A syndrome of cirrhosis, achlorhydria, small intestinal bacterial overgrowth, and fat malabsorption

OBJECTIVES

The purposes of this report were to examine whether or not a positive bile acid breath test in cirrhotic patient was associated with bacterial overgrowth in the upper small intestine, to verify that these bacteria have deconjugation ability, and, in addition, to elucidate whether or not changes in the gastric pH are related to bacterial overgrowth.

METHODS

Twenty-seven patients with liver cirrhosis were tested by breath analysis technique using glycine-1-14C-labeled glycocholate. Jejunal fluids were aspirated through a double-lumen tube with a rubber cover on the tip. Anaerobes and aerobes were isolated and identified. After culturing, we used thin layer chromatography to determine whether each bacteria had the ability to deconjugate bile salts.

RESULTS

Expired breath samples from seven of 27 patients with liver cirrhosis showed a marked increase of 14CO2-specific activity. Bacterial overgrowth was found in the jejunal fluid of these patients. Administration of chloramphenicol to the seven patients reduced 14CO2 specific activity significantly. The majority of the species identified deconjugated bile acids. Seventeen healthy control subjects showed no increase in CO2 excretion, and 16 of the 17 had no bacteria isolated from jejunal fluid. The relationship between 14CO2 specific activity of expired breath samples and gastric pH was also tested in the cirrhotic patients. There was a relatively good correlation (n = 27, r = 0.87, p < 0.05) between 14CO2 activity and gastric pH.

CONCLUSION

We conclude that some patients with liver cirrhosis have bacterial overgrowth in the proximal small intestine that contains species that can deconjugate bile salts, and that the bacterial overgrowth is probably associated with the shift to alkaline pH in gastric juice.

Thiazohalostatin, a new cytoprotective substance produced by Actinomadura. I. Taxonomy, production, isolation and biological activities

Thiazohalostatin has been isolated from the culture broth of Actinomadura sp. by a screening program designed to find novel cytoprotective substances. It was purified by use of column chromatography on silica gel, reversed phase HPLC and then isolated as colorless powder. Thiazohalostatin prevented cell death caused by calcium overload and exhibited an inhibitory activity against lipid peroxidation.

Thiazohalostatin, a new cytoprotective substance produced by Actinomadura. II. Physico-chemical properties and structure determination

Thiazohalostatin is a new cytoprotective substance produced by Actinomadura sp. HQ24. Its structure was elucidated as shown in Fig. 1 by NMR spectral analyses and chemical modifications. Thiazohalostatin was found to possess a novel skeleton containing trichloropyrrole and thiazoline ring moieties.

Enhanced inhibitory effect of polymeric star burst formed yigsr Peptide on newly established nude-mouse spontaneous adenocarcinoma metastatic model

A highly metastatic nude mouse adenocarcinoma cell line, XK-4, was established, and the inhibitory effect of the polymeric star burst YIGSR peptide on XK-4 metastasis was examined. XK-4 adenocarcinoma arose spontaneously in a nude mouse after the subucutaneous transplantation of a human colon cancer. XK-4 cells were first cultured in February, 1990 after serial transplantation of the tumor in nude mice since October, 1985. The XK-4 cell line produces blood borne lung or liver metastasis 2 weeks after injection into the tail vein or anterior mesenteric vein, respectively. Chromosomal analysis of the XK-4 cell line revealed only murine chromosomes, and isozyme analysis showed a murine pattern. Transplantation of XK-4 cells into a thymus-intact litter mate was rejected. These results suggest that the XK-4 adenocarcinoma grew spontaneously in the nude mouse due to some kind of human cancer stimulation. A peptide consisting of the active domain of laminin, YIGSR, was chemically synthesized as a polymer with a star burst pattern. The inhibitory effect of polymeric star burst YIGSR on XK-4 metastasis was enhanced, compared with monomeric YIGSR. These effects appear to be due to the prolonged half-life of polymeric star burst YIGSR in vivo, and increased binding of polymeric star burst YIGSR to the YIGSR receptor. In this study we established a new metastatic model, and confirmed the enhanced metastatic inhibitory effect of a polymeric form of the star burst YIGSR peptide.

Phenazoviridin, a novel free radical scavenger from Streptomyces sp. Taxonomy, fermentation, isolation, structure elucidation and biological properties

Phenazoviridin is a newly discovered free radical scavenger from microorganisms. It was isolated from the culture of Streptomyces sp. HR04. The structure of phenazoviridin was determined as 6-(3-methyl-2-butenyl)phenazine-1-carboxylic acid 6-deoxy-alpha-L-talopyranose ester on the basis of its spectroscopic and physico-chemical properties. The novel substance showed strong inhibitory activity against lipid peroxidation in rat brain homogenate and exhibited antihypoxic activity in mice.

[Muscle sympathetic nerve activity (MSNA) in a patient with tetanus]

Autonomic nervous function was studied in a 57-year-old female patient with tetanus of mild degree, by recording muscle sympathetic nerve activity (MSNA) using the microneurographic method, as well as by measuring blood pressure, heart rate and plasma content of norepinephrine (NE). No apparent clinical signs of autonomic dysfunction were observed. Recording of MSNA on the 7th hospital day revealed decreased discharge rates compared with age-matched healthy subjects, indicating suppressed sympathetic nerve function. The decreased MSNA returned to closely normal level after 3 months, when the clinical symptoms and signs were almost completely cleared up. Previous studies have shown facilitated sympathetic nerve function, while some sympathetic nerves remain suppressed, and therefore unstable cardiovascular dysfunction might be elicited in tetanus.

[Anesthetic management of an infant with Menkes disease]

Menkes disease is a rare, sex-linked recessive disorder characterized by kinky hair, convulsion, mental retardation, bone and connective tissue lesions, and hypothermia. These symptoms have been attributed to suppression of copper-dependent enzymes resulting from copper deficiency. We report a case of a 7-month-old infant with Menkes disease who underwent repair of inguinal hernia. Anesthesia was maintained with sevoflurane-N2O-O2, and the operation was carried out uneventfully. Although the patient had been medicated with anticonvulsants preoperatively, transient seizure occurred in the recovery room. We also discuss pathophysiology and anesthetic management of a patient with Menkes disease.

[Adult T cell leukemia/lymphoma effectively treated with chronic oral etoposide]

A 52-year-old man, who complained of tarry stool and systemic lymphadenopathy, was admitted to our hospital on July 2, 1992. Biopsy showed diffuse large cell lymphoma. Leukocytosis with atypical lymphocytes was not shown in the peripheral blood, but there was an elevated serum LDH level. The man was found to have both HTLV-I antibody and the monoclonal integration of proviral DNA in malignant lymph node cells obtained at biopsy. The diagnosis was lymphoma-type adult T-cell leukemia (ATLL). The chemotherapy regimens of MI-FP, CHOP and modified DHAP were used for the treatment, but were not effective. So, he was treated with etoposide 75 mg orally for 25 days (chronic oral etoposide therapy) and achieved partial remission. This chemotherapy induced myelosuppression with neutropenia, but there was no documented infection. Chronic oral etoposide therapy is an effective regimen for patients with relapse or refractory lymphoma.

Effects of acupuncture on somatosensory evoked potentials: a review

Although acupuncture has a long history of analgesic effects, the mechanisms underlying its effects are still unclear. Somatosensory evoked potential (SEP) methodology has been adopted in the research of acupuncture since the 1970s. In research on the effects of acupuncture on the conventional SEP, variable results have been observed, and two different opinions concerning the presence or absence of acupuncture effects on the conventional SEP are discussed. Since the conventional SEP is mediated mainly by fast conducting sensory nerve fibers, the conventional SEP methodology, especially that for recording short-latency SEP, may be inadequate for studying acupuncture mechanisms. In the case of the long-latency cortical SEP, there are too few data available to judge the effects of acupuncture analgesia (AA). Studies on the effects of AA on pain SEPs demonstrated that AA has a suppressive effect on amplitude of the pain SEP (and affecting the latency as well in some experiments) in both animals and humans, being accompanied by increased pain threshold. Thus, acupuncture seems to have analgesic effects that are probably related to activation of the antinociceptive system, and application of the pain SEP methodology to the study of mechanisms of AA may be promising.

Vicenistatin, a novel 20-membered macrocyclic lactam antitumor antibiotic

A new antitumor antibiotic vicenistatin was isolated from the culture broth of Streptomyces sp. HC34. The structure of vicenistatin was elucidated by NMR spectral analysis. Vicenistatin exhibited antitumor activity against human colon carcinoma Co-3 in the xenograft model.

Hepatic arterial infusions of interleukin-2-based immunochemotherapy in the treatment of unresectable liver metastases from colorectal cancer

In preclinical studies, hepatic arterial infusion of interleukin-2 (IL-2) in dogs significantly induced lymphocyte proliferation and augmented antitumor killing activity in the liver. Based on these findings, a pilot study of hepatic arterial infusions of IL-2-based immunochemotherapy was conducted in 21 patients (15 men, 6 women) with unresectable liver metastases from colorectal cancer, to determine whether the addition of IL-2 improved the therapeutic efficacy of chemotherapy alone. Interleukin-2 was given to all patients as 7 to 8 x 10(5) Japanese reference units (JRU) in addition to 5-fluorouracil (5-FU) 250 mg daily and mitomycin C (MMC) 4 mg once weekly, through a subcutaneous port for 3 weeks. After completion of the initial course, patients were discharged from the hospital and continued on a modified regimen for outpatient therapy: IL-2, 2.0 to 2.1 x 10(6) JRU and 5-FU 250 mg twice weekly; MMC 4 mg once weekly. Patient response rate was 76%, and the median survival from initiation of treatment was 24 months. Toxicity of the combined regimen was minimal. Peripheral lymphocyte phenotype study showed notable decreases in CD8+, CD16+, and CD57+ cells and an increase in CD4+ cells (ie, elevation of 4:8 ratio) during therapy. Electron microscopic analysis of the resected liver of a patient receiving the IL-2-mitomycin-C/5-fluorouracil (IL-2.MF) infusion showed a pronounced accumulation of lymphocytes, penetrating from the space of Disse, around the cancer cells. The present study explores hepatic arterial infusion of IL-2-based immunochemotherapy as a new strategy, based on the activation of liver-associated immune response; this technique may provide improved response and survival for unresectable liver metastases.

Rumbrin, a new cytoprotective substance produced by Auxarthron umbrinum. II. Physico-chemical properties and structure determination

The structure of rumbrin (Fig. 1), a new cytoprotective substance, was elucidated by NMR spectral analysis. Rumbrin was found to possess a novel skeleton containing alpha-pyrone, tetraene and pyrrole moieties.

Rumbrin, a new cytoprotective substance produced by Auxarthron umbrinum. I. Taxonomy, production, isolation and biological activities

Rumbrin has been isolated from a fungus, Auxarthron umbrinum, by a screening program designed to find microorganism-produced cytoprotective substances. It was purified by use of column chromatography on silica gel, reversed phase HPLC and then isolated as fine red needles. Rumbrin prevented cell death caused by calcium overload and exhibited a potent inhibitory activity against lipid peroxidation.

Chemical transformation of gilvocarcin V. Modification of the side-chain

Gilvocarcin V was chemically transformed to alter its biological activities as well as its solubility by mainly focusing on the vinyl side chain. The oxirane and oxime derivatives showed slightly decreased in vivo antitumor activity, while the aminoethylmorpholine derivative turned out to be soluble in some organic solvents.

Pyrrolostatin, a novel lipid peroxidation inhibitor from Streptomyces chrestomyceticus. Taxonomy, fermentation, isolation, structure elucidation and biological properties

Pyrrolostatin, a new lipid peroxidation inhibitor, was isolated from the culture of Streptomyces chrestomyceticus EC40. The structure was determined to be 4-geranylpyrrole-2-carboxylic acid on the basis of its spectroscopic and physico-chemical properties. Pyrrolostatin inhibited lipid peroxidation in rat brain homogenate.

Magnetic resonance imaging in kainic acid-induced limbic seizure status in cats

Magnetic resonance imaging before, during, and after kainic acid (KA)-induced limbic seizure status in cats demonstrated the bilateral hippocampi as slightly high-intensity areas on the T2-weighted images during the limbic seizure status, and isointensity areas 1-2 weeks after KA injection when the limbic seizure status subsided. However, the hippocampi again became high-intense 1-3 months after KA injection. Histological study suggested that the high-intensity area during the limbic seizure status resulted from regional edema, and in the chronic period from marked gliosis and/or atrophic change as a consequence of tissue damage in the hippocampus.

Adrenal metastasis from carcinoma of the colon and rectum: a report of three cases

We report herein three cases of patients with adrenal metastases from colorectal carcinoma. Recurrent disease was suspected following markedly elevated levels of serum carcinoembryonic antigen (CEA), and adrenal metastases were confirmed by computed tomography (CT) scanning in all three patients. The adrenal metastasis was solitary in one patient and this patient is still alive and free from disease 1 year after undergoing complete removal of the adrenal metastasis. On the other hand, metastatic disease was not limited to the adrenal gland in the other two patients and both died of recurrent disease, 33 months and 4 months after undergoing removal of the adrenal metastases, respectively. Thus, although the prognosis of adrenal metastasis from colorectal cancer is usually poor, we believe that patients with a solitary adrenal metastasis will benefit from complete removal of the metastasis.

Acute hemorrhagic cystitis caused by adenovirus following renal transplantation: review of the literature

We report on 4 male patients with acute hemorrhagic cystitis caused by adenovirus following renal transplantation. These patients showed symptoms of gross hematuria, urinary frequency, burning urination and fever. Adenovirus was isolated in all patients and 3 were positive for serotype 11. Complement-fixing antibody was positive for adenovirus in all cases. Acute hemorrhagic cystitis caused by adenovirus was self-limiting and reduction of immunosuppression was not required for its resolution. Clinical presentation of these patients is described and the literature is reviewed.

[Evaluation of chemosensitivity test for cancer using the collagen gel embedded culture system--DNA ploidy pattern and chemosensitivity]

The authors previously reported the advantages of a collagen gel embedded culture system for chemosensitivity tests for cancer. In this report, the chemosensitivities of surgically resected specimens were evaluated by the collagen gel embedded culture system and compared with the DNA ploidy pattern, measured by flow cytometry. The chemosensitivity and DNA ploidy pattern were determined in 11 patients with lung cancer, 8 with gastric cancer and 46 with colorectal cancer. Anticancer agents were MMC and CDDP at Cmax for one hour of exposure, and 5-FU, VDS, VP-16 and ADM at one tenth the Cmax for 24 hours of exposure. Results were compared with those of DNA histogram. In eight lung cancers which were demonstrated to be sensitive by the collagen gel system, 5 showed DNA aneuploidy (DA) and 3 DNA diploidy (DD). Seven cases (87.5%) of gastric cancer were demonstrated to be sensitive with the collagen gel system. Two of them showed DA and five DD. On the other hand, 19 cases (41.3%) of colorectal cancer were found to be sensitive, and 7 of them showed DA and twelve DD. Lung cancer and gastric cancer exhibiting aneuploidy demonstrated sensitivity with the collagen gel system, but the rate of sensitivity was only 28% in colorectal cancer, and even aneuploidy cases showed a low sensitivity.

Microneurographic analysis of muscle sympathetic nerve activity in amyotrophic lateral sclerosis

Muscle sympathetic nerve activity by (microneurograph) blood pressure and heart rate has been studied in patients with amyotrophic lateral sclerosis and in age-matched normal subjects (controls) at rest and during head-up tilt. Muscle sympathetic nerve activity in amyotrophic lateral sclerosis patients was significantly increased at rest unlike controls. There was no correlation between muscle sympathetic nerve activity and age in the patients with amyotrophic lateral sclerosis. Elevated muscle sympathetic nerve activity was present mainly in younger patients. There were no differences between blood pressure or heart rate in either group at rest or during head-up tilt in amyotrophic lateral sclerosis. The increase in muscle sympathetic nerve activity following tilt in the amyotrophic lateral sclerosis patients was less than in the controls, but they had no postural hypotension. The possible reasons for this observation of increased muscle sympathetic nerve activity at rest in amyotrophic lateral sclerosis are discussed.

Responses of plasma adrenocorticotropic hormone, cortisol, and cytokines during and after upper abdominal surgery

There is currently accumulating evidence for bidirectional communication between the neuroendocrine and immune systems. Various cytokines have been suggested to be involved in the stimulation of stress hormone secretion during the times of infection and inflammation. To assess the possible involvement and pathophysiologic significance of cytokines in the mechanisms responsible for the perioperative stress response of the hypothalamo-pituitary-adrenal axis, we observed the changes of plasma adrenocorticotropic hormone and cortisol levels together with those of plasma endotoxin and cytokine levels. In patients undergoing pancreatoduodenectomy, perioperative stimulation of adrenocorticotropic hormone and cortisol secretion was accompanied by a significant elevation of plasma cytokine levels. Application of epidural block up to the upper thoracic levels failed to suppress this stress response effectively. In patients undergoing unilateral total hip replacement, the response of plasma hormone levels was smaller and briefer with no significant increase of plasma cytokine levels. Application of epidural block up to the lower thoracic levels suppressed this hormonal response almost completely. In patients undergoing pancreatoduodenectomy, a significant elevation of plasma endotoxin level was followed by a gradual but significant elevation of plasma tumor necrosis factor alpha and interleukin-6 levels. It seems likely that the stimulatory effects of these cytokines on the secretion of adrenocorticotropic hormone and cortisol might be involved in the development of the greater and more prolonged stress response of hypothalamo-pituitary-adrenal axis. Our present study suggests that not only neural input from the surgical wound but also stimulation of cytokine production were responsible for the development of the stress response of the hypothalamo-pituitary-adrenal axis during and after upper abdominal surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Flumazenil does not antagonize halothane, thiamylal or propofol anaesthesia in rats

We have studied the effects of flumazenil on sleep time and EEG in rats anaesthetized with 1.5% halothane, propofol 20 mg kg-1, thiamylal 30 mg kg-1, or combinations of diazepam 5 mg kg-1 and anaesthetic agents. We also studied the effects of flumazenil 0.3, 3 and 30 mg kg-1 on behaviour and EEG. Flumazenil 0.3 and 3 mg kg-1 alone had no effect on behaviour or EEG, but flumazenil 30 mg kg-1 had depressive effects similar to those of diazepam on behaviour and EEG. Flumazenil 0.3, 3 and 30 mg kg-1 i.v., antagonized the effects of diazepam 10 mg kg-1 i.v. on behaviour and EEG. Flumazenil had no antagonistic effect on sleep time induced by anaesthetic agents, but flumazenil 30 mg kg-1 potentiated propofol-induced anaesthesia. Flumazenil did not affect anaesthesia-induced EEG changes. Diazepam 5 mg kg-1 potentiated anaesthesia. Flumazenil antagonism of diazepam potentiation varied with anaesthetic agent: flumazenil 0.3 mg kg-1 antagonized diazepam action in halothane anaesthesia, but 30 mg kg-1 was required in propofol anaesthesia; this large dose was insufficient in thiamylal anaesthesia.

Bacillus subtilis inositol dehydrogenase-encoding gene (idh): sequence and expression in Escherichia coli

The Bacillus subtilis inositol dehydrogenase (Idh)-encoding gene (idh) was cloned in the B. subtilis temperate phage, rho 11, and then in Escherichia coli plasmids (pBR322 and pUC118). The nucleotide sequence of the idh gene, which consists of 344 codons and whose product has an Mr of 38,351, was determined. E. coli, bearing pIOL05d15, in which expression of the idh gene is under the control of the lac promoter of pUC118, overproduced an active Idh to approx. 20% of total protein upon addition of isopropyl-beta-D-thiogalactopyranoside. This overproduced enzyme cross-reacted with an anti-Idh antibody, and exhibited the same Mr and substrate specificity as those of the B. subtilis enzyme.

[Sympathetic nerve activity in amyotrophic lateral sclerosis--analysis by microneurography]

Muscle sympathetic nerve activity (MSA) was quantitatively analyzed in amyotrophic lateral sclerosis (ALS) by using microneurography. Studies were conducted in 10 ALS patients (2 males, 8 females; mean age 56.4 SD 17.3 years; range 31-77 years). The duration of the disease after onset of symptoms was from 0.8 to 2.5 years. They were classified as a type of classical ALS having mild degree of bulbar signs, an ability to walk by themselves and no subjective breathing impairment. Control groups were selected from 16 healthy age-matched volunteers (8 males, 8 females; mean age 52.9, SD 15.5 years; range 29-76 years). MSA was recorded directly from peroneal nerve fascicles at the popliteal fossa by means of tungsten microelectrodes. The changes in MSA, blood pressure and heart rate were analyzed in the ALS groups and controls laid at recumbent and 30 degrees head-up tilted positions. The parasympathetic functions were evaluated by CVR-R and baroreflex latency. MSA bursts/minute, bursts/100 heart rate and total MSA at recumbent position were significantly higher (p less than 0.01), but their changes at 30 head-up tilted position were slightly lower in the ALS groups compared with the controls. Furthermore, a linear correlation between age of the subjects and MSA in the controls was not found in ALS groups. There were no differences between both groups in blood pressure and heart rate at the two positions. The parasympathetic function was normal in ALS groups. In ALS, sympathetic hyperfunction independent of cardiovascular systems was found especially at the recumbent position. These findings were considered specific to ALS, but the etiology was unclear.

Comparison between muscle sympathetic nerve activity and calf vascular resistance with head-up tilting in humans

The purpose of this study was to determine the relationship between muscle sympathetic nerve activity (MSA) to calf muscle and calf vascular resistance with head-up tilting in humans. In nine healthy volunteers, we performed simultaneous measurements of MSA using microneurography and calf vascular resistance using electrical impedance plethysmography in the same leg. The volunteers were laid on a tilt table and the examinations with head-up tilting (0 degrees, 30 degrees, 60 degrees) were performed. Corresponding to the increase in angles of head-up tilting, MSA and calf vascular resistance significantly increased. A statistically significant positive linear correlation was demonstrated between MSA and calf vascular resistance. These data suggest that impedance plethysmographic measurement of calf vascular resistance can be reliably used to assess the status of MSA with head-up tilting.

[A case of Kearns-Sayre-Shy syndrome with abnormal signal intensity on MRI in cerebral white matter and brainstem]

A 42-year-old woman was admitted for complaining of gait disturbance lasting for 2 years. She had a past history of hearing loss and bilateral ocular ptosis since her age of 21 years. Neurological examinations revealed severe external ophthalmoplegia, ptosis and muscular weakness of neck and extremities, but no dementia. Laboratory examinations showed high level of serum CK and slight elevations of CSF protein, lactate and pyruvate. The QT interval on ECG was prolonged. The EEG finding was slightly abnormal. The neurogenic pattern on EMG was noted. Muscle biopsy was performed at the quadriceps muscle. Its specimens demonstrated mixed changes of muscular atrophy and ragged red fibers. From these findings, Kearns-Sayre-Shy syndrome was diagnosed. It was noted in this case that brain MRI (T2-weighted image) revealed bilateral diffuse high signal intensity areas on cerebral white matter and brainstem. It seems that the lesions of central nervous system may progress subclinically for many years in cases of KSS, as our case shows.

Measurement of leukotriene C4 and D4 in arterial blood of asthmatic patients during remission

We measured the amounts of leukotriene C4 and D4 in the arterial blood of asthmatic patients during remission and compared these with the amounts of leukotrienes in the arterial blood of asthmatic patients during acute asthma, which had been reported in our previous study. Leukotriene C4 and D4 was detected in five patients during remission at 50.68 +/- 8.28 and 36.68 +/- 17.31 pg/mL (mean +/- SD), respectively. In five control subjects, the amounts of leukotriene C4 and D4 were 78.22 +/- 34.65 and 55.06 +/- 13.54 pg/mL (mean +/- SD), respectively. As cited in our previous report, the amounts of leukotriene C4 and D4 in arterial blood of asthmatic patients during acute asthma were 523.33 +/- 737.06 and 495 +/- 304.48 pg/mL. Hence, there were no significant differences in the leukotriene C4 and D4 values between asthmatic patients during remission and control subjects, whereas there was a significant difference in the leukotriene D4 values between asthmatic patients during acute asthma and, asthmatic patients during remission or control subjects (P less than .01). In addition, the leukotriene C4 values in asthmatic patients during acute asthma were larger than in asthmatic patients during remission or control subjects without a significant difference. The amounts of leukotriene C4 and D4 in arterial blood of asthmatic patients may reflect the degree of severity of acute asthma.

[Adverse effects of branched chain amino acid transfusion on type-II citrullinemia--report of an adult case]

A 24-year-old man was admitted to our hospital, because two days before the admission he had abruptly lost consciousness following generalized convulsive seizures. He had a past history of transient amnesia and a favor for peanuts. His grandparents had a record of consanguinity. On admission, he was comatose and flaccid with his four extremities. Laboratory examination revealed the followings; mild degree of abnormal liver function, slight elevation of blood ammonia, irregular theta basic rhythm on EEG, marked brain edema on CT and a normal liver ultrasonography. From the second hospital day, in addition to antiepileptic drugs and adrenocorticosteroids, branched chain amino acid was administered to reactivate damaged brain functions. Thereafter, the concentration of blood ammonia increased to more than 3,000 micrograms/dl, and as a result he fell into status epilepticus. On the fourth hospital day, the levels of citrulline in the plasma and urine taken on the first hospital day were found to have increased by 20 and 100 times, respectively. Although the transfusion of branched chain amino acid was stopped, he died while in coma on the 12th hospital day. Enzymatic analyses of necropsied liver specimens revealed that the quantitative activity of argininosuccinate synthetase had decreased to less than 10% in his urea cycle. In this patient, it was noted that, after transfusion of branched chain amino acid, his brain activities turned worse and blood ammonia was markedly elevated. There is a possibility that intravenous administration of branched chain amino acid may interrupt the urea cycle balance in an adult patient of citrullinemia with dysfunction of the brain, kidney and muscle, especially with brain edema.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mycological and clinical study of cryptococcosis in Yokohama City University Hospital during the period from 1965 to 1989]

Among patients examined at the Central Laboratory of Yokohama City University Hospital over the 25 years from 1965 to 1989, those whose clinical samples showed Cryptococcus were studied in greater detail. The following findings were obtained. Of 16 patients who were found to have cryptococcosis, 14 (87.5%) were treated at the department of internal medicine, and one each at the departments of neurosurgery and dermatology. A study of these patients in terms of clinical type revealed 10 patients (62.5%) with meningitis, two with pneumonia and one with sepsis. The remaining three patients had complicated diseases: meningitis with sepsis, pneumonia with cutaneous cryptococcosis, or pleuritis with sepsis. Underlying disease, including liver cirrhosis, leukemia, multiple myeloma, malignant lymphoma and collagen disease, was found in 6 patients (37.5%), who were all from the department of internal medicine. All patients but one were given antimycotic agents. They were treated by a combination therapy except for three patients who received single amphotericin B (AMPH) therapy. The most frequent combination was AMPH + 5-flucytosine (5-FC), which was found in 7 cases. Seven patients (43.4%) died, three males and four females. Analysis of these cases in terms of clinical type revealed meningitis in four, and pneumonia, sepsis, or pleuritis complicated with sepsis in the remaining three patients. Four patients (57.1%) had underlying diseases. In addition, eleven strains isolated from the specimens were examined for serotypes and minimum inhibitory concentration (MIC) using three types of antimycotic agents. Serotypes of Cryptococcus neoformans were all A and the MIC was 0.1-0.39 micrograms/ml for AMPH, 0.05-0.2 micrograms/ml for 5-FC and 0.2-0.78 micrograms/ml for miconazole (MCZ).

[Does the pelvic nodes dissection for the rectal cancer patients make any contribution to the end-results of surgery?]

Extended pelvic nodes dissection (PND) was adopted to 182 curatively resected rectal cancer patients from 1978 to 1986 at Kinki University Hospital. All patients were diagnosed preoperatively that the depth of cancer invasion were the proper muscular layer or more. Dissected lymph nodes were examined in detail by the clearing method. Pelvic nodes involvement was found in 19 patients or 10.3% out of 182 with PND, and 5-year survival of 19 patients was 26.3%. All over 5-year survival of 182 patients with PND was 69.0% while 62.2% without PND before 1978. There was no significance in the rates of local recurrence between 13.2% with PND and 13.7% without PND. Urinary and sexual dysfunction was increased from 41% and 38% without PND to 66.7% and 88% with PND respectively. It is difficult to evaluate the meaning of PND in the rectal cancer surgery from this non-randomized study. As 80% of the pelvic nodes involvement, however, were found in the cancer with deeper penetration from the muscular layer (a2) and with the location of the middle or lower rectum, PND should be considered only to these two conditions.

Simultaneous measurement of intestinal blood flow and plasma levels of vasoactive substances in a case of early dumping syndrome. Case report

Increase in intestinal blood flow was observed in a patient with postprandial hypotension. Simultaneous measurement of hemodynamic parameters and plasma levels of gut hormones revealed that the release of various vasoactive substances and resulting vasodilation of abdominal organs were responsible for the vasomotor changes of early dumping syndrome.

Effects of interleukins on plasma arginine vasopressin and oxytocin levels in conscious, freely moving rats

To elucidate whether interleukins are involved in vasopressin or oxytocin release during cytokine-related stressful conditions, we examined the effects of human interleukin-1 beta and interleukin-6 on plasma vasopressin and oxytocin levels in rats. Interleukin-1 beta administrated intravenously stimulated both the vasopressin and oxytocin secretion in dose-dependent manners. Neither hormone release was observed following interleukin-6 administration. Pretreatment with aspirin significantly attenuated the effects of interleukin-1 beta on both the vasopressin and oxytocin levels. SC-19220, a prostaglandin E2 receptor antagonist, did not affect the interleukin-1 beta-induced increase of plasma oxytocin levels, but almost completely abolished its effect on plasma vasopressin levels. These results suggest that under certain stressful conditions which accompany the stimulation of cytokine production, interleukin-1 is involved in the increase of plasma vasopressin and oxytocin levels and, moreover, different kinds of prostaglandins are suggested to participate in these interleukin-1-induced hormone release.

[Measurement of immunoreactive endothelin-1 in plasma of a patient with malignant hemangioendothelioma]

We measured immunoreactive endothelin-1 in plasma of a patient with malignant hemangioendothelioma. A 74-year-old female first visited our clinic in July, 1989. Physical examination revealed reddish nodule measured 4 x 5 x 1 cm and erythematous plaque with erosion on her scalp. A biopsy specimen showed extensive proliferation of atypical tumor cells intermingled with a large number of capillary vessels in dermis. Some of tumor cells were positively stained for factor VIII related antigen by PAP method. From these findings we diagnosed malignant hemangioendothelioma and resected the tumor on August 3. The measurement of immunoreactive endothelin-1 in plasma was performed by radio-immunoassay on August 2 (before operation), October 20 and December 27 (after operation). The results were 16.2, 4.3 and 5.6 pg/ml, respectively (normal range: 0.5 +/- 0.2 pg/ml). Plasma endothelin-1 level may be run parallel to quantity of tumor cells in malignant hemangioendothelioma.

[Survey on clinical isolates from 13 hospitals in Akita Prefecture--changes in frequency and susceptibility of isolates by scale of hospital. Survey Group for Clinical Isolates, Chemotherapy Research Committee of Akita Prefecture]

Isolates from various clinical materials in 13 hospitals in Akita prefecture and their drug susceptibility were investigated by the Chemotherapy Research Committee of Akita Prefecture during the period from Dec., 1987 to Feb., 1988. The results were as follows: 1. The total number of isolates was 8,387, including Staphylococcus aureus (18.9%), Pseudomonas aeruginosa (10.9%), Staphylococcus epidermidis (7.3%) and Enterococcus faecalis (6.6%). S, aureus and P. aeruginosa were detected more frequently in the larger hospitals. 2. The detection frequency of S. aureus from the sputum, throat swab and pus exudate was also very high. There was a diversity in isolates from the urine and the frequency of Escherichia coli was low. More than half of the isolates from the blood were S. epidermidis and S. aureus. Many kinds of bacteria were detected from pleural fluid and ascites, but the isolate showed no particular tendency. 3. The susceptibility of S. aureus to oxacillin were variable in hospitals, and the susceptibility to cefazolin were even lower. Low susceptibility were also seen with norfloxacin. S. aureus showed the highest susceptibility to minocycline. The susceptibility was lower for inpatients than for outpatients. P. aeruginosa showed low susceptibility to cefsulodin. The number of ampicillin-resistant Haemophilus influenzae isolates tended to decrease. Enterobacter cloacae showed a low susceptibility for cephems. Serratia marcescens showed low susceptibility to many drugs. Based on the above results, we concluded that attention should be paid to S. aureus, P. aeruginosa and Enterobacter in clinical practice.

[Granulocyte beta-adrenoceptor density increased with methylprednisolone in patients receiving dopamine infusion]

Methylprednisolone (MP) is frequently used in shock states, its antishock mechanisms, however, have not been clarified. Effect of MP 10 mg.kg-1 on granulocyte beta-adrenoceptor density was studied in two patients who required dopamine infusion postoperatively. The granulocyte beta-adrenoceptor density was calculated from the binding of [3H] dihydroalprenolol. Arterial blood pressure and cardiac output increased 1 hr after MP administrations. Beta-adrenoceptor densities were low in both cases prior to the administration of MP (16.1 and 24.6 fmol.mg-1 protein), which increased 11 hr after MP (31.2 and 35.8 fmol.mg-1 protein, respectively). The effects of MP to improve status of cardiovascular system in patients receiving catecholamine-infusion may be associated with the increase in the density of myocardial "down-regulated" beta-adrenoceptor.

[A clinicopathological study on patients with bladder cancer treated with cystectomy]

A clinical and histopathological investigation was made on 170 patients with bladder cancer who underwent total cystectomy at our institutions between 1982 and 1986. The overall 5-year survival rates of patients with pTis + pTa, pT1, pT2, pT3, pT3b and pT4 were 100, 71.8, 60.7, 39.2, 31.4 and 0% respectively, those of patients with G1, G2 and G3 were 100%, 67.6%, 35.7% respectively. As for histopathological growth and spread pattern (INF), intramural lymphatic invasion (ly) and venous invasion (v), INF beta, INF gamma, ly2, v (+) showed the worst prognosis. These histopathological factors were considered to be closely correlated to each other. Studies on these histopathological factors are very important in planning the subsequent therapy.

Measurement of leukotriene B4 in arterial blood of asthmatic patients during wheezing attacks

To investigate whether leukotriene B4 is present in the arterial blood of asthmatic patients during wheezing attacks, 20 ml of arterial blood was drawn from the inguinal artery of five patients. Leukotriene B4 was detected in all five individuals, and its identity was confirmed by a combination of high pressure liquid chromatography and radioimmunoassay techniques. The concentration of leukotriene B4 was 48.34 +/- 16.27 pg ml-1 (mean value +/- SE). However, in five control subjects the leukotriene B4 concentration was found to be 9.43 +/- 5.44 pg ml-1. Thus there was a significant difference between the two groups (P less than 0.05). These results suggest that leukotriene B4 may be important in elucidation of the pathogenesis of bronchial asthma.

[123I-iodoamphetamine single photon emission computed tomography in three patients with amyotrophic lateral sclerosis]

We examined the 123I-iodoamphetamine SPECT for 3 patients with ALS, who were clinically diagnosed. Patient 1 was a 31-years-old man, who had bilateral muscle weakness of his upper extremities, and spasticity in lower extremities. Patient 2 was a 51-years-old woman, who had marked weakness of her upper extremities and bulbar sign. Patient 3 was a 68-years-old man, who had severe degree of marked weakness of his upper extremities and mild bulbar signs. Cerebral cognitive function were all normal in three patients. Computed tomographic and magnetic resonance imagings showed moderate degree of cortical atrophy in patient 1, but no abnormalities in patients 2 and 3. In 123I-IMP SPECT, however, hypoperfusion were recognized on the bilateral fronto-parietal border zone areas in these three patients with ALS. It was suggested that patients with ALS showed varying degrees of impaired perfusion in the fronto-parietal border zone areas in spite of normal cognitive functions.

Successful use of vancomycin hydrochloride in the treatment of lactulose resistant chronic hepatic encephalopathy

Vancomycin hydrochloride (2 g daily) was administered to 12 patients with cirrhosis and lactulose resistant portal systemic encephalopathy in a double blind crossover trial. All 12 patients showed a remarkable clinical improvement after vancomycin treatment. The mean (SE) electroencephalographic (EEG) frequency changed from 6.3 (0.2) to 8.5 (0.2) cps (p less than 0.001) and the mean arterial ammonia concentration from 152 (4) micrograms/ml to 97 (8) micrograms/ml (p less than 0.001). Their clinical condition deteriorated when treatment was switched to lactulose, returning to the previous slower EEG frequency and high arterial ammonia concentrations. Vancomycin seems to be effective in chronic portal systemic encephalopathy in patients who are not helped by lactulose alone.

[Calf impedance plethysmographic evaluation of peripheral sympathetic nerve activity--comparison with microneurographic analysis]

Although the method of impedance plethysmography made it possible to evaluate the vascular resistance of lower extremities, the actual correlation to the sympathetic nerve activity is not known. We performed examinations of microneurography and impedance plethysmography of the lower extremities, in six healthy volunteers, placed on a tilting table. Blood pressure, heart rate, muscle nerve sympathetic activity to calf muscles (microneurography), calf vascular resistance (impedance plethysmography) were simultaneously recorded with increasing angles of the head-up tilting (0, 30, 60 degrees). With the increase of tilting angles, sympathetic nerve activity and the calf vascular resistance significantly increased and these values were statistically correlated to the increase of tilting angles (expressed as sine function). Moreover, a statistically significant positive correlation was observed between the sympathetic nerve activity and vascular resistance. We concluded that the impedance plethysmographic method for measurement of calf vascular resistance is a good indicator for evaluating the peripheral sympathetic nerve activity.

[Colostomy devices for the extracorporeal organ]

Colostomy devices are classified as follows: One-piece and two-piece by structure; Closed, open-end or straight, open-top, drainable, and mini by pouch function. The one-piece device is simple and convenient (disposable) but not cheap; The two-piece one has various exchangeable pouches but some skill is necessary for fitting a pouch to the flange. A closed pouch is disposal en bloc, while an open pouch allows a hand to be inserted several times. The drainable pouch is useful for draining faeces easily with water, while a mini-pouch is unobtrusive and attractive. The skin barrier has been used frequently as a part of the device. Its contents are hydrophilic colloid, hydrophobic colloid and agglutinant. The barrier functioning is dependent on content-ratio and on structure. The latter is classified as blend, laminate, swiss-roll, polka-dot, and froth in type. The apparatus must be used for individual colostomy, utilizing the characteristics based on its specificity; an open-type one-piece unit is used with skin barrier for a postoperative colostomy in the first week, a drainable-type, two-piece unit for another week following suture removal or for diarrhea, and a closed type for rehabilitation. This procedure is called a pouch total system. The irrigation method is good for a scheduled defecation and for peri-stomal dermatitis and for a deformed stoma, but takes more than a half hour and needs a special toilet for irrigation. Indication of the method is for a young ostomate, a sportsman, a field worker, a neurotic or myosophobic person and so on. Today a pouch-free natural defecation method is becoming popular; a kind of stopper is used for a colostomy. This is a foam plug which expands to block feces and eliminates noise and odor. The method is good for pouch-free living, but fecal leakage is encountered in diarrhea.

[Long-term follow-up results of TUL (transurethral ureterolithotripsy)]

We experienced 112 cases of urolithiasis treated with transurethral ureterolithotripsy (TUL) between December, 1985 and September, 1988. We analyzed 35 patients treated with TUL and who had come to our hospital to be examined by cystography, renal ultrasonography, plain X-ray, and urinalysis more than 3 months later. The follow-up term ranged from 3 to 30 months after TUL. The patients were treated using a 12Fr Stortz rigid lithotripter or flexible uretero-fiberscope with electrohydraulic lithotripter. Urinalysis, kidney-ureter-bladder X-ray (KUB), ultra-sonography and cystogram were the main disciplines for follow-up. Urinalysis revealed 4 cases of hematuria, 3 cases of hematopyuria and 2 cases of pyuria. KUB showed no newly formed stones, but 2 cases of ureteral stones had moved from the kidneys. Renal ultrasonography demonstrated no hydronephrosis of operated side, except for 1 case of mild hydronephrosis, who had had severe hydronephrosis preoperatively. We searched for vesicoureteral reflux (VUR) in 34 of the long-term follow-up patients after TUL, but no VUR was seen on their cystograms. No significant late complications of TUL were observed. No harmful effects of ureteral dilation during transureteral operation were found even in long-term follow-up patients.

[Impedance plethysmographic evaluation of sympathetic activity to lower extremity]

Impedance plethysmographic analysis was performed in two cases of late cortical cerebellar atrophy (LCCA) and two cases of Shy-Drager syndrome. Blood pressure, heart rate and peripheral hemodynamics (arterial blood flow and vascular resistance of lower extremity) were measured during head-up tilting. In cases of LCCA, there was no decrease of blood pressure by tilting up. Impedance plethysmography showed significant increase in vascular resistance of lower extremity and heart rate was also increased. In cases of Shy-Drager syndrome, however, marked decrease of blood pressure was shown during tilting up, while there was no significant change in heart rate and vascular resistance of lower extremity was decreased. Therefore, in cases of Shy-Drager syndrome, decrease of peripheral sympathetic activity to lower extremity was suggested. Impedance plethysmography of lower extremity is simple, non-invasive and useful method to assess the status of peripheral sympathetic activity.