Regional diagnosis of lymphoedema and selection of sites for lymphaticovenular anastomosis using elastography

AIM

To evaluate the use of ultrasound elastography as a basis for determining the most appropriate sites for lymphaticovenular anastomosis (LVA) for treatment of lymphoedema.

MATERIALS AND METHODS

Preoperative elastography and LVA were performed in 11 patients (11 legs) with leg lymphoedema, including two cases of primary oedema and nine of secondary oedema.

RESULTS

The mean number of LVAs applied per leg was 4.4 (range 3-7). The mean reduction in the leg circumference was 91.7%, and 10 of the 11 cases (90.0%) were improved. Hardness was reduced from a mean of 1.6 before surgery to 0.9 after surgery, and improvement was also noted in 10 cases (90.9%). The severity of oedema was determined in five regions in each leg, and was classified as elastography stage (ES) 0 in 11 regions, ES1 in 23, ES2 in 15, and ES3 in six.

CONCLUSIONS

These results demonstrate the value of ultrasound elastography for the diagnosis of early-stage lymphoedema and determination of LVA sites. This is the first report of diagnosis of lymphoedema using elastography and the findings suggest that this procedure followed by LVA could be used as a new therapeutic method for early-stage lymphoedema.

Vascularized nerve flap for spinal cord repair-a preliminary study

OBJECT

By making the "vascularized nerve flap for complete spinal cord gap" model, we assessed the histological effect of this method.

METHOD

Eight female Sprague-Dawley rats were divided into 2 groups: group A and group B. Group A included "nonvascularized nerve flap" models, whereas group B consisted of "vascularized nerve flap" models. In each group, we transferred peripheral nerves to fill the void made by complete surgical transection of the spinal cord. Postoperatively, we administered intravenous antibiotics and performed urethral catheterization and disimpaction everyday. Tissue sampling was done on postoperative day 10.

RESULTS

No necrosis occurred in group B, vascularized models. In group A, nonvascularized models, necrosis of the grafted nerves was observed in 2 of the 4 rats. As for the specimens of Kluver-Barrera's method for selective myelin sheath staining, in group B, all specimens were stained with Kluver-Barrera's method for selective myelin sheath staining, whereas in group A, 2 specimens with successful engraftment were not stained. With type IV collagen immunostaining, the increase of type IV collagen around the grafted area was not so severe, compared with that of normal region in vascularized cases. In nonvascularized cases, the appearance of type IV collagen was prominent. Therefore, in the vascularized cases, it was made clear that Schwann cells survived in vascularized models and that fibrotic scar formation was inhibited.

CONCLUSION

Histological comparison between vascularized and nonvascularized peripheral nerve transfer for complete spinal cord gap showed significant differences in 10 days. A longer follow-up period is necessary for observation of functional differences.

Intraoperative Lymphography Using Indocyanine Green Dye for Near-Infrared Fluorescence Labeling in Lymphedema

A new method for easy detection of functional lymphatic vessels in the superficial layer is reported. In a clinical trial, lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphaticovenular anastomoses was performed in 5 patients with lymphedema. The technique is simple and enables a minimally invasive operation to be performed. The results indicate that this technique is useful for acceptance as one of the examinations to evaluation of lymphedema.

Combination of Costal Cartilage Graft and Rib-Latissimus Dorsi Flap

In secondary reconstruction of the maxilla, skeletal reconstruction as well as soft tissue augmentation is required to obtain a good contour. We present a new strategy for combining a costal cartilage graft with a rib-latissimus dorsi flap. We used this method to treat a 39-year-old man who had previously undergone total maxillectomy. First, a vascularized rib, elevated together with a latissimus dorsi flap, was fixed between the middle of the maxilla and the edge of the zygomatic arch. The small defects that could not be reconstructed with the rib only were reconstructed with a costal cartilage graft. The patient did not develop any postoperative infection or flap necrosis. Thirteen months after the secondary reconstruction, he presented with a good contour of the cheek. Our method was effective for the reconstruction of a complex skeletal defect of the maxilla.

A woman who required long-term mechanical ventilation to treat limbic encephalitis during pregnancy

We describe our experience with a woman who had severe non-herpetic acute limbic encephalitis at 20 weeks' gestation. Despite receiving mechanical ventilation for about 3 months because of impaired consciousness and frequent convulsions, she had a normal delivery and an uneventful recovery with no sequelae. The patient did not respond to treatment with antiviral agents. Anticonvulsant agents were given while monitoring plasma drug concentrations. Early treatment and the prevention of complications apparently contributed to good outcomes in the mother and child.

Transduction of human islets with the lentiviral vector

Establishment of an efficient gene delivery system for human pancreatic beta cells is important for the development of diabetes-targeted cell therapies. The human immunodeficiency virus type 1 (HIV-1)-derived lentiviral vector is well documented to be an effective gene transfer tool for various types of cells. Thus, we examined the efficiency of lentivirus-mediated gene delivery for human islets. Human islets were isolated using defined protocols for enzymatic dissociation and purification using discontinuous Ficoll gradients with a refrigerated Cobe 2991 machine. Isolated islets were shipped to Japan, cryopreserved for 3 months, and then subjected to transduction. A vesicular stomatitis virus G-protein (VSV-G)-pseudotyped lentiviral vector LtV-NLS/LacZ was produced in 293T cells under the Fugene6 method. 804G extracellular matrices were applied for monolayer formation of islets. Detection of NLS/LacZ expression was performed using X-gal staining. Lentiviral transduction was effective in these monolayer islets.

Different hepatic vascular response to noradrenaline and histamine between guinea-pig and rat

AIM

Hepatic xenotransplantation from guinea-pig to rat has not been established. This failure is partly ascribed to differences in hepatic vascular characteristics between two species. However, the differences in hepatic vascular resistance distribution and responses to vasoconstrictors are not known. The present study was designed to determine basal levels of segmental vascular resistances and the responses to histamine and noradrenaline in isolated guinea-pig and rat livers.

METHODS

The livers were haemoperfused (Hct 8.3%) via the portal vein at a constant flow. The sinusoidal pressure was measured by the double occlusion pressure, and was used to determine the pre- (Rpre) and post-sinusoidal (Rpost) resistances.

RESULTS

There was no significant difference in basal total hepatic vascular resistance (Rt) between two species, whereas Rpre in rat (69% of Rt) was significantly greater than that in guinea-pig (61% of Rt). The responses to noradrenaline were similar; Rpre increased in a greater magnitude than Rpost, and liver weight was reduced. However, the noradrenaline-induced increase in Rt was greater in rats than in guinea-pigs. In contrast, histamine increased predominantly Rpost over Rpre, and increased liver weight in guinea-pig, while it affected no haemodynamic variables in rat.

CONCLUSION

There exist species differences in the hepatic vasculature between rat and guinea-pig. Basal pre-sinusoidal resistance in rat is greater than that in guinea-pig. Although noradrenaline predominantly contracts pre-sinusoidal vessels in both species, histamine causes predominant post-sinusoidal vasoconstriction in guinea-pig liver, while it has no vasoactive effects on rat liver.

[Evaluation of rapidly growing Mycobacteria isolates in a general hospital: reports from the hospital microbiology laboratory]

Forty isolates of rapidly growing Mycobacteria, Mycobacterium fortuitum group including M. fortuitum and M. peregrinum and M. chelonae group including M. chelonae subsp. chelonae and M. chelonae subsp. abscessus at Showa University Fujigaoka Hospital collected between February 1981 and December 1997 were investigated in this study. These isolates were from the patients who were not infected with HIV. The average age of fourteen patients, from whom M. fortuitum group was isolated, was 58 years, ranging from 17 to 80 years old. One patient (71-year-old) with chronic myelogenous leukemia and another (64-year-old) with chronic diabetes mellitus were diagnosed with skin abscesses of M. fortuitum group, which were located on the right site of the neck and in the scar after injecting insulin (injection abscess), respectively. The average age of twenty-six patients, from whom M. chelonae group was isolated, was 57 years, ranging from 32 to 84 years old. One patient (75-year-old) with articular rheumatism was diagnosed with a lung infection of mixed M. chelonae group and Pseudomonas aeruginosa, and another (74-year-old) with diabetes mellitus and kidney failure was strongly suspected of a lung infection. The isolates of the two mycobacteria from the remaining patients were due to colonization, while these patients had the following underlying diseases contributing to infections: pulmonary emphysema; diabetes mellitus; leukemia; collagen diseases; lung cancer; chronic kidney diseases; systemic lupus erythematosus; carcinomatous pleurisy; bronchiectasis; post-tuberculosis. Most isolates of the two mycobacteria were separated from the specimens of patients' respiratory tracts, but since M. chelonae group was a contaminant in the tap-water for diluting concentrated chlorhexidine, the organism happened to be isolated with the mucous membranes of the 6 patients' colons that were picked up while using the washed fiber-scope. These findings suggest that M. fortuitum and M. chelonae groups, in spite of the fact that they rarely cause infection, have a significant risk of infecting aged patients in general hospitals with various underlying diseases attributable to infections. As only a few colonies were isolated from patients' specimens in the majority of cases, it took time to carry out these clinical examinations, and to improve this "laboratory's delay", it is needed to make faster report to clinicians.

Video-assisted thoracoscopic sterilization for exacerbation of chronic empyema thoracis

STUDY OBJECTIVE

To investigate the efficacy of video-assisted thoracoscopic sterilization to treat patients with exacerbation of chronic empyema thoracis.

DESIGN

Case reports and literature review.

SETTING

Academic department of surgery.

PATIENTS

Two elderly, debilitated patients with worsening, chronic empyema thoracis as diagnosed by radiographs, CT, and thoracentesis. Both patients had a history of therapeutic pneumothorax for tuberculosis without bronchopleural fistulas.

INTERVENTIONS

Video-assisted thoracoscopic sterilization of the thoracic cavity.

MEASUREMENTS AND RESULTS

There was no recurrence of empyema during a 6-year follow-up period for one patient and a 2.5-year follow-up period for the other patient.

CONCLUSIONS

Video-assisted thoracoscopic sterilization is a minimally invasive useful treatment for elderly or debilitated patients with exacerbation of chronic empyema thoracis.

[Compensatory growth of residual lung after pneumonectomy in childhood]

Though pneumonectomy proved to be a potent stimulus to compensatory growth in the animal model, the literature on this subject in human patients is sparse. We report a rare case of compensatory growth after pneumonectomy in childhood. A 17-year-old man was admitted to our hospital because of chest pain. He had been capable of normal exercise despite a history of pneumonectomy at the age of 4. Chest radiography showed pneumothorax and a displaced heart. In a chest CT scan, both pleural spaces were filled with the enlarged left lung. Since thoracoscopic examination showed a bulla at the surface of S3, bullectomy was performed. The specimen resected from the lung showed slight dilatation of the alveoli. It is considered that the enlargement of the residual lung had occurred as a result of alveolar multiplication rather than by dilatation of the existing alveoli. This case demonstrates lung regeneration in childhood.

[A case of tracheobronchomegaly]

We report a rare case of tracheobronchomegaly with crescent-type tracheobronchomalacia. A 77-year-old man with a chronic cough was referred to our hospital because of fever and dyspnea. Radiographic examination showed enlargement of the trachea and main bronchi. On chest radiography, the transverse diameter of the trachea was 31 mm, and consolidation shadows were seen in both upper lung fields. Tracheobronchomegaly with pneumonia was diagnosed. The pneumonia was improved by administration of PAPM/BP. On bronchoscopic examination, the trachea and main bronchi were extremely dilated on inspiration, and were collapsed on expiration. The biopsy specimen from the bronchial mucosa showed non-specific chronic inflammation.

[Lung cancer obscured by aspergillus hyphae]

A 66-year-old man was referred to our hospital because of cough. Chest X-ray films showed complete atelectasis of the left lung. Serum CYFRA was elevated. Bronchoscopic examination disclosed a white polypoid lesion occluding the left main bronchus. A biopsy specimen from the lesion revealed numerous aspergillus hyphae. Oral itraconazole (100 mg) and weekly endobronchial instillation of fluconazole were administered. Three months later, on the 12th bronchoscopic examination, the tumor occluding the left main bronchus was detected after the removal of aspergillus, and the biopsy findings yielded a diagnosis of squamous cell carcinoma. Aspergillosis complicated by lung cancer without cavity formation is very rare, and compounded the difficulty of diagnosing lung cancer in this case.

Vaginal nylon sling: loop length and surgical outcomes in those with urethral hypermobility and intrinsic sphincter deficiency

Fifty-four women with stress incontinence underwent a vaginal nylon sling procedure. Of these, 15 were diagnosed as having type I, 27 as type II, and 12 as type III genuine stress incontinence. Follow-up averaged 25 months (range 6-42). The total suture length prior to ligation, which supports the bladder neck with no tension, varied from 200 to 313 mm and demonstrated weak correlation with body mass index (R2 = 0.076, P = 0.043) and body weight (R2 = 0.082, P = 0.036). The objective success rate was 89% (48 of 54 patients) 25 months later; the subjective rate was 93% (50 of 54 patients). Kaplan-Meier analysis demonstrated that the cumulative continence rate was 85.6% at 42 months for those with type I, 88.4% at 42 months for those with type II, and 91.7% at 40 months for those with type III incontinence (P>0.05). The main postoperative complication was retention or difficulty in urination. It was concluded that the total suture length cannot be determined in relation to patient's physical parameters, but rather on surgical experience, and that this operation is recommended to those with not only intrinsic sphincter deficiency but also with urethral hypermobility, provided surgery is executed with safe precautions.

The Stamey and Gittes procedures: long-term followup in relation to incontinence types and patient age

PURPOSE

We report the long-term results of needle suspension of the bladder neck for stress incontinence.

MATERIALS AND METHODS

A total of 382 patients with stress incontinence underwent either the Stamey (group 1, 342 women) or Gittes procedure (group 2, 40) in a nonrandomized trial. Surgical outcomes and patient satisfaction were assessed by questionnaires. Surgical outcomes were then analyzed in relation to surgical procedures, McGuire incontinence types and patient age. Followup averaged 8.1 years for group 1 and 5.0 years for group 2.

RESULTS

Kaplan-Meier cumulative continence rates were 71.5% for the Stamey at 14 years and 37.0% for the Gittes at 6 years postoperatively (p < 0.0001). Patients with type III incontinence attained a 10-year cumulative continence rate of 38.3%, which was significantly inferior to those with type I (76.4% at 11 years) or II (73.9% at 13 years). Older patients had an 11-year cumulative continence rate of 61.4%, which was not statistically different from the younger women (68.9% at 14 years). Of the patients 79% were extremely satisfied or satisfied with surgical results, and urge incontinence developed de novo in 12% of the patients.

CONCLUSIONS

We conclude that the Stamey is superior to the Gittes operation, needle bladder neck suspension is as effective in older as in younger adults and women with type III incontinence should not undergo either operation.

[Analysis of inspiratory flow-volume curve]

Inhaled antiasthmatic agents can be effective, but their efficacy depends on the delivery system and on inhalation technique, especially in metered-dose inhalers (MDI). To find out whether inhalation therapy for asthmatics had been performed correctly, we studied inspiratory flow in the slow matter in healthy subjects and bronchial asthma patients. About half of 30 patients studied inspired more than 1 L/sec inspiratory flow rate, especially in male. Inspiratory flow in the fast matter (peak inspiratory flow; PIF) is important in the use of dry powder inhaler, so we studied the correlationship between PIF and expiratory flow and volume parameters. PIF correlated with PEFR, FEV1 and FEV1% in female, FVC and %FVC in male, respectively. In summary, we must recognize slow inspiratory flow can not be gotten easily, and asthmatic patients always have to use MDI carefully in inspiratory flow. Some expiratory parameters of spirometry can accurately predict PIF. The analysis of inspiratory flow-volume curve gives us beneficial data in inhalation therapy.

[Vesicoureteral reflux and urinary incontinence in myelodysplastic patients: a comparison between those who had anti-reflux surgery alone and those who were treated by anti-reflux surgery combined with bladder augmentation with or without sling operation]

BACKGROUND

Vesicoureteral reflux and urinary incontinence are frequently observed among myelodysplastic patients. Since the conservative therapy is not always effective to improve these pathologies, surgical intervention is necessary for some of the patients.

METHODS

Thirty-eight myelodysplastic patients were divided into 2 groups: Group A comprised 17 patients who had been operated by anti-reflux surgery (crossover method) alone and Group B 21 patients who had undergone anti-reflux surgery (Orikasa's method) and augmentation enterocystoplasty with or without sling operation. Cessation rate of reflux, bladder capacity, bladder compliance and operative complications were analyzed in the 2 groups. A questionnaire was sent to the patient asking to answer frequency of clean intermittent catheterization (CIC), severity of urinary incontinence, satisfaction rate for operation and so on. Mean followed-up periods were 11.7 (5.3-13.6) years for Group A and 3.7 (0.6-6.9) years for Group B, respectively.

RESULTS

Reflux was successfully eradicated in 19 of 24 ureters (79%) of Group A and in 25 of 29 ureters (86%) of Group B, which was not significantly different. In Group A, bladder capacity and compliance slightly improved. The latter, however, remained less than 10 ml/cmH2 O. Bladder capacity and compliance of Group B increased more than twice the original value with statistical significance. Operative complication in Group A was ureteral obstruction in 1 patient, which eventually necessitated peritoneal dialysis. In Group B revision of ventriculoperitoneal shunt was necessary in 4 patients, incomplete ileus was conservatively treated in 3, and a bladder stone was formed in 1. The patients assessed that frequency of pyelonephritis was less in Group B compared to Group A. Other subjective parameters, however, such as frequency of CIC, severity of urinary incontinence, postoperative changes in the amount of urinary incontinence, and satisfaction rate for operation, were not different between the 2 groups.

COMMENTS

Though operation-related complications occurred more frequently in those of Group B, these patients enjoyed significant improvement in bladder capacity and bladder compliance. We conclude when the conservative therapy fails to cure and improve vesicoureteral reflux and urinary incontinence, surgical interventions including anti-reflux surgery and augmentation cystoplasty with or without sling operation are recommended as a treatment option.

[The efficacy of Turbuhaler dry powder inhaler in Japanese asthma--measurement of peak inspiratory flow when using Turbuhaler]

Inhaled antiasthmatic agents can be effective, but their efficacy depends on the delivery system and on inhalation technique. The dry powder inhaler Turbuhaler is being evaluated clinically, and correct inhalation technique with this device has been shown to be easy to teach. To find out whether this device could be useful in Japan, we studied inspiratory flow and inhalation technique with the Turbuhaler in Japanese patients with asthma. Of the 105 patients studied, 80 patients (76.2%) used the Turbuhaler correctly after only one practice session; 58 patients (55%) found it easy or very easy to use, and 19 patients (18%) found it difficult to use. The mean peak inspiratory flow for all patients was 61 L/min. Peak inspiratory flow was less than 30 L/ min in only two patients, both of whom were women over 65 years old. Peak inspiratory flow did not correlate with other indices of pulmonary function. In summary, inspiratory flow in Japanese patients with asthma was sufficient for the Turbuhaler to be effective, and these patients soon learned to use the device even though they had no previous experience with a dry powder inhaler. Therefore, the Turbuhaler should be clinically useful in Japan.

[The study of the relationship between serum eosinophil cationic protein and bronchial responsiveness in the patients with bronchial asthma]

Eosinophil cationic protein (ECP) has been expected as an index of eosinophilic inflammation in bronchial asthma. However, there are many questions about the clinical meaning of the serum ECP, yet. To examine that problem, we measured serum ECP levels in healthy subjects and the asthmatics patients, with and without attack. We also studied the relationship between bronchial responsiveness and serum ECP levels in the asthmatics patients without attack. Patients taking any steroids (including inhaled steroid), anti-allergic agents or cigarettes were excluded. The highest levels of ECP were found in serum sampled from the patients with asthma attack. The levels of the patients without attack were lower, and the levels of the healthy subjects were the lowest of all. To study the relationship between serum ECP and bronchial responsiveness in the asthmatics patients, who had not an asthma attack for at least one week, serum was sampled and simultaneously bronchial responsiveness (Dmin) was measured by Astograph. The serum ECP levels correlated negatively with Dmin, a threshold-type index of bronchial responsiveness (r = -0.569, p < 0.01). These data indicate that between attacks of bronchial asthma, bronchial responsiveness is related to the levels of serum ECP, and that during attacks the level of serum ECP increases further. They also suggest that abnormally high levels of serum ECP are associated with a preattack state in patients with bronchial asthma.

[Needle suspension of the bladder neck for stress urinary incontinence: surgical results of 394 patients operated on with quantitative procedures]

We have investigated surgical results of quantitative suspension of the bladder neck for stress urinary incontinence. Three hundred ninety-four female patients suffering from stress incontinence have been operated on with Stamey's or Gittes' procedures during the past 8 years. While the bladder neck was elevated by quantifying tension of nylon threads in 84 patients, 310 patients subsequently were operated on by quantifying both tension and length of nylon loops. A follow-up period averaged 51 months for a group of the Stamey's and 19 months for a group of Gittes' procedures. Postoperative continence rate was defined by patients' subjective evaluation. Those whose nylon loops were quantified as from 130 to 149 mm attained the highest continence rate, which was not related to age or severity of incontinence. Postoperative difficulty in urination was less in those who had nylon loops of 130 to 149 mm, and was more in those over 60 years of age. Eighty-eight percent of the patients stated very much satisfied or satisfied with the surgery they had undergone. Continence rate was 78% for those operated on with the Stamey's (51 months later) and 69% with the Gittes' procedures (19 months later). The 7-year continence rate was 77% for the former and the 3-year continence rate was 38% for the latter, indicating that the Stamey's procedure was significantly more useful than the Gittes' procedure. Postoperative complications were encountered with 17% of the patients. We conclude that quantitative suspension of the bladder neck is of value to obtain the high success rate of the needle suspension procedure.

[The clinical application of quantitative computed tomography to osteoporosis and it's related disorders]

Bone mineral in spinal vertebral bone, using the methods of single and dual energy tomographies (SEQCT and DEQCT) were applied to the studies of osteoporosis. The measurement of bone mineral in spinal bone with DEQCT was useful for elimination of fat mass effect in bone marrow, but has poorer reprocibility and higher dose-expose of radioactivity, compared with these of bone mineral by the SEQCT method. Bone mineral in the third lumbar spine of osteoporosis patients without bone fracture was employed in the SEQCT method, indicated that bone loss was age dependent in both sex and bone mineral showed O level which might be influenced by the fat mass in the marrow. The fat mass in the marrow was age-dependent. Bone mineral, in addition to fat mass effect was evaluated to give a diagnosis of osteoporosis. Physical activity was responsible for an increase of bone mineral. The more disable physical activity life was, the more diminished bone mineral was. The role of bone mineral was rationally distributed, and unbalanced bone mineral disposition permitted to induction into the degenerative central nervous system. The measurement of bone mineral in the spinal bone by the SEQCT method made possible a diagnosis and prevention of osteoporosis and observation of the therapeutic effect and clinical course was possible in osteoporosis patients.

Ejaculation obtained by intracavernous papaverine in a cervical spinal cord injury patient resulting in pregnancy and childbirth. Case report

A 28 year old male sustained a cervical spinal cord injury (C5, complete) from a traffic accident and was impotent. He started intracavernous injection therapy, by his partner, of papaverine hydrochloride for impotence, restoring ejaculation. His partner had a successful pregnancy after normal sexual intercourse, and delivered a mature female child weighing 3330 g. To our knowledge this is a rare case of a patient with a complete spinal cord injury fathering a child by the above technique.

Pelvic fascia strength in women with stress urinary incontinence in comparison with those who are continent

Biophysical properties of the anterior vaginal wall as well as the rectus fascia were evaluated in vivo by penetrating the Stamey needle into these tissues of 26 female patients with stress incontinence in comparison with those of 21 continent subjects. The results demonstrated that shear strength of the anterior vaginal wall was lower in incontinent patients than in continent subjects (P < 0.01). Shear strength of the rectus fascia in the patients, which was not supposed to be related to urinary incontinence and should have had the same strength as the control subjects, was also found to be lower than the control (P < 0.01). Shear strength of the vaginal wall was not correlated with age irrespective of their continence status (P > 0.05). Based on our findings it is concluded that some women suffering from stress incontinence may have a hereditary disorder of biophysical properties of the tissues.

[Clinical usefulness of visual analog scale for assessment of dyspnea at rest in patients with chronic respiratory diseases]

To evaluate the validity and clinical usefulness of the visual analog scale (VAS) for the measurement of dyspnea at rest, we employed the 150 mm VAS in 29 chronic respiratory disease patients who were clinically stable, and repeated the measurement 4 weeks and 8 weeks later for the evaluation of reproducibility. For the 8-week period, the individual medical treatments remained generally unchanged in all patients. Two patients were excluded from the study due to infection and pneumothorax. Dyspnea at rest was detected on VAS in 23 patients at the first measurement. The VAS measurement was 23.9 +/- 28.4 (mean +/- SD) mm at the first time, 22.0 +/- 23.1 mm at the 4th week, and 22.4 +/- 26.0 mm at the 8th week. There was no significant change among the three measurements. Twenty among the 23 patients with VAS indicative of dyspnea at rest were categorized into grades 4 and 5 of the Fletcher dyspnea category. However, the intensity of dyspnea was distributed widely within each Fletcher category. These results lead to the conclusion that VAS shows good reproducibility over a period of as long as 8 weeks and that VAS measurements can reveal patient-to-patient individual differences in dyspnea intensity which cannot be detected by the Fletcher dyspnea category. We propose that measuring dyspnea at rest using VAS is a useful method to obtain a valid clinical parameter.

[Antibiotic prophylaxis for transurethral resection of the prostate--comparison of oral administration therapy with intravenous administration therapy]

To compare the prophylactic effect of oral and intravenous antibiotics against postoperative fever and urinary tract infection (UTI) after transurethral resection of the prostate (TUR-P), we conducted a multi-center prospective randomized study. The incidence of pyrexia over 38 degrees C was defined as the primary endpoint. One hundred and fifty patients with sterile urine before TUR-P were entered into this study. The patients were allocated randomly into the two arms; arm A cefotiam 4 g a day for 7 days, arm B tosufloxacin 300 mg a day for 7 days, based on the stratification into the 4 groups determined with/without preoperative indwelling catheters and with/without the history of preoperative UTI. Of these patients, 143 were eligible. We divided 124 patients without preoperative UTI and without indwelling catheters as the "low risk group", and the other 19 patients with preoperative UTI and/or with indwelling catheters as the "high risk group". In the low risk group, 9 patients out of 63 (14.3%) in arm A and 6 out of 61 (9.8%) in arm B had pyrexia during 7 postoperative days. The incidence of fever in arm B was 4.4% less than that in arm A and the 95% confidence limit was from -7% to 16%. In the high risk group, 4 out of 11 (36.4%) patients in arm A and none of 8 in arm B had fever but the difference was not significant. The incidence of post operative UTI in the low risk group on the 4 to 5, 9 to 12, 23 to 26 and 37 to 40 postoperative days was 8.3, 16.4, 25.0 and 23.9% in arm A and 6.7, 16.7, 29.6 and 36.7% in arm B, respectively. The prophylactic effect of oral administration of tosufloxacin is equivalent to that of the intravenous administration of cefotiam. The use of oral antibiotics is beneficial to reducing the cost of medication.

[Clinical effects of transabdominal simple hysterectomy on micturition function]

We prospectively investigated micturition function in 68 women who were operated on by transabdominal simple hysterectomy for uterine myoma. Twelve parameters including stress urinary incontinence, obstructive symptoms, irritative symptoms, uroflow curves and amount of residue were subjectively or objectively evaluated before surgery and a mean of 4.4 months post-operatively. Though 55 patients (81%) had had one or more symptoms of micturition disorders prior to operation, surgery significantly reduced this number to 32 (47%) (p < 0.01). Hysterectomy significantly decreased the number of patients suffering from stress urinary incontinence, weak urinary stream, straining micturition, interrupted stream, urgency and frequency in the daytime. The relationship between the weight of the uterus removed and pre-operative symptoms of micturition disorders was assessed. Interrupted stream was present significantly more in the patients with a uterus weighing less than 400 grams and urgency in the patients with a uterus weighing more than 401 grams. We conclude that transabdominal simple hysterectomy is of use to improve micturition disorders pre-operatively recognized.

[Clinical study of tuberculous pleuritis, diagnosed by thoracoscopy using flexible fiberoptic bronchoscope]

Examination by thoracoscopy, using flexible fiberoptic bronchoscope, was performed in 43 patients with pleural effusion according to our reported method. In these patients, 14 cases were diagnosed as tuberculous pleuritis. These 14 cases were investigated with respect to clinical and thoracoscopic findings. Their mean age was 38.1 years, and 11 cases were younger than 50 years old (78.5%). The male:female ratio was 2/1. Clinical symptoms recognised were fever (100%), cough (64.2%), chest oppression (50%) and sputum (35.7%). In 5 cases, gastrointestinal symptoms were recognized such as vomiting, abdominal pain, and diarrhea. Tuberculin reaction was positive in all patients with tuberculous pleuritis on admission. With respect to the thoracoscopic findings of tuberculous pleuritis, yellow-white miliary granulomas were observed on the parietal pleura in 12 cases (85.7%), and this characteristic finding was especially observed at the apex. Biopsy specimens, obtained from these miliary granulomas on the parietal pleura showed histological findings of tubercles. In the other 2 cases, generalized reddening of the entire parietal pleura was observed, with no yellow-white miliary granulomas. Biopsy specimens obtained from the reddened lesions on the parietal pleura showed histological findings of tubercles, and these 2 cases were also diagnosed as tuberculous pleuritis. These results indicate that this method may be very useful for the diagnosis of tuberculous pleuritis in patients with pleural effusion.

[A case of pulmonary arteriovenous fistulas (PAVF) treated with detachable balloon embolotherapy]

A case of pulmonary arteriovenous fistulas (PAVF) treated with detachable balloon embolotherapy is reported. A 31-year-old man was admitted to hospital because of polycythemia and hypoxemia. He had a history of dyspnea on exertion and transient cerebral ischemic attacks (TIA). Chest roentgenogram revealed a peripheral lobulated lesion in the right upper lung field and a coin lesion in the left lung field connected by dilated blood vessels to each hilus. Pulmonary angiography and right heart catheterization was performed. Four PAVFs were observed in bilateral lung field, and the intrapulmonary shunt ratio was 25.8%. Because the patient was symptomatic, we embolized each PAVF with a detachable balloon without complications. After embolotherapy, there was improvement in his symptoms. hypoxemia and shunt ratio. Recent reviews have highlighted the need to consider embolotherapy for bilateral multiple PAVF. We conclude that embolotherapy with detachable balloon is a very useful procedure for treatment of bilateral multiple PAVF.

[Clinical evaluation of usefulness of cefixime (200 mg administered once daily) in the treatment of acute uncomplicated cystitis]

A comparative study of cefixime (CFIX), a new oral cephem antibiotic, was carried out at the Department of Urology, Nagoya University Hospital and its four affiliated hospitals to evaluate the clinical efficacy and safety of two dosage regimens of CFIX, given either in twice daily doses (BID group) or once daily dose (UID group), in the treatment of acute uncomplicated cystitis. Forty six female patients (BID group) were administered the daily dose of 200 mg in two divided doses for 3 days, 30 female patients (UID group) were administered 200 mg once daily for 3 days. The clinical efficacy was evaluated in 33 cases from the BID group and in 22 cases from the UID group, respectively, according to the criteria recommended by the Japan UTI Committee. In the BID group, the clinical efficacy was evaluated as excellent in 18 cases, moderate in 13 and poor in 2, with an overall clinical effectiveness rate of 94%. In the UID group, it was evaluated as excellent in 9 cases, moderate in 12 and poor in 1, with an overall clinical effectiveness rate of 96%. Safety was monitored in 71 patients, and only one case of stomatitis was seen in the UID group. This findings suggest that 200 mg once daily dosing regimen of cefixime is as effective as 100 mg twice daily dosing regimen in treatment of acute uncomplicated cystitis, and is well tolerated in terms of safety.

Bladder compliance in myelodysplastic children: effect of anti-reflux surgery and conservative treatment. Paediatric urology

Little is known about changes in bladder compliance and bladder capacity in myelodysplastic patients following anti-reflux surgery. A study group of 70 patients was divided as follows: group A included 20 myelodysplastic patients who had been operated on for reflux and whose subsequent treatment was conservative. Group B comprised 31 myelodysplastic patients who had been treated conservatively; a third group of 19 non-myelodysplastic patients, treated by anti-reflux surgery because of primary reflux, formed the control group. The follow-up period for group A averaged 61 months (extending from a urodynamic study 3 months after surgery to the most recent test). In group B the mean follow-up period between the initial test and the latest test was 86 months. Bladder compliance in group A patients did not increase significantly (from 5.5 to 6.9), but patients in group B did show a significant increase (from 5.9 to 10.7). Compliance in the 19 non-myelodysplastic patients decreased only marginally 6 months after surgery (from 29.6 to 26.3). Changes in bladder capacity showed a similar trend. In their most recent test, however, the bladder capacity of group A patients increased to the same volume as that of group B. A high correlation between radiological bladder deformity and bladder compliance was found. We propose a bladder compliance of 10.0 as the lower limit for myelodysplastic patients' preferred range. It was concluded that anti-reflux operations prevent any improvement in bladder compliance (but not in bladder capacity) compared with conservative treatment.

[A case of aortoduodenal fistula following radiotherapy of retroperitoneal metastatic disease]

A new case of aortoduodenal fistula was added to the five cases previously reported in the literature, in which malignancy and/or its treatments could be implicated. This 67 year-old woman, six years previously had been placed on a therapy including irradiation on the pelvis for cancer of uterine cervix. For this time she underwent a radiotherapy completed in a total dose of 55.6 Gy combined with hyperthermia and chemotherapy for retroperitoneal metastatic disease with excellent response. Three months later she had hematemesis followed by melena and deteriorated to hemorrhagic shock. Emergent aortography detected contrast extravasation from the aorta with subsequent opacification of the duodenum, and immediate intraaortic balloon occlusion was done, but she died soon thereafter. Postmortem examination revealed the fistula from the aorta just above the bifurcation to a 2 by 1.5 cm. area of the posterior wall of the third portion of the duodenum. Accentuated arteriosclerosis in locally irradiated portion of the aorta, obstruction of small arteries from organized thrombus and hyaline necrosis in the wall of the fistulous tract were defined without evidence of tumor invasion. Based upon the findings of the patient reported herein, radiation might be another possible etiologic factor in aortoduodenal fistula, as well as tumor invasion per se.

[Studies of adenosine inhalation in asthmatic patients]

In order to determine the mechanism of bronchoconstriction induced by the inhalation of adenosine in asthmatics, we measured, by the astograph method, cyclic nucleotides, leukotrienes and thromboxane B2 before and after the inhalation, and we studied the relationship between serum theophylline concentration and Rrs cont, Dmin and S Grs/Grs cont of the astogram obtained by inhaled adenosine. Plasma TXB2 level was significantly raised (p less than 0.05) after inhalation, but cAMP, cGMP, LTB4 and LTC4 did not change. In the astogram, Dmin was significantly elevated (p less than 0.01) when plasma theophylline concentration was raised to the therapeutic level, but Rrs cont and S Grs/Grs cont showed no remarkable change. We confirmed that inhaled adenosine caused bronchoconstriction in asthmatic patients, and that Dmin was elevated after the administration of theophylline. These results suggest that TXB2, a metabolic product of arachidonic acid, may be one of the most important mediators in the bronchoconstriction mechanism of inhaled adenosine.

[A case of primary anterior mediastinal choriocarcinoma]

A 25-year-old man was admitted to our hospital because of hemosputum and abnormal shadows on chest X-ray film. The chest film showed a mass shadow located in the right hilum and multiple coin lesions in bilateral lung fields. The chest CT scan showed a bulky mass sized 7 cm X 6 cm at the anterior mediastinum. This case was suspected to be choriocarcinoma because he was young, it was rapidly progressive and also because serum LDH and beta-HCG values were raised. The specimens obtained by surgical biopsy showed HCG-stain positive syncytiotrophoblasts. Cancer chemotherapy was started with CDDP and other anti-cancer drugs, but he succumbed about 3 months after admission. Autopsy findings showed no scar formation of his testes, and the primary lesion was finally diagnosed to be in the anterior mediastinum. Extra-gonadal choriocarcinoma is rare, and beta-HCG is very useful for its diagnosis and the follow-up of the clinical course.

[A case of malignant ovarian tumor complicated by pregnancy, from the standpoint of tumor marker and quality of life]

It has been reported that malignant ovarian tumor is complicated in a ratio of one to 25,000 pregnancies. In the present study, a 22-year-old, nulliparous woman was presented, who had had her right ovary extirpated for serous cystadenoma (low potential for malignancy) and had undergone chemotherapy previously. Seven years later, she was subjected to celiotomy in the fourth month of gestational age because of left ovarian tumor. Intraoperative work-up disclosed a mucinous cystadenoma (low potential for malignancy) of stage Ia (FIGO). Left salpingo-oophorectomy and omentectomy were undertaken, and fetus-bearing uterus was preserved for the sake of the patient. Serum CA 19-9, with a preoperative level of 106.7 U/ml, fell exponentially into the normal range one month after the operation, and she successfully gave birth to a baby at term. After that, combination chemotherapy was instituted against an elevated level of CA 19-9, and she has been in remission while caring for her child.

[A clinical experience of ofloxacin in patients with respiratory infection]

To a total of 31 patients (18 in- and 13 out-patients) having respiratory infections, we administered ofloxacin (OFLX) orally at a daily dose of 300 to 600 mg and examined its clinical effect. The clinical effect in the 31 cases was as good as 83.9%. Among these cases, 6 cases showed Pseudomonas aeruginosa, thereby indicating the effective rate of OFLX at 50%. In the present examination, we experienced cases in which OFLX-resistant P. aeruginosa appeared in the cases of long-term administration of OFLX. Therefore, our clinic carried out the sensitivity test of P. aeruginosa against OFLX, gentamicin (GM) and imipenem (IPM) in 1987, using clinically-segregated strains of P. aeruginosa obtained by sputum tests. The sensitive strains, which were 100% sensitive to OFLX, GM, IPM respectively in 1985, showed, in segregated strains in 1987, sensitivity of OFLX 57.1%, GM 85.7% and IPM 100%, thus indicating the high resistance-acquiring frequency of P. aeruginosa against OFLX.

[Clinical study of a modified Stamey's endoscopic bladder neck suspension procedure for one hundred female patients with stress incontinence]

One hundred female patients with stress incontinence have been operated on by means of modified stamey's endoscopic bladder neck suspension procedure, i.e. quantifying the thread tension for bladder neck suspension. Twelve patients had 1,000 grams in the nylon loop, 5,800 grams, 9,700 grams, 25,600 grams and 49,400 grams. A follow-up period varied from 10 to 32 months (mean: 20.5 months). A 60-min pad-weighing test revealed urinary loss of 1.0 to 196.0 grams/hour (mean: 36.0) prior to operation. 1. The modified Stamey's procedure was successful in 95 patients (95%). The appropriate thread tension for bladder neck suspension was 400 grams. 2. Various complications were encountered: removal of unilateral nylon suture was necessitated in 2 patients, bleeding from operative wound in 2, bladder tamponade in 2, and clean intermittent catheterization for more than one month in 4. 3. Micturition parameters, i.e. maximum and average flow rates, temporarily got worse post-operatively. Maximum urethral closure pressure decreased and functional profile length elongated which were significantly different from those of pre-operative values. 4. Questionnaire sent to the patients revealed that 89 percent of them were satisfied with the operative results but 11 percent were not. 5. The modified Stamey's procedure is simple to perform and prevents over-tightness of nylon loops. We conclude that this operative method is the treatment of choice for correction of stress incontinence.