Closed rupture of the flexor digitorum profundus tendon of the little finger caused by calcification of the triangular-fibrocartilage

A case of rupture of flexor digitorum profundus tendon of the little finger caused by calcification of the triangular fibrocartilage (TFC) is reported. At operation, a round defect of the TFC and rupture of the flexor digitorum profundus tendon (FDP) of the little finger were observed. The defect of TFC was repaired using the palmaris tendon and FDP of the little finger was woven into FDP of the ring finger. Eleven months after operation, the patient had almost full flexion and extension of the distal and proximal interphalangeal joints.

Increasing coronary perfusion pressure on diastolic and systolic performance is less pronounced in right ventricle than in left ventricle

OBJECTIVE

Little is known as to whether an increase in coronary perfusion pressure can alter the right ventricular (RV) distensibility and the contractile function as it does in the case of the LV.

METHODS

In eight isolated isovolumically contracting canine hearts, RV and LV volumes and coronary perfusion were independently controlled. Effects of an increase in coronary perfusion pressure (from 73 +/- 1 to 152 +/- 6 mmHg) on the end-diastolic and end-systolic pressure-volume relations in both RV and LV were assessed.

RESULTS

Following an increase in coronary perfusion, and at a similar volume of the ventricles, end-diastolic pressure was elevated by 2.8 +/- 0.8 mmHg in RV and 8.9 +/- 2.0 mmHg in LV (P < 0.01; RV vs LV), and the slope of RV end-systolic pressure-volume relation, Ees, increased by 11 +/- 6% (P < 0.05) and that of the LV Ees by 21 +/- 5% (P < 0.01). The percent change of RV pressure-volume area (PVA) was less than that in LV-PVA (26 +/- 9 vs 48 +/- 11%; P < 0.05).

CONCLUSIONS

Accordingly, increases in coronary perfusion pressure and/or flow decreased the RV distensibility and enhanced the RV contractile function, the extent of which, however, was less than that in the LV.

Innervated radial thenar flap for sensory reconstruction of fingers

A radial thenar flap, which is supplied by the superficial palmar branch of the radial artery and innervated by the superficial branch of the radial nerve, was used in four patients for sensory reconstruction of the fingers. Two patients had degloving injuries of the hand and two had amputation injuries of the thumb. Three of the cases underwent free-flap transfers, and one case underwent a reverse-flow island flap. The size of these flaps was about 3 x 5 cm except in one case, where a 15 x 5 cm flap combined with a radial forearm flap was used. Sensory reinnervation was excellent and donor site morbidity was minimal in all four cases. An innervated radial thenar flap from the ipsilateral hand offers an alternative choice to reconstruct large palmar defects of the fingers.

[Hemostatic mechanism associated with aprotinin during and after the extracorporeal circulation for cardiac and great vessel surgery]

It has been reported that aprotinin (apr) is effective for hemostasis during and after the extracorporeal circulation (ECC) for cardiac or great vessel surgery. However its mechanism remains still obscure. In this study, we observed relationships between changes in interleukin-8 (IL-8), endothelial factors, or D-dimer and aprotinin administered before and after the ECC. Fourteen patients in whom cardiac or great vessel surgery was done using ECC were divided randomly into two groups. Seven subjects in Group I (G-I) were infused 10(6) KIU of apr immediately after anesthesia, immediately before and after the ECC, respectively, and 10(6) KIU of apr were also added during the ECC. Seven other subjects (G-II) were infused 10(6) KIU of apr immediately before and at three hours after the ECC, and also 2 x 10(6) KIU of apr immediately after the ECC. No marked hemorrhagic tendency was noted in all subjects and increase in plasma D-dimer was not marked. Immediately after the ECC, granulocyte elastase in plasma increased markedly in both groups but subsequently decreased in the G-II alone while it remained unchanged in the G-I. Similar changes were observed in plasma IL-8 values. During the ECC, intercellular adhesion molecule-1 in plasma decreased in both groups but von Willebrand factor activity decreased in the G-I alone. From the above data, the hemostatic effect of apr may contribute to protect the dysfunction of endothelial cells or to enhance recovering from the dysfunction during the ECC.

Partial soleus muscle island flap transfer using minor pedicles from the posterior tibial vessels

A new method for partial soleus muscle island flap transfer using minor pedicles from the posterior tibial vessels was designed and executed. A portion of the soleus muscle body that was slightly wider than the defect was harvested with minor pedicles. The muscle flap was transposed by turning it over or by creating an island flap. Skin grafts were applied to the exposed muscle. This new type of muscle flap was applied to six patients with a pretibial skin defect at the lower third of the leg. It was used for treatment of an open fracture with an associated skin defect in four patients, chronic osteomyelitis in one patient, and a recurrent stasis ulcer in one patient. In all patients the transferred muscle flap survived completely.

"Plasmatic imbibition" in the rabbit flow-through venous flap, using horseradish peroxidase and fluorescein

In the present study, the phenomenon of "plasmatic imbibition" was investigated histologically in a rabbit flow-through venous flap model, using horseradish peroxidase and fluorescein. Horseradish peroxidase introduced between the flap and the recipient bed, produced brown staining of the entire contact surface 10 min postoperatively. At 30 min, erythrocytes in the flow-through vein stained red. The flap and the erythrocytes became more intensely stained over time. When horseradish peroxidase was introduced from a central artery after a Silastic sheet had been inserted between the flap and recipient bed, the flap color became a soft brown and the erythrocytes of the flow-through vein stained red 10 min postoperatively. In the experimental groups subjected to fluorescein, introduced between the graft (or flap) and the recipient bed, fluorescence was seen 10 min postoperatively, except in the flow-through vein. At 30 and 120 min, the whole graft (or flap) showed fluorescence. Fluorescein was introduced into the femoral vein after flap elevation, or a Silastic sheet was inserted between the flap and the recipient bed. At 10 min, these groups showed a weak fluorescence only in the flow-through vein; subsequently, at 120 min, the flow-through vein and its surrounding tissue showed fluorescence, but the flap showed none. Plasmatic imbibition was proved to be acting in the flow-through vein, and it is considered as important a phenomenon in flap survival as venous flow itself.

Comparison of mesoderm-inducing activity with monomeric and dimeric inhibin alpha and beta-A subunits on Xenopus ectoderm

Activin possesses mesoderm-inducing activity, erythroid-differentiating activity, and follicle-stimulating hormone-releasing activity. The chemical structures of the activin molecule are formed by a combination of two beta-subunit peptides of inhibin. Inhibin is a dimer consisting of an alpha and beta subunit. To examine the mesoderm-inducing activity of these substances, we tested several configurations including: (1) two types of alpha-subunit peptide; (2) two types of inhibin A and B dimer; (3) beta A-subunit peptide monomer; (4) three types of activins A, AB and B, and (5) follistatin (activin-binding protein) by the animal cap assay using Xenopus laevis ectoderm, and by the erythroid-differentiating factor (EDF) test. Activins, which are composed of dimeric inhibin beta A- or beta B-subunit peptides, had the highest mesoderm-inducing and EDF activities. The monomeric beta A-subunit peptide exhibited mesoderm-inducing and EDF activities that were much lower than activin A. The inhibitory effect of follistatin on mesodermal induction by the beta A-subunit peptide was also lower than that of activin. Both inhibins A and B had very weak mesoderm-inducing activity and no EDF activity. The two types of inhibin alpha-subunit monomer had little mesoderm-inducing activity and no EDF activity. The mesoderm induction caused by activin A was not suppressed by the addition of the alpha-subunit monomer and inhibin. The mesoderm-inducing activity in relation to the chemical structures of the monomeric and/or dimeric inhibin alpha and beta A subunits is discussed.

To see or not to see: the debate over pornography and its relationship to sexual aggression

The role played by pornography in the generation of thoughts, feelings, impulses and behaviours in its viewers has long been a topic of debate and controversy. The uncertainty about its potential effects on human behaviour, especially its relationship to sexual aggression, has stimulated the recent debate with the possibility of tighter censorship laws being implemented throughout this country. A review of the topic from a number of different perspectives fails to establish that pornography in its purely erotic form has any significant detrimental effect on human behaviour. More difficult to determine are its effects on psychological development. If behavioural disturbances do occur following exposure to such material, they occur in the context of an individual who shows more global disturbances of personality. The current debate regarding pornography provides an opportunity to address in a broader social context issues perhaps more significant for our society: the relationships between men and women, and the roles and recognition provided to each of the sexes.

Malignant lymphoma of the esophagus associated with macroglobulinemia: report of a case

A case of non-Hodgkin's lymphoma of the esophagus in a 74 year old man is presented. Grossly, the surgically removed esophagus had a fusiform submucosal mass covered with smooth surfaced mucosa. Microscopic examination revealed that the mass consisted of a dense infiltrate of small to medium-sized lymphoid cells with plasmacytoid differentiation, leading to a diagnosis of diffuse small cell lymphoma with lymphoplasmacytic subtype. Laboratory data as well as immunohistochemical studies proved that the lymphoma produced monoclonal immunoglobulin M, giving rise to macroglobulinemia.

Reproducibility of magnetic resonance spectroscopy in patients undergoing dialysis and evaluation of the therapeutic response of tumors

RATIONALE AND OBJECTIVES

The reproducibility of repeated magnetic resonance (MR) spectroscopy was studied in patients undergoing dialysis and treatment of a variety of malignant tumors.

METHODS

Localized MR spectra were obtained using a 1.5-T system by image-selected in vivo spectroscopy. Total metabolite signal was integrated between phosphomonoester and beta-adenosine triphosphate resonance. We termed this measurement AREA.

RESULTS

Intrapatient variability was evaluated on repeated thigh muscle spectroscopy for 10 patients. Sequential spectra of 10 malignant tumors of the extremities were analyzed and compared with the histology of surgical specimens in seven patients. Intrapatient variability in AREA was calculated as 14.0%. The extent of necrosis and AREA ratio (definition: AREA post-therapy/AREA pretherapy) were as follows; 6.1% in > 90% necrosis, 43% in 50% to 90% necrosis, and 79% in < 50% necrosis.

CONCLUSIONS

Localized MR spectra are fairly reproducible and may relate to treatment efficacy.

Control of cell differentiation and morphogenesis in amphibian development

We reviewed cell differentiation and morphogenesis by mesoderm-inducing factors during amphibian embryogenesis. Recently, two kinds of growth factors, activin and FGF, have been identified as influential candidates for natural mesoderm-inducing factor in amphibian development. These factors are present in early Xenopus embryos. In particular, activin has been shown to induce many kinds of mesodermal tissues in a dose-dependent manner. Activin-treated ectodermal sheet (animal cap) acts as an organizer causing gene expression, mesoderm formation and functional events such as secondary axis formation. Follistatin, an activin-specific binding protein, also present in the early Xenopus embryo, makes a complex with activin. Follistatin protein exerts no inducing activity of Xenopus animal cap. Endogenous follistatin may, however, play the role of an activin regulation factor. Endogenous actions of activin and FGF were studied using injection of their receptor mRNAs. Disruption of the FGF signaling pathway by its non-functional dominant negative receptors produced trunk and tail defects. In the case of activin, an embryo cannot form axial structures. Animal-half blastomeres from the late 8-cell stage Xenopus embryo respond to activin, and there are prepatterns in ventral and dorsal cells from very early stages. The timing of mesoderm induction during development and the relationship between the inducing factors and competent cells are discussed in this report. Differentiation of tissues and organized formation of organs can be understood as a system of serial inductive reactions originating from the organizer. We have attempted to construct a model of organizer formation based on the results of recent studies.

Identification of activins A, AB, and B and follistatin proteins in Xenopus embryos

There are several lines of evidence that activin is a crucial molecule for mesoderm induction in early Xenopus embryos. However, it is not known what kind and what amounts of activin proteins exist in cleavage stage embryos. Three isoforms of activins, A, AB, and B, were demonstrated to be present at least in part as a complex with abundant follistatin, an activin-binding protein, in early Xenopus embryos (stage 1-5). These results suggest that activin stored in eggs has an important role for mesoderm induction during early Xenopus embryogenesis and that follistatin can modulate the function of activin in signaling developmental changes.

Present status of replantation in Japan

We conducted a survey among 94 members of the Japanese Society of Reconstructive Microsurgery on the present status of replantation in Japan. The results indicate that 9,664 extremities were replanted (157 upper arms, 415 forearms, 471 hands, 8,320 digits, 33 thighs, 103 calves, 37 feet, and 128 toes); 8,227 replants survived, for a success rate of 85%. The survival rate was over 90% in 23 hospitals, and 7 of these hospitals replanted more than 100 limbs. Postoperative treatment consisted of continuous intravenous infusion of urokinase (120,000-240,000 U/day), heparin (10,000-20,000 U/day), and prostaglandin E1 (80-120 micrograms/day) for 3-10 days. Fifty-six surgeons attempted replantation whenever the patient requested it. At Nara Medical University, continuous local intra-arterial infusion of anticoagulants and fibrinolytic agents has increased the survival rate of the replantation to 97%, compared with 88% when using intravenous infusion.

Venous flap--its classification and clinical applications

We previously reported pedicled venous flap survival using the rat model, as well as venovenous, arteriovenous, and arterialized flow-through venous flap survival using the rabbit ear model. For this study, we utilized these flaps clinically. Five of seven pedicled venous flaps survived, displaying superficial necrosis. The others became partially necrotic; they were transferred after dissection of a long pedicle vein. Eight of nine venovenous flow-through venous flaps survived; six displayed superficial necrosis. The nonsurviving flap became completely necrotic, possibly because only one donor vein and one recipient vein were used. Six of 10 arteriovenous flow-through venous flaps survived. The remaining four became partially necrotic, possibly because only one vein was anastomosed for outflow. The arterialized flow-through venous flap survived. The pedicled venous and venovenous groups studied seem likely to survive despite superficial necrosis. However, the draining vein should not be dissected more than 5 cm, and many draining veins should be anastomosed with recipient vessels.

Resetting of regional preload due to ventricular shape change alters diastolic and systolic performance

The diastolic and systolic pressure of one ventricle is increased by an increase in volume and/or pressure of the opposite ventricle; however, a mechanism for the ventricular interaction remains unclear. We hypothesized that the shape change of one ventricle elicited by the opposite ventricle would lead to resetting of the regional length, which may explain the ventricular interaction. We used 15 cross-circulated isovolumically contracting canine hearts in which both ventricular volumes were independently controlled. Diastolic regional segment area was calculated by multiplying circumferential and longitudinal lengths on right ventricular free wall (RVFW; n = 6), interventricular septum (IVS; n = 11), and left ventricular (LV) FW (n = 12). The regional area at relatively small volumes of both ventricles were expressed as 100%. With constant RV volume, increasing LV from 7 to 19 ml increased RV diastolic and systolic pressures by 2.7 and 5.5 mmHg, respectively. Conversely, increasing RV volume increased LV diastolic and systolic pressures by 2.3 and 7.5 mmHg, respectively. Increasing LV volume increased RVFW regional area from 121.0 to 124.6% (P < 0.01) and increased IVS regional area from 103.3 to 108.7% (P < 0.01), whereas the RV volume was held constant. Increasing RV volume also increased LVFW and IVS regional areas from 109.9 to 111.6% (P < 0.01) and from 106.8 to 108.9% (P < 0.05), respectively. Ventricular shape change elicited by ventricular interaction will increase the regional wall area, even though the volume of the chamber is unchanged. The increase in the regional area alters the position of the tissue on its resting and active length-tension relations and, thus, leads to enhancement of the chamber pressure.

Isolation and characterization of Xenopus follistatin and activins

Xenopus follistatin and activins were purified from a Xenopus laevis cell line (XTC-F1) by four purification steps consisting of consecutive affinity chromatography on dextran sulfate-Sepharose and Sulfate Cellulofine, fast protein liquid chromatography gel permeation, and reverse-phase high performance liquid chromatography (HPLC). Our results thus obtained indicated that almost equimolar amounts of activins A, AB, and B were found to be present as a complex with follistatin (activin-binding protein) in the conditioned medium of XTC-F1 cells. Reverse-phase HPLC of the complex gave Xenopus follistatin and activins A, AB, and B. The purified Xenopus follistatin showed four major bands in a molecular mass range from 34 to 39 kDa by SDS-polyacrylamide gel electrophoresis under nonreducing conditions. The ability of each form of the protein to specifically bind activin was determined by activin-binding assay and ligand blotting analysis. Each protein was found to have the same NH2-terminus and its sequence was very homologous to that of mammalian follistatin. Several criteria including immunoblotting analysis and various functional assays revealed the existence of three isoforms of activins A, AB, and B in Xenopus, as in mammals. Xenopus activins significantly induced both ventral and dorsal mesoderm in explants of Xenopus blastula cells that would otherwise form epidermis. In a dose-dependent manner of each isoform of activin, the induced explants were able to differentiate into blood-like cells, coelomic epithelium, mesenchyme, muscle, and notochord. The induction patterns of three Xenopus activins were essentially the same. The mesoderm induction by the purified Xenopus activins was shown to be inhibited stoichiometrically by the purified Xenopus follistatin. These results indicate that Xenopus XTC-F1 cells secrete several molecular forms of follistatin/activin-binding protein and three isoforms of activins AB and B in addition to activin A.

Blood flow through prefabricated flaps--an experimental study in rabbits

Prefabricated flaps were created by femoral vessel implantation beneath the abdominal skin in rabbits. The area of survival and blood flow through the prefabricated flap were measured after 1, 2, 4, 6, 8, and 12-week intervals. The parameters at 6, 8 and 12-week intervals were significantly larger than those for random pattern flaps (p < 0.01), but were significantly smaller than those for axial pattern flaps (p < 0.01). The minimum interval at which the prefabricated flap could be transferred successfully was between 6 and 8 weeks in this model. Microangiography demonstrated that neovascularisation began at the distal end of the implanted vascular bundle and spread throughout the flap by 8 weeks.

An autopsy case of intracranial hemorrhage during tissue plasminogen activator infusion

We describe an autopsy case of severe intracranial hemorrhage which occurred during the infusion of tissue plasminogen activator (t-PA) for acute myocardial infarction. A 75-year-old man was admitted with substernal chest pain of 3-h duration and electrocardiographic changes consistent with an acute inferior myocardial infarction. Physical examination was unremarkable, except for an initial blood pressure reading of 160/96 mmHg. The patient received 3,000 IU intravenous heparin followed by a 2.4 x 10(6) IU bolus dose of tissue plasminogen activator (t-PA) (Alteplase). This was followed by a drip infusion of 21.6 x 10(6) IU of t-PA over 1 h (total dose 41 mg). Thirty minutes after the infusion of t-PA was initiated, the patient suddenly lost consciousness and began to have violent convulsions, followed by cardiac arrest. Autopsy revealed massive hemorrhage in the bilateral cerebrum and brain stem. To our knowledge, this is the first case of sudden death during t-PA infusion therapy.

PC-766B, a new macrolide antibiotic produced by Nocardia brasiliensis. II. Isolation, physico-chemical properties and structure elucidation

A new macrolide antibiotic, PC-766B, was isolated from the cells of Nocardia brasiliensis SC-4710 by acetone extraction, and purified by gel filtration, silica gel chromatography, HPLC and TLC. The structure of PC-766B was determined by NMR spectral analysis to be a new class of the hygrolidin family antibiotics. PC-766B had a 16-membered macrocyclic lactone ring, a 6-membered hemiketal ring and a 2-deoxy-D-rhamnose moiety. DL-alpha-Tocopherol, known as an antioxidant agent, significantly improved the stability of PC-766B and prevented the decomposition of PC-766B during the storage of the antibiotic.

PC-766B, a new macrolide antibiotic produced by Nocardia brasiliensis. I. Taxonomy, fermentation and biological activity

An actinomycete strain SC-4710, a new soil isolate, was found to produce a new macrolide antibiotic, PC-766B. Chemotaxonomic analysis of the producing organism revealed that the cells of SC-4710 had type IV cell wall, type A whole cell sugar pattern, type PII phospholipids, menaquinone MK-8(H4), cellular fatty acids comprising straight-chain saturated, unsaturated and tuberculostearic acids, and mycolic acids. The strain was identified as Nocardia brasiliensis (Lindenberg) Pinoy. The antibiotic, PC-766B, was active against Gram-positive bacteria, and some fungi and yeasts, but inactive against Gram-negative bacteria. It also showed antitumor activity against murine tumor cells in vitro and in vivo, and a weak inhibitory activity against Na+, K(+)-ATPase in vitro.

[A stick type filter unit for prevention of biohazard in a research laboratory]

It is important to prevent unexpected laboratory infections in a biosafety area. It is recommended that extreme caution should be used when handling needles and syringes to avoid autoinoculation, and that needles and syringes should be used only when there is no alternative. To remove cells and cell debris, a disk-type microfilter unit, which is recommended using a needle, has been used for filtrating supernatant from HIV-1-infected cell cultures. We compared a stick-type microfilter unit, which can be used without a needle, with a disk-type one for their safety and recovery of human immunodeficiency virus particle after filtration. To confirm the right of our comparison, we observed the filter electron microscopically for the virus particles and virus suspensions were carried out and discussed. In conclusion, the stick-type filter should be improved, since the filter unit is inferior to the disk-type filter unit in purification of the virus, but for the safety is superior to the disk-type.

The pedicled venous flap. An experimental study

Musculocutaneous pedicled venous flaps on the dorsum of rats survived at a statistically significantly higher rate than musculocutaneous composite grafts (p < 0.01). With a Silastic sheet (Dow Corning) beneath, both composite grafts and pedicled venous flaps necrosed. When a Silastic sheet with holes in it to allow some revascularisation from the bed was placed beneath, the survival rate was significantly better than with a complete Silastic sheet (p < 0.01). These results demonstrate that pedicled venous flap survival depends both on the draining vein, and revascularisation from the underlying bed.

Non-radioactive coloured microsphere measurement of regional tissue blood flow for axial pattern flaps in rabbits

We administered non-radioactive coloured microspheres (NRACM) to measure the regional tissue blood flow (RTBF) of eight axial pattern flaps and four kidneys in four rabbits using four repeated injections into each animal. As a control, we used radioactive microspheres (RAM) for six kidneys in three rabbits. There were no significant differences for RTBF values between NRACM and RAM, between the numbers of microspheres used (2 x 10(6) and 4 x 10(6)), or between the number of injections. These results showed that NRACM is a useful and safe laboratory method.

[A case of stunned myocardium with marked 99mTc-PYP accumulation]

A 71-year-old woman with unstable angina was admitted to our department. Upon admission, electrocardiography revealed a QS pattern in Leads V1-V3. Left ventriculography disclosed akinesis of the anterior wall and the septum. Myocardial scintigraphy with 99mTc-pyrophosphate (PYP) revealed marked accumulation (Parkey's grade III) in the anterior wall, septum and apical region. Coronary arteriography revealed stenosis (99% with delay) in the LAD #6. Based on these findings, we performed percutaneous transluminal coronary angioplasty (PTCA) on this patient. About 3 months later, the patient underwent PTCA again because stenosis had recurred. The resting 201Tl myocardial scintigram, taken immediately after the first PTCA, demonstrated complete defects in the anterior wall, septum and apical region. After the second PTCA, no stenosis was observed. About 1 year later, the wall motion returned to normal (except in part of the apical region), suggesting that this was a case of stunned myocardium. On the same occasion, the 201Tl uptake was normal except in the apical region. The present case was regarded as stunned myocardium which demonstrated marked radioactivity accumulation when examined by 99mTc-PYP myocardial scintigraphy. In the past, 99mTc-PYP has been thought to be incorporated into irreversibly impaired myocardium (e.g., in cases of acute myocardial infarction). The uptake of 99mTc-PYP into stunned myocardium has not been reported before. Thus, this case is rare and noteworthy.

The arterialised venous flap: experimental studies and a clinical case

It is accepted that small arterialised venous flaps (AVF) can survive on a recipient bed with poor blood supply but survival of larger flaps is not always satisfactory. Possible reasons for this include the flap anatomy, particularly the pattern of the venous network, or factors at the recipient site. To investigate the possible factors in the flap design and the recipient site of an arterialised venous flap, we studied the relationship between (1) size of the artery used to arterialise the flap at the recipient site and the survival rate and (2) the number of draining veins and the survival rate, using rabbit ear skin flap models. Our results suggest that AVFs may become necrotic in the presence of a relative excess of arterial blood inflow, and that two exit veins are more effective than one. We also report a case where a 10 x 15 cm sized free AVF harvested from the lower extremity survived on the forearm.

"Plasmatic imbibition" in the rat musculocutaneous pedicled venous flap: enzymatic proof using horseradish peroxidase

To determine the reason for survival of a pedicled venous flap in which only a draining vein is preserved, it is important to clarify what kind of blood flow is present in the preserved draining vein. Pedicled venous flaps were prepared on the dorsum of the rat and histologically evaluated using horseradish peroxidase (HRP). HRP was applied between the flap and recipient bed in one group. In the other group, HRP was injected into the femoral vein after the flap was turned over (to prevent contact with the recipient bed). The flaps in these HRP-treated groups were compared with untreated control groups. HRP applied between the flap and recipient bed was imbibed into the flap and subsequently transferred into the preserved draining vein. HRP that was injected into the femoral vein was also found in the draining vein of the flap. These results suggest that (1) plasmatic imbibition occurs in pedicled venous flaps; and (2) antegrade and retrograde blood flow are present in the draining vein.

The pedicled venous flap. Clinical applications

Experimental findings of survival of pedicled venous flaps were clinically applied in seven cases for traumatic skin defects on digits. Five flaps which were transferred to or on digits other than the thumb survived, but two flaps from the index to the thumb developed partial necrosis. In order to prevent flap necrosis, the draining vein should be short.

Extracorporeal circulation for tissue transplantation (in the case of venous flaps)

During free-tissue transplantation, recipient vessels are often crushed as a result of trauma or radiation therapy, making anastomosis of vessels difficult. In some cases, a second operation is unavoidable because of formation of a postoperative thrombus at sites of the anastomosis. To solve such problems, it should be possible to transplant tissue anywhere in the body without vascular anastomosis by extracorporeal circulation. This study mainly concerned venous flaps that were spindle-shaped and 4 x 3 cm in size. One hundred and forty-six male Japanese White rabbits, weighing 2.0 to 2.5 kg, were used. Stabilized hemoglobin, lactated Ringer's solution, whole blood, and plasma were used as perfusate. Each of these perfusates was injected at a rate of 5 ml per hour continuously for 3 days in good recipient sites and for 7 days in poor recipient sites. Five rabbits were used in each group. The flaps were examined histologically and electron microscopically. Moreover, in the plasma group, microangiography was performed to observe blood circulation between the flap and the surrounding tissue. The flaps survived in all cases in which the plasma group had good recipient beds but did not survive in any of the other cases, in which degeneration of the endothelial cells was detected prior to edema. According to the results of this examination, tissue viability of the venous flap could be maintained for at least 3 days by perfusion of plasma. During this time, in the cases of good recipient sites, blood may begin to recirculate between the flap and the surrounding tissue.

Vascular complications of vascularized composite tissue transfer: outcome and salvage techniques

Two hundred fifty-two vascularized composite tissue transfers were performed from 1985 to 1992 at Nara Medical University Hospital. Free tissue transfers were performed in 185 patients and island tissue transfers in 67 patients. Of these, 39 flaps were reexplored because of vascular complications. On initial reexploration, vascular obstruction was found at the site of anastomosis or in the main vascular pedicle in 36 patients and in the perforating vessels to the monitor flap in three patients. Arterial thrombus occurred in 11 patients, venous thrombosis in 12, and both in nine. Twenty-five reexplored flaps were salvaged. Initially, heparin was administered systemically when vascular compromise was suspected intraoperatively or postoperatively. Recently, we have used a "continuous local heparinization" technique to minimize blood loss. This method has been used in 12 patients who underwent reexploration and in nine patients in whom vascular compromise was suspected. Nineteen flaps survived completely, and two flaps failed.

An experimental study of the flow-through venous flap: investigation of the width and area of survival with one flow-through vein preserved

A quantitative analysis was undertaken to investigate the width and area of survival of flow-through venous flaps in 20 ears of 10 rabbits. The 3.0- x 3.0-cm flap models, which included one flow-through vein, were prepared with additional circulation from the graft bed and surrounding tissue excluded, as far as possible. The flaps were divided as follows: Group A--composite grafts (n = 10), and Group B--flow-through venous flaps (n = 10). All flaps in Group A became necrotic and all those in Group B showed partial survival along the flow-through vein. The average survival width was 1.10 +/- 0.48 cm, and the survival rate was 44 +/- 19.3 percent. Microangiograms revealed patency of the flow-through vein in all flaps of Group B. Histologically, there tended to be progressively more fibrous tissue in the area further away from the flow-through vein. The model is useful to investigate the width and area of survival in flow-through venous flaps.

[Clinical application of 31P MRS to malignant liver tumors--with an emphasis on evaluation of response to therapy]

Malignant liver tumors in 19 cases (13 hepatomas and 6 metastatic tumors) were studied by 31P magnetic resonance (MR) spectroscopy. Five healthy volunteers were also studied. Volume localization was performed using the ISIS sequence. Compared with normal liver, the MR spectra of malignant tumors showed an elevated phosphomonoester (PME) peak relative to beta ATP (p less than 0.005), and tumors were slightly alkaline (pH 7.32 +/- 0.08) before therapy. Nine cases of hepatomas responding to chemoembolization showed extremely reduced signal intensity of spectra. Tumor pH was compared before and after therapy in four cases that showed good response to therapy, and was elevated in all of them. Three metastatic tumors with good response showed reductions in PME and ATP after therapy. MR spectroscopy with adequate localization technique is useful in demonstrating the response of malignant tumors to therapy.

Proof of plasmatic imbibition in rat musculocutaneous grafts: enzymatic proof using peroxidase

At present, the concept of plasmatic imbibition is generally accepted. That is, observation of weight change or pigmentation methods of the grafts were established to support it. In the present study, we investigated plasmatic imbibition in rat musculocutaneous grafts histologically using peroxidase, which is one of the reductases. Tissue pigmentation by peroxidase became an insoluble sediment that indicated the sites of peroxidase activity. The entire contact surface of the graft with the recipient bed was stained brown within a few minutes after the operation. At 30 minutes, the panniculus carnosus and dermis were stained dark brown diffusely, extending toward the epidermis. This condition continued until the sixth day at least. As a result, peroxidase that was dissolved with the exudate between the graft and recipient bed was imbibed into the musculocutaneous graft.

[Coronary artery disease in diabetic patients]

Although it is well known that diabetics have high mortality rates due to ischemic heart disease (IHD), controversies still exist about the severity of coronary artery disease in diabetics compared to nondiabetics. We compared coronary arteriographies of 50 diabetics with IHD to those of 50 nondiabetics with IHD. In regard to coronary risk factors, incidence of obesity was significantly higher in diabetics. Incidence of hypertension, hypercholesteremia, hyperuricemia was higher, although not significant, in diabetics. Incidence of smoking was significantly higher in nondiabetics. The diabetic group showed a significantly higher incidence of patients with more than two or three diseased vessels, and a significantly higher number of diseased coronaries with more than 50% stenosis per patient compared to nondiabetics (5.6 +/- 3.7 vs 3.7 +/- 3.2). The distribution of diseased coronaries with more than 75% stenosis showed no difference between diabetics and nondiabetics. The incidence of coronary spasm was significantly lower in diabetics (12% vs 28%). The high incidence of multiple vessel disease in diabetics was thought to be due to other complicated coronary risk factors, especially hypertension and hypercholesteremia.

[Signal contamination problem in three-dimensional localization technique of MR spectroscopy--experiment and an analysis of patient data]

Signal contamination from the surrounding volume was studied using the ISIS sequence, a three-dimensional localization technique. In phantom experiments, contamination decreased with the increase of Tr, regardless of where the contamination originated from. In 52 localized liver spectra with a Tr of 2 sec, PCr contamination was estimated at 3 to 4%, and contamination of ATP signals from the surrounding liver tissue at less than 1%, because of the relatively short T1 of ATP in the liver. In the spectra of brain neoplasms obtained using the simultaneous double-volume selection technique, the PCr ratio in the tumor relative to the control area was high in low grade astrocytoma (0.80, n =8) and low in others (0.45, n = 11). Considering contamination and spectral noise, a PCr ratio of less than 0.4 does not strongly suggest the existence of PCr in tumors. Among 25 cases whose therapeutic processes were monitored by MRS, signal disappearance was observed in two cases in the localized spectra after therapy. In both of them, tumor necrosis was proved pathologically and correlated well with spectroscopic findings. It was found that the ISIS technique suppressed signal contamination to the level of several percents, providing spectra of acceptable quality through localization.

A new cell line (XTY) from a tumor of Xenopus laevis

A new cell line (XTY) was derived from a tumor of a female Xenopus laevis. This cell line has been proliferating in standard amphibian culture medium for more than 4 years (470 generations) and has a doubling time of 75.5 h at 25 degrees C. The cells aggregate into large groups, and their stellate morphology and the expression of desmin demonstrated by immunocytochemistry suggest that their origin is not epithelial.

Continuous local intraarterial infusion after prolonged arterial stasis in the fingers and toes

Seven patients with trauma to eight digits and one toe went untreated for arterial stasis, with subsequent development of posttraumatic changes in skin coloration. In two patients involving two digits, a daily dose of 2,000 ml containing 240,000 U urokinase, 80 micrograms prostaglandin E1, and 10,000 U heparin in lactated Ringer's solution was administered by intravenous infusion for 10 consecutive days; one of the two digits became necrotic. In all subsequent patients, a daily dose of 80 ml containing 240,000 U urokinase, 40 micrograms prostaglandin E1, 10,000 U (maximum) heparin, and low-molecular-weight dextran was administered by continuous local intraarterial infusion for 10 consecutive days. These seven extremities survived, even in the case of two digits and one toe with over 50 hr of arterial stasis. We believe that revascularization of extremities following prolonged periods of arterial stasis may be possible by means of continuous local intraarterial infusion of antithrombotic agents.

[Changes in blood sugar levels following infusion of lactated Ringer's solution with various concentrations of potassium and glucose]

Lactated Ringer's solution was prepared, in which concentration of potassium was either 10 or 20 mEq.l-1, and that of glucose was 1.4%. Each preparation was infused into 10 patients who underwent surgical operations under general anesthesia. Effects of this fluid therapy on changes in serum potassium and blood sugar were studied comparing with infusion of lactated Ringer's solution in which concentration of potassium was 10 mEq.l-1, and glucose was 0.7%. Both serum potassium and blood sugar levels were maintained within normal ranges with the lactated Ringer's solution containing 20 mEq.l-1 of potassium and 1.4% of glucose. On the other hand, the former tended to decrease and the latter tended to increase with the lactated Ringer's solution containing potassium 10 mEq.l-1 and glucose 1.4%. We consider that the homeostatic effect with the lactated Ringer's solution containing 20 mEq.l-1 of potassium and 1.4% of glucose would be to lower blood glucose level by concomitant intracellular influx of potassium and glucose. Therefore these high potassium lactated Ringer's solutions balanced adequately with glucose are useful for fluid therapy during surgical procedure under general anesthesia.

Continuous local intra-arterial infusion of antithrombotic agents for replantation (comparison with intravenous infusion)

The success rate of replantation of amputated digits and limbs appears to be improved by local continuous intra-arterial infusion of urokinases, heparin and PGE1 at a daily dose of 240,000 I.U., 10,000 U, and 40 micrograms, respectively, for ten days, in comparison to intravenous infusion of the drugs. The purpose of this study was to investigate the difference between the haematological effects of intra-arterial and intravenous infusion. Accordingly coagulation and fibrinolytic enzyme levels were examined before, and at 4 and 12 hours after the start of infusion and on the 3rd and 10th postoperative days. Intra-arterial infusion was advantageous over intravenous infusion probably because the effect of general metabolism on drug levels was small, drugs exhibited immediate action and efficacy was localised. No particular side effects were demonstrated.

The sliding venous flap for covering skin defects with poor blood supply on the lateral aspects of fingers

For the treatment of skin defects with poor blood supply on the lateral aspects of the fingers, particularly the radial side of the index finger and the ulnar side of the little finger which have been difficult to cover conventionally, we have developed the sliding venous flap. The flap can be moved by using the "sag" obtained from the dissected dorsal veins of the same finger. We have applied this technique in six cases with excellent results. The indications are limited to cases with only slight crushing of the dorsum of the finger. We consider this technique safe and effective in covering skin defects with poor blood supply on the lateral aspects of fingers.

An investigation of venous pressure and oxygen tension in human extremities: an experimental study of survival in pedicled venous flaps

The pedicled venous flap is used at various sites, such as the finger, forearm, and leg. The authors previously reported that the reasons for the viability of such flaps, based on the digital dorsal vein and used for repairing digital skin defects in the earlier study, were high venous pressure or oxygen tension, as well as the possible effects of plasmatic imbibition and outflow through the draining vein. To investigate the importance of venous pressure and oxygen tension in the survival of these flaps at other sites in the body, measurements were made comparing these parameters in the digital vein, cephalic vein, and greater saphenous vein, which are all used clinically as draining veins in pedicled venous flaps. Although measurements in other sites were consistently lower than in the digital dorsal vein, since these other venous flaps are nevertheless viable in the clinical situation, their viability may not be due only to relatively high venous pressure and oxygen tension. The authors intend to carry out further comparative studies on plasmatic imbibition in the flap and outflow through the draining vein.

Combined therapy with antithrombotic agents and radical scavengers for reperfusion injury of flaps

The usefulness of combining antithrombotic agents and radical scavengers in the treatment of reperfusion injury (an almost ideal approach) was substantiated using an ischemic flap model. The cause(s) of reperfusion injury was hypothesized on the basis of differences in effects between antithrombotic agents and radical scavengers in the experimental groups. Flap specimens were also obtained regularly for histologic examination. The experiment was conducted in nine rabbit groups. For continuous treatment with intraarterial antithrombotic agents, both heparin and urokinase were continuously injected at respective administration rates of 20 U/kg/hr and 200 IU/kg/hr for seven consecutive days immediately before reperfusion. For intraarterial radical scavenger treatment, a solution of both 30,000 U/kg SOD and 30,000 U/kg catalase in 5 ml of a lactated Ringer's solution was injected over a period of about 30 min immediately before reperfusion. The ischemic time of the flaps was 10 hr for Group I and 12 hr for Group II. Each group was comprised of subgroups a, b, c, and d: a = control; b = continuous intraarterial antithrombotic agent injection; c = intraarterial lactated Ringer's solution alone; and d = intraarterial radical scavenger injection. For Group II, an additional subgroup e was established, which received continuous injection of both intraarterial antithrombotic agents and injected intraarterial radical scavenger. In the 10-hr ischemic treatment group, an effect was obtained by continuous intraarterial antithrombotic agents alone. In the 12-hr ischemic treatment group, a significant improvement in flap-take ratio was obtained using intraarterial radical scavenger, in combination with antithrombotic agents. Observation of the flaps that survived in subgroups Ib and IIe revealed skin thinning, vascular wall thickening, and muscular tissue degeneration, although the skin architecture was well preserved.