase after ACZ injection in the PSM on the lesion side, whereas rCBF increased significantly in the contralateral PSM after ACZ injection compared with the level at rest. This result suggests that despite a decreased hemodynamic reserve, there is a nearly normal flow response to neural activation, indicating that the mechanism of vasodilation responsible for perfusion change is different for acetazolamide and neural activation. The relations among neural activation, hemodynamic status, and cerebral metabolism in the ischemic stroke patients are discussed.

Coronary artery diameter increase induced by a phosphodiesterase 5 inhibitor, E4021, in conscious pigs

The effects of intravenous infusions of 1, 3 and 10 microg/kg/min of the phosphodiesterase 5 inhibitor, E4021, at 30-min intervals on coronary artery diameter were studied in 8 conscious pigs monitored with a pair of piezoelectric crystals. The highest dose increased the diameter by 2.9 +/-0.5% (P <0.01 vs vehicle) of the baseline diameter, with a significant decrease in mean pulmonary arterial pressure. However, there were no changes in mean aortic pressure and heart rate. Additionally, E4021 significantly prolonged the duration of the diameter increase induced by nitroglycerin. Thus, phosphodiesterase 5 inhibition causes coronary artery diameter increase and produces an amplifying effect with nitroglycerin.

[Clinical usefulness of contrast-enhanced intracoronary ultrasound (ICUS) and evaluation of suitable contrast agents for ICUS]

It is sometimes difficult to visualize the luminal borders of the vessel even by intracoronary ultrasound (ICUS), especially after coronary intervention. In this study, we evaluated the potential for improving visualization at intervention sites using contrast-enhanced ICUS and the suitable contrast agents for this procedure in humans. In 37 patients, ICUS (30 MHz) was performed with intracoronary injection (3 ml) of 7 different contrast preparations and without the contrast agents (control) after coronary intervention. The contrast agents used were as follows: saline solution, standard iomeprol, standard ioxaglate, sonicated iomeprol, sonicated ioxaglate, 50% Albunex, and 100% Albunex. Vessel wall delineation, contrast homogeneity (Grade 0-3), peak contrast intensity and shadowing were examined. Homogeneous and complete opacification of the vessel lumen and false lumen was observed with sonicated ioxaglate, 50% and 100% Albunex. Shadowing was not observed at all with sonicated ioxaglate and was uncommon with 50% Albunex, whereas 100% Albunex caused shadowing in all cases. The coronary delineation rate with the other contrast agents was only 50-70 %, and the homogeneity and peak intensity were relatively low. Thus, sonicated ioxaglate and 50 % Albunex both achieved good visualization, but the former is cheaper, stable and takes shorter to prepare. Large dissection in 5 patients were found by contrast-enhanced ICUS' whereas they were not detected by coronary angiography. All of them needed additional interventional therapy due to the results of contrast-enhanced ICUS. In conclusion, contrast-enhanced ICUS is useful for evaluation of the results by intervention therapy, and of the agents we studied sonicated ioxaglate is best for contrast-enhanced ICUS.

Assessment of vasoreactivity in brain edema by acetazolamide activation SPECT and PET

Our study was performed to find out cerebrovascular reactivity post acetazolamide administration in patients with peritumoral edema. Adult patients (n = 9) underwent CBF measurement by 99mTc-HMPAO SPECT pre and post 1 gram i.v. acetazolamide. In all patients, this procedure was repeated once again within 10 days of performing tumor removal. Five of these patients also underwent CBF measurement pre and post 1 gram i.v. acetazolamide post surgery only using oxygen-15 labeled H2O PET. Asymmetry index (AI) was calculated as ratio of ROI counts in the peritumoral edematous area and symmetrical ROI on the contralateral normal hemisphere. The AI increased after acetazolamide in edematous gray matter post operatively though the resting AI remained almost same post operatively. AI in edematous white matter showed non-significant increase post operatively both at rest and after acetazolamide. Good linear correlation of AI between PET and SPECT was observed both in gray and white matter. The improvement of vascular reactivity in edematous gray matter after tumor removal suggests that mass effect not only reduces CBF but also suppresses vascular reactivity. White matter vascular reactivity in early post operative period is little improved, possibly due to factors other than mass effect i.e. excess water accumulation in white matter perivascular space.

[E 4021, a cGMP phosphodiesterase inhibitor, is a selective pulmonary vasodilator in chronically hypoxic pulmonary hypertensive rats]

To test whether a potent cGMP-specific phosphodiesterase inhibitor, E 4021, is a selective pulmonary vasodilator in pulmonary hypertension, we studied its acute hemodynamic effects in conscious, chronically hypoxic pulmonary hypertensive rats. Chronically hypoxic pulmonary hypertension was induced by keeping adult Sprague-Dawley rats in a hypobaric chamber for 3 weeks. Two days after catheterization. E 4021 was injected intravenously at doses of 3, 10, 30, 100, 300, and 1,000 micrograms/kg at 10-min intervals. E 4021 caused significant decreases in mean pulmonary arterial pressure of 11 +/- 5, 12 +/- 6, and 18 +/- 5% at doses of 100, 300, and 1,000 micrograms/kg, respectively. In contrast to its depressor effect on mean pulmonary arterial pressure, E 4021 decreased mean systemic arterial pressure significantly (by 9 +/- 2%) at a dose of 1,000 micrograms/kg only. Heart rate and cardiac output were unchanged after the administration of E 4021. Tissue cGMP-specific phosphodiesterase activity was markedly higher in lung than in aorta. These results indicate that E 4021 is a relatively selective pulmonary vasodilator in chronically hypoxic pulmonary hypertensive rats. We conclude E 4021 may be useful for the treatment of pulmonary hypertension.

Thoracoscopic treatment of esophagobronchial fistula with esophageal diverticulum

Thoracoscopic fistulectomy and diverticulectomy for esophagobronchial fistula with esophageal diverticulum were performed on a 49-year-old-woman. The neck of the diverticulum and the fistula were divided with endo-stapling technique. Intraoperative esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. To avoid the recurrence of fistula, a pedicle of viable mediastinal pleura was interposed between esophageal and bronchial closures. Postoperative course was uneventful, and the complete relief of symptom was experienced for a period of 10 months after the operation. It is to be considered that the present thoracoscopic procedure with intraoperative esophagoscopy can be used as a standard operative procedure for esophagobronchial fistula with esophageal diverticulum.

Esophageal anisakiasis accompanied by reflux esophagitis

A case with esophageal anisakiasis accompanied by reflux esophagitis is described. A 38-year-old man visited our hospital with complaints of heartburn and disturbance of food passage about seven hours after eating raw cuttlefish. The first esophagogastroscopy revealed an anisakis larva invading the squamocolumnar junction. Near the anisakis larva, a whitish exudate was demonstrated in the distal esophagus just proximal to the squamocolumnar junction. An anisakis larva was easily extracted from the esophagus by forceps. Reflux esophagitis with whitish exudative mucosal lesions and an area of linear erythema more than 5mm long were noted endoscopically 8 weeks after treatment with lansoprazole and cisapride. After six months the third endoscopic examination clarified that there was neither exudate nor erythema in the distal esophagus. Judging from the clinical course that he complained of newly experienced heartburn about seven hours after eating raw cuttlefish, and that whitish exudative mucosal lesions and an area of linear erythema did not disappear at three months after extraction of the anisakis larva. It was concluded that an anisakis larva enters the stomach first and then returns to the esophagus by gastroesophageal reflux.

[Information on von Willebrand disease]

The revised classification of von Willebrand disease (VWD) was approved by the International Society of Thrombosis and Haemostasis (ISTH)/SSC in 1993. It consists of three major categories : quantitative defect in type 1, qualitative defect in type 2, and complete deficiency in type 3. Type 2 has four subtypes : decreased GPIb binding with deficient larger multimer of VWF in type 2A, excessive GPIb binding in type 2B, defective GPIb binding with larger multimer in type 2M, and defective FVIII binding in type 2N. Subsequently, criteria for diagnosis of VWD is being reconsidered by the association. Therefore, we introduced the guidelines for diagnosis of VWD type 1 and type 2N in our department.

Prethrombotic state due to hypercoagulability in patients with permanent transvenous pacemakers

Venous thrombosis is a relatively usual but serious complication of permanent transvenous pacing. However, the pathogenesis has not been defined. To clarify underlying abnormalities in the coagulation-fibrinolysis system in patients with permanent transvenous pacemakers, we measured serum levels of fibrinopeptide A (FPA), thrombin-antithrombin III complexes (TATs), plasmin-alpha 2 plasmin inhibitor complexes (PICs), D-dimer (D-D), beta-thromboglobulin (beta-TG), and platelet factor 4 (PF4) in 53 patients with permanent transvenous pacemakers and 10 control subjects. The patients were divided into two groups, as follows, according to the presence of mural thrombus documented along the pacing lead(s) by digital subtraction angiography and transesophageal echocardiography: Group Th (-), patients without venous route thrombus; and Group Th (+), patients with venous route thrombus. FPA and TAT levels increased significantly even in Group Th (-), and further increased in Group Th (+) compared with control subjects (FPA: 7.5 +/- 4.9, 15.3 +/- 8.8 vs 3.0 +/- 1.4 ng/mL, respectively, P < 0.05; TAT: 2.9 +/- 1.3, 4.8 +/- 2.3 vs 1.7 +/- 0.6 ng/mL, respectively, P < 0.05). There were no differences in levels of D-D, PIG, beta-TG, and PF4 among control subjects, Group Th (-), and Group Th (+). These findings suggest that the hypercoagulable state appears in patients with permanent transvenous pacemakers, even without apparent venous thrombosis. The patients with permanent transvenous pacemakers are thought to be in the prethrombotic state even if they have no venous route thrombosis.

The revised classification of von Willebrand disease including the previously masqueraded female hemophilia A (type 2N)

The revised classification of von Willebrand disease was proposed by the working committee (Chairperson: J.E. Sadler) and approved by the Scientific and Standardization Committee/the International Society on Thrombosis and Hemostasis in 1993. It consists of three major types; type 1 with decreased level of normal von Willebrand factor (VWF) and type 3 with complete deficiency of VWF as quantitative abnormality, and type 2 with qualitative anomaly of VWF subcategorized into 2A, 2B, 2M and 2N, respectively, depending on the functional abnormalities (decrease of GPIb binding with defect of VWF large multimers, increase of GPIb binding, decrease of GPIb binding with VWF large multimers, decrease of FVIII binding). This classification is frequently quoted in the USA and Europe. We introduce this classification and review again the structural abnormalities of VWF, including the previously masqueraded female hemophilia A (type 2N).

Echographic detection of latent severe thrombotic stenosis of the superior vena cava and innominate vein in patients with a pacemaker: integrated diagnosis using sonography, pulse Doppler, and color flow

Thrombosis of the innominate vein and SVC is a serious complication in patients with pacemakers, inducing pulmonary embolism or SVC syndrome. Venography is the definitive method for its diagnosis; however, it is too invasive for related studies. The purpose of this study was to validate sonography, pulse Doppler, and color flow in detecting noninvasively innominate vein or SVC thrombosis in patients with pacemakers. In 53 patients with pacemakers, the 1 severe SVC stenosis and 18 severe innominate vein stenoses due to thrombosis were diagnosed by digital subtraction angiography. Sonography accurately showed the severe SVC stenosis due to thrombosis, but had limitations on the innominate vein thrombosis. Color flow demonstrated mosaic flow, indicating poststenotic turbulence due to stenosis of the innominate vein and SVC caused by thrombosis in 15 of 16 patients, and pulse Doppler disclosed absence of flow due to complete occlusion of the innominate vein in 2 of 2 patients. Sensitivity and specificity for detecting severe innominate vein stenosis due to thrombosis using combined color flow and pulse Doppler was 94% and 100%, respectively. In conclusion, sonography, pulse Doppler, and color flow allow accurate detection of severe innominate vein or SVC stenosis due to thrombosis, and are therefore useful for the follow-up of patients with a pacemaker.

Comparison of vasodilatory effect of carbon dioxide inhalation and intravenous acetazolamide on brain vasculature using positron emission tomography

Carbon dioxide (CO2) and acetazolamide are increasingly being used as vasodilators to detect cerebrovascular reserve capacity in patients of chronic cerebrovascular disease. The functional cerebrovascular reserve or ability of cerebral vessels to lower their resistance in response to decrease in cerebral perfusion pressure is expressed as change in cerebral blood flow from baseline under a vasodilatory stimuli. Theoretically a vasodilator causing maximum vasodilation, and thereby expressing complete reserve capacity would be more suitable for such a purpose. We quantitatively compared the vasodilating effect of 5% CO2 inhalation and 1 g of intravenous acetazolamide by positron emission tomography. Cerebrovascular reserve was quantified in six patients with chronic cerebrovascular disease in the same sitting, using oxygen-15 labeled water (H2(15)O) positron emission tomography at rest, during 5% CO2 inhalation and after 1 g intravenous acetazolamide. A significant linear correlation in both nonlesion hemisphere (r = 0.701, p < 0.001) and in lesion hemisphere (r = 0.626, p < 0.005) was found between CO2 and acetazolamide for cerebrovascular reserve capacity. This correlation improved by considering cerebrovascular reserve per unit change in arterial carbon dioxide (r = 0.744, p < 0.001 in nonlesion hemisphere and r = 0.721, p < 0.001 in lesion hemisphere). The quantitative value of global reserve capacity was different by CO2 stimuli (5.2%) and acetazolamide (49.7%). Though a similar vasodilatory response is elicited by both vasodilators, acetazolamide seems to be more potent and therefore should be preferred to detect patients with exhausted cerebrovascular reserve capacity.

Thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor

This report introduces our new technique of thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor. A 68-year-old woman noticed a tumor palpable in the left supraclavicular fossa. The patient had no pain around the neck and shoulder. A radio-opaque shadow 6 cm in diameter was detected in her left apical lung field on chest roentgenogram. Chest CT and MRI showed that the tumor was located in the superior mediastinum, extending up to the thoracic inlet, and there was no invasion of the surroundings. At first, a thoracoscopic examination was performed to assess the possibility of the excision. After dissecting the tumor from the mediastinal tissue and the first costovertebrae as far as possible by thoracoscopic surgery, a supraclavicular approach was used to enter the thoracic cavity. Complete resection of the tumor was successfully performed by thoracoscopic surgery combined with a supraclavicular approach. The tumor was removed in a plastic bag through the supraclavicular defect. Postoperative histopathology revealed that the tumor was a benign neurogenic one. A satisfactory follow-up of 5 postoperative days was observed without any complications, and the patient was discharged. The procedure was safe, easy, and minimally invasive to perform. Moreover, the supraclavicular approach could be used to add trocar port if needed.

Histopathologic study of veins in steroid treated rabbits

Although arterial factors have been regarded as playing an important role in the pathogenesis of osteonecrosis, more attention has been given to venous factors because steroids cause an increase in the intraosseous pressure despite a decrease in blood flow in the femoral head. The authors examined changes in the veins of steroid treated rabbits. Forty rabbits were used: 30 rabbits (the steroid treated group) were injected with methylprednisolone acetate (4 mg/kg) weekly and 10 rabbits (the control group) were treated without steroids. The veins around the femoral head, ear veins, femoral veins, and inferior vena cava were obtained after 8 weeks of treatment, and the specimens were examined by immunohistochemical staining and electron microscopy. In the steroid treated group, proliferation of foam cells was observed in the intima of the vein in 7 of 30 rabbits. Immunohistochemical studies, using monoclonal antibodies for smooth muscle cells and macrophages, showed that the foam cells were derived from smooth muscle cells. Electron microscopy showed damage to the endothelial cells and smooth muscle cells. These results indicated that corticosteroids damaged the venous system. It is suggested that steroid induced disturbance of the draining veins causes stasis and that steroids are an important factor in osteonecrosis of the femoral head.

Early magnetic resonance imaging and histologic findings in a model of femoral head necrosis

The authors examined early magnetic resonance images and histologic findings of avascular necrosis of the femoral head in a canine model. The avascular necrosis of the femoral head model was surgically induced. Animals were euthanized at 3 days, 1, 2, and 4 weeks, and the proximal femurs were retrieved. Magnetic resonance images and histologic sections were performed on each of the specimens obtained. Twenty-five mongrel dogs were studied, 4 dogs at 3 days and 7 dogs at each of the other intervals. Findings suggest that histologic changes may be seen as early as 3 days, with marrow edema and hemorrhage as early findings, and fibrous marrow transformation and appositional bone growth as later findings. Magnetic resonance imaging abnormalities did not occur until 1 week after injury and were seen in all animals by 4 weeks.

Pathological and hemodynamic study in a new model of femoral head necrosis following traumatic dislocation

The blood of the femoral head is thought to be supplied by vessels originating from the medial and lateral circumflex femoral arteries and via the marrow cavity of the neck. Therefore, it is difficult to induce osteonecrosis of the femoral head when the marrow cavity of the neck is preserved. In the present study, we established a new model of femoral head necrosis by dislocating the hip joint and ligating the medial and lateral circumflex femoral arteries and veins. Measurement of femoral head blood flow revealed that a marked decrease to 14.7% of the control value was achieved by both hip dislocation and ligation of blood vessels. Pathologic examination showed no necrosis with either dislocation or ligation alone, whereas at 2 and 4 weeks 80% of the animals subjected to both procedures showed widespread necrosis. These pathologic findings considered in the light of results of the blood flow measurements suggest that a decrease in femoral head blood flow below 20% of the control value is needed to cause osteonecrosis. In addition, magnetic resonance images (MRI) of the model were evaluated in the combined dislocation and ligation group at 4 weeks (n = 5). Changes on MRI were seen in 3 of 5 dogs. The necrotic changes of the femoral head are thought to be detectable on MRI within 4 weeks after ischemia without enhancement.

Fluorine-18 fluoro-2-deoxyglucose positron emission tomography in recurrent rectal cancer: relation to tumour size and cellularity

The aim of this study was to assess the value of fluorine-18 fluoro-2-deoxyglucose (FDG) positron emission tomography in patients with recurrent rectal cancer, in relation to tumour size and cellularity. Thirty-seven patients (21 mean and 16 women; mean age, 55.4+/-9.58 years) with suspected recurrence of rectal cancer were studied. FDG uptake was quantified by the differential absorption ratio (DAR). In 29 patients magnetic resonance imaging was also performed. To evaluate the signal intensity of the lesion, the lesion to muscle signal intensity ratios (SIR) were calculated on T2-weighted images. In seven patients who received surgical treatment the DAR and SIR were compared with the tumour cellularity. All 32 patients with confirmed recurrence showed increased FDG accumulation in the mass (DAR=4.57+/-1.89) in comparison with low FDG accumulation in five patients with scar (DAR=1.17+/-0.43). There was a significant correlation (r=0.661, P<0.001) between the DAR and the tumour diameter. There was no correlation between the DAR and SIR, whereas there was a significant correlation (r=0.565, P<0.01) between the DAR corrected using count recovery coefficient (DAR*) and SIR. In the histopathological findings there was a tendency for the DAR* and SIR to correlate with tumour cellularity. It is concluded that the DAR of recurrent rectal cancer should be evaluated taking into consideration the tumour size and cellularity.

[13C-acetate breath test for the measurement of gastric emptying rates]

Although acetaminophen (APAP) method is widely used to evaluate the gastric emptying rates of liquids in Japan, patients need to take a large dose of APAP. A scintigraphic technique requires the gamma camera. In this present state we try to search for an alternative method, which is easy to perform and noninvasive for the patient. 13C-acetate breath test and APAP method were performed at the same time in 59 patients after overnight fasting. The liquid test meal OKUNOS-A (200 ml, 200 kcal), contained APAP (20 mg/kg) and 13C-acetate 100 mg was orally administered to the patient. Breath sampling for 13CO2 measurements was obtained every 5 min up to 20 min and every 10 min up to 90 min. Blood sampling for plasma APAP concentration was collected 15, 30, 45, and 60 min after oral administration of the test meal. The time of 13CO2 peak excretion in 13C-acetate breath test was ranged from 50 to 70 min in 37 out of 59 patients. Plasma APAP concentration at 45 min in over 80 min group was significantly lower than in 50-70 min group. In contrast, that in under 40 min group was significantly higher. 13CO2 breath excretion at 30-40 min correlated with plasma APAP concentration at 45 min significantly. These results suggest that optimal sampling time of breath test is 20-40 min. In conclusion, 13C-acetate breath test is reliable as a qualitative analysis, easy to perform, and a noninvasive method without taking blood and radiation exposure for a measurement of gastric emptying rates.

Superior vena cava syndrome due to a permanent transvenous pacing lead

Superior vena cava (SVC) syndrome after pacemaker implantation is a very rare complication. We present a 56-year-old man with severe swelling of the face, neck, and upper arms about 6 years after pacemaker implantation. Digital subtraction angiography showed occlusion of the left innominate vein and severe stenosis of the SVC. The patient eventually required surgical treatment, since anticoagulant therapy and balloon venoplasty were not effective. We conclude that surgical repair is the most effective method for treating similar patients.

Changes in factor VIII binding capacity of von Willebrand factor and factor VIII coagulant activity in two patients with type 2N von Willebrand disease after hemostatic treatment and during pregnancy

The changes of the FVIII binding capacity of vWF after the infusion of FVIII/vWF concentrate was studied in two patients with type 2N vWD, and also during pregnancy in one of them. After infusion of FVIII or DDAVP to the patients, FVIII:C in plasma increased as expected, but it then decreased, with a markedly short half-life, of about 2 h, due to the defect in the FVIII binding capacity of vWF in plasma. However, after infusion of FVIII/vWF concentrate (40 U of FVIII:C/kg), FVIII:C increased, from 4-6 to 100-160 U/dl, more than the expected values, and decreased with the half-life expected. The FVIII binding capacity of vWF in plasma changed in parallel with the concentration of exogenous normal vWF, with a half-life of more than 24 h. During pregnancy, no increase of FVIII:C was observed, although vWF:Ag increased from 40 (before pregnancy) to 90 U/dl in plasma at 35th week of gestation. The FVIII binding capacity of vWF in plasma showed no increase during pregnancy. Accordingly, the administration of FVIII/vWF concentrate to the patient at delivery resulted in adequate hemostasis.

Recovery of impaired left ventricular function in patients with acute myocardial infarction is predicted by the discordance in defect size on 123I-BMIPP and 201Tl SPET images

A discrepancy between myocardial perfusion defect and wall motion abnormalities is frequently found early after coronary reperfusion in patients with acute myocardial infarction. The purpose of this study was to assess recovery of impaired left ventricular function by reference to the discordance in defect size between myocardial fatty acid uptake and myocardial perfusion using combined single-photon emission tomographic (SPET) imaging early after coronary perfusion therapy. In 37 patients with acute myocardial infarction, iodine-123 15-(p-iodophenyl)-3(R, S)-methylpentadecanoic acid (BMIPP) and thallium-201 SPET scans were performed early after coronary reperfusion. A severity score was determined from the extent of the imaging defect with each tracer. Left ventricular wall motion score (WMS) and ejection fraction (EF) were obtained at admission and at 4 weeks after the onset of infarction. In 32 of the 37 patients, discordance in defect sizes delineated with the two SPET studies was found during the acute stage. The severity score for BMIPP was larger than that for 201Tl during the acute stage (7. 7+/-2.4 vs 4.4+/-2.5, P <0.001). There was a fair correlation between the severity score for BMIPP and WMS (r=0.82, P <0.0001), but a poor correlation between that for 201Tl and WMS. The extent of discordance in severity scores between BMIPP and 201Tl during the acute stage correlated well with the extent of the improvement in WMS (r=0.86, P <0.0001) and that of EF (r=0.85, P <0.0001). We conclude that the discordance in defect size on BMIPP and 201Tl SPET images during the acute stage of infarction is an early predictor of the viability of the myocardium at risk of infarction.