[Perioperative mortality and morbidity in 1999 with a special reference to age in 466 certified training hospitals of Japanese Society of Anesthesiologists--report of Committee on Operating Room Safety of Japanese Society of Anesthesiologists]

Perioperative mortality and morbidity in Japan from Jan. 1 to Dec. 31, were studied retrospectively. Committee on Operating Room Safety of Japanese Society of Anesthesiologists (JSA) sent confidential questionnaires to 774 Certified Training Hospitals of JSA and received answers from 60.2% of the hospitals. We analyzed their answers with a special reference to the age group. The total number of anesthetics available for this analysis was 732,788. All cases were divided in to 7 groups; group A(< 1 months), group B(< 12 months), group C(< 5 years), group D(< 18 years), group E (< 65 years), group F(< 85 years), and group G(> 85 years). The incidences of all critical events including cardiac arrest, severe hypotension, and severe hypoxemia were 168.14, 47.86, 24.63, 14.65, 28.43, 50.4, and 43.68 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The overall mortality rate (death during anesthesia and within 7th postoperative day) were 74.10, 6.63, 3.30, 3.07, 4.82, 13.74, and 11.84 per 10,000 anesthetics in patients with group A, B, C, D, E, F, and G, respectively. The incidences of cardiac arrest were 54.15, 8.84, 5.08, 2.56, 4.84, 11.02, and 6.66 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The mortality rates after cardiac arrest were 42.75, 2.95, 2.54, 1.70, 2.00, 6.56, and 5.18 in patients with group A, B, C, D, E, F, and G, respectively. The incidences of all critical events, the incidence of cardiac arrest, and the overall mortality rate were much higher in group A than other groups and lower in group D. Mortality and morbidity due to all kinds of causes including anesthetic management, intraoperative events, co-existing diseases, and operation were as follows. The incidence of all critical events attributable to co-existing disease were the highest in these four groups, and 94.04, 15.46, 7.87, 6.13, 7.26, 17.38, and 16.29 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidences of all critical events attributable to anesthetic management were 31.35, 16.94, 4.60, 6.09, 10.77, and 14.07 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidence of cardiac arrest in group A was much more attributable to co-existing disease and operation than other causes. The incidences of cardiac arrest attributable to anesthetic management were 0.00, 1.47, 0.25, 0.34, 0.83, 0.92, and 0.22 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The mortality rates in these groups were 0.00, 0.00, 0.00, 0.17, 0.07, 0.05, and 1.48, and no death was found in cases under 5 years of age. The two cases of death in G group were due to too high anesthesia levels in spinal anesthesia. Other causes including overdose of anesthetics, toxic effect of local anesthetic, improper management of airway, and incompatible blood transfusion were preventable with the anesthesiologists' effort in protocol development and skilled assistance.

Changes in auditory P300 with clinical remission in schizophrenia: effects of facial-affect stimuli

The auditory P300 is affected by arousal and emotion. We examined the effect of drawings expressing sadness or pleasure on auditory event-related potentials (ERP) during recovery from schizophrenia. Oddball-paradigm auditory ERP were recorded while presenting one of these drawings to nine patients with paranoid schizophrenia and seven patients with other types of schizophrenia during the acute stage and again during remission. P300 parameters (amplitude, area, and latency), reaction time, and symptom scores were evaluated. P300 amplitude and area were significantly greater in the recovery than in the acute phase. Increases were larger when viewing drawings that expressed sadness than when viewing drawings that expressed pleasure. In paranoid-type patients, P300 when viewing pleasurable drawings was similar to that when viewing sad drawings during the acute phase; in remission, P300 was significantly larger when viewing sad drawings than when viewing pleasurable drawings. In non-paranoid patients, P300 while viewing pleasurable drawings was significantly larger than that while viewing sad drawings during the acute phase; this difference disappeared during recovery. P300 latency and reaction time were not influenced by facial-affect stimuli or recovery. A significant negative correlation was noted between amplitude and negative symptom scores. P300 amplitude and area may be useful state markers during recovery in schizophrenic patients. Effects involving attention resources and emotional arousal are also involved.

Significance of adrenomedullin under cardiopulmonary bypass in children during surgery for congenital heart disease

To elucidate the effect of adrenomedullin (AM) on fluid homeostasis under cardiopulmonary bypass (CPB), we investigated the serial changes in plasma AM and other parameters related to fluid homeostasis in 13 children (average age, 28.2 months) with congenital heart disease during cardiac surgery under CPB. Arterial blood and urine samples were collected just after initiation of anesthesia, just before commencement of CPB, 10 min before the end of CPB, 60 min after CPB, and 24 h after operation. Plasma AM levels increased significantly 10 min before the end of CPB and decreased 24 h after operation. Urine volume increased transiently during CPB, which paralleled changes in AM. Simple regression analysis showed that plasma AM level correlated significantly with urinary vasopressin, urine volume, urinary sodium excretion, and plasma osmolarity. Stepwise regression analysis indicated that urine volume was the most significant determinant of plasma AM levels. Percent rise in AM during CPB relative to control period correlated with that of plasma brain natriuretic peptide (r = 0.57, P < 0.01). Our results suggest that AM plays an important role in fluid homeostasis under CPB in cooperation with other hormones involved in fluid homeostasis.

BIP, a BRAM-interacting protein involved in TGF-beta signalling, regulates body length in Caenorhabditis elegans

BACKGROUND

The TGF-beta superfamily has diverse biological activities and is involved in the early development of animals. We previously identified a novel family member, BMP receptor associated molecule (BRAM), which binds to the intracellular domain of BMP type IA receptor and is involved in the BMP signalling pathway.

RESULTS

To identify novel molecules involved in TGF-beta signalling pathways, we performed yeast two-hybrid screening using BRAM as bait. From a Xenopus cDNA library, we cloned a cDNA encoding 693 amino acids and containing the motif for an oxysterol binding protein (OSBP), which we designated BRAM interacting protein (BIP). We then isolated a BIP homologue from the Caenorhabditis elegans that encodes 733 amino acids and also contains the OSBP-like motif. Immunoprecipitation and Western blotting studies revealed that C. elegans BIP could interact with the C. elegans BRAM homologues BRA-1 and BRA-2. C. elegans BIP was expressed in pharyngeal muscle, hypodermis and several neuronal cells, an expression pattern overlaps with those of BRA-1 and BRA-2. Finally, we found that inhibition of BIP expression in C. elegans by double stranded RNA interference produces a Sma phenotype.

CONCLUSIONS

BIP was isolated using the yeast two-hybrid systems. BIP may function in the TGF-beta pathway and regulate body length in C. elegans.

Reconstruction of urinary tract utilizing transverse colon conduit for a cystectomized patient with post-ureterocutaneostomy complications and sigmoid colon cancer

A seventy-four years old man had been suffering from symptomatic and infectious complications associated with conjoined cutaneoureterostomy following the radical cystectomy for advanced transitional cell carcinoma of the bladder 3 years ago. He underwent urinary reconstruction using transverse colon conduit after diagnostic exclusion of recurrent urothelial tumor in the upper urinary tract, evaluation of performance status and endoscopic examination of the colon. Enteroscopy incidentally revealed he had an early stage adenocarcinoma in his sigmoid colon to be resected, and the resection was followed by the urinary diversion. Postoperatively he is satisfied to be free from urinary complications and frequently visits the outpatient clinic for painful and troublesome ureteral catheter exchange.

The polymorphism in the caudal-related homeodomain protein Cdx-2 binding element in the human vitamin D receptor gene

The major physiological activity of 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] is the regulation of calcium absorption in the small intestine, and the level of vitamin D receptor (VDR) is an important factor in this regulation. In a previous study, we indicated-that the caudal-related homeodomain Cdx-2 played an important role in the intestine-specific transcription of the human VDR gene. In this study, the polymorphism was identified in the core sequence 5'-ATAAAAACTTAT-3' in the Cdx-2 binding site in the VDR gene promoter. In 261 Japanese women with genotyped VDR polymorphisms, 48 were genotype Cdx-A (adenine at -3731 nucleotides [nt] relative to the transcription start site of human VDR gene 5-ATAAAAACTTAT), 82 were genotype Cdx-G (guanine at -3731 nt, 5'-GTAAAAACTTAT-3'), and 131 were genotype Cdx-A/G (heterozygote). In postmenopausal Japanese women, the bone mineral density (BMD) in the lumbar spine (L2-L4) with the Cdx-G homozygote was 12% lower than that with the Cdx-A homozygote (p < 0.05). In electrophoretic gel mobility shift assay (EMSA), the oligonucleotide with Cdx-G allele markedly decreased the binding to Cdx-2 compared with that in the Cdx-A allele. The transcriptional activity of the VDR promoter with Cdx-G allele was decreased to 70% of the Cdx-A allele. In addition, in the herpes simplex virus thymidine kinase promoter, the Cdx-2 binding element with the G allele showed significantly lower transcriptional activity than that of the A allele. Thus, the polymorphism in the Cdx-2 binding site of the VDR gene (Cdx-polymorphism) would affect the expression of VDR in the small intestine. In addition, this polymorphism may modulate BMD in postmenopausal Japanese women.

Nociception and allodynia/hyperalgesia induced by intrathecal administration of fenvalerate

The intrathecal injection of fenvalerate, a sodium channel activator, at doses of 0.01 to 3 microg, dose-dependently induced the duration of a characteristic behavioral syndrome mainly consisting of reciprocal hind limb scratching directed towards caudal parts of the body and biting or licking of the hind legs in mice. Fenvalerate-induced behavior was inhibited by morphine (1-10 mg/kg, i.p.). The characteristic behavior was also inhibited by mexiletine, a sodium channel blocker; MK-801, a N-methyl-D-aspartate ion-channel blocker; and GR82334, a neurokinin-1-receptor antagonist. Calphostin C (3 pmol, i.t.), a protein kinase C inhibitor, inhibited fenvalerate-induced behavior. On the other hand, phorbol-12, 13-dibutyrate (50 pmol, i.t.), a protein kinase C activator, markedly enhanced the fenvalerate-induced behavior. The present results also showed that fenvalerate produced thermal allodynia and hyperalgesia in the tail-flick test. Furthermore, fenvalerate-induced thermal allodynia and hyperalgesia were inhibited by the pretreatment with calphostin C. These results suggest that the intrathecal administration of fenvalerate induces a marked nociceptive response and thermal allodynia/hyperalgesia, and they suggest that tetrodotoxin-resistant sodium channels may play an important role in this effect.

[Right ventricular outflow tract reconstruction with PTFE mono-cusped transannular patch for tetralogy of Fallot]

Conotruncal repair for tetralogy of Fallot consists of (1) precise closure of the VSD with the membranous flap and (2) reconstruction of the right ventricular outflow tract (RVOT) by a short transannular patch (< 30% of the RV length) with a wide PTFE monocusp. This report describes the mid-term results in 46 patients with tetralogy of Fallot who underwent conotruncal repair with PTFE monocusped transannular patch and have been followed up for 4 years or more. There was no early and late death and no patient required reoperation. No patient has had a significant residual defect or tricuspid regurgitation (> II). The right and left ventricular pressure ratio was 0.41 +/- 0.12 and the pressure gradient across RVOT was 10.5 +/- 5.9 mmHg, signifying sufficient relief of RVOT obstruction. The mobility of the PTFE monocusp was echocardiographically detected in 86% over a mean follow-up period of 84 +/- 34 months and % freedom from pulmonary regurgitation (> II) was 85.9% at 10 years postoperatively. Excellent long-term durability of the PTFE monocusp provided the normal right vent performance with RVEDV of 91.8 +/- 29.5% of normal and a central venous pressure of 5 +/- 1 mmHg. In conclusion, conotruncal repair with a wide and short transannular patch has provided good mid-term results with the excellent long-term durability of PTFE monocusp.

West Nile virus-induced bax-dependent apoptosis

The mechanism of cell death induced by West Nile virus (WNV), a causative agent of human febrile syndrome and encephalitis, was investigated. WNV-infected K562 and Neuro-2a cells manifested the typical features of apoptosis, including cell shrinkage, chromatin condensation and subdiploid DNA content by flow cytometry. DNA fragmentation into nucleosomal size and changes in outer cell membrane phospholipid composition were also observed in K562 cells. UV-inactivated virus failed to induce the above-mentioned characteristics, suggesting that viral replication may be required for the induction of apoptosis by WNV. Additionally, signals involved in WNV-induced apoptosis are associated with the up-regulation of bax gene expression.

Role of vanilloid VR1 receptor in thermal allodynia and hyperalgesia in diabetic mice

We examined the role of the vanilloid VR1 receptor in the thermal hyperalgesia and allodynia seen in diabetic mice. Tail-flick latencies at source voltages of 35 and 50 V for a 50-W projection bulb in diabetic mice were significantly shorter than those in non-diabetic mice. Tail-flick latencies at 35 and 50 V in diabetic mice were increased by pretreatment with anti-vanilloid VR1 receptor serum. Intrathecal (i.t.) injection of anti-VR1 serum resulted in a significant increase in the tail-flick latency at 50 V in non-diabetic mice. However, i.t. pretreatment with anti-vanilloid VR1 receptor serum did not affect the tail-flick latency at a heat intensity of 35 V in non-diabetic mice. Thus, it seems likely that thermal allodynia and hyperalgesia in diabetic mice may be due to the sensitization of vanilloid VR1 receptors in primary sensory neurons in the spinal cord.

[Perioperative mortality and morbidity for the year of 1999 in 466 Japanese Certified Anesthesia-training Hospitals: with special reference to ASA-physical status--report of Committee on Operating Room Safety of Japan Society of Anesthesiologists]

Perioperative mortality and morbidity in Japan for the year 1999 were studied retrospectively. Committee on Operating Room Safety of the Japan Society of Anesthesiologists (JSA) sent confidential questionnaires to 774 Certified Training Hospitals of JSA and received answers from 60.2% of the hospitals. We analyzed their answers with special reference to ASA physical status (ASA-PS). The total number of anesthetics analyzed was 655, 644. Mortality and morbidity due to all kinds of causes including anesthetic management, intraoperative events, co-existing diseases, and operation were as follows. The incidence of cardiac arrest (per 10,000 anesthetics) was 0.68, 3.76, 14.37, 67.03, 0.36, 4.68, 27.96, 206.30 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The incidences of critical events including cardiac arrest, severe hypotension, and severe hypoxemia were 8.93, 26.99, 71.30, 188.52, 8.68, 31.27, 136.16, and 790.92 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The mortality rates (death during anesthesia and within 7th postoperative day) after cardiac arrest were 0.16, 0.94, 5.71, 33.51, 0.00, 1.46, 16.41 and 167.76 per 10,000 anesthetics in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The overall mortality rates were 0.24, 1.66, 12.16, 67.03, 0.00, 3.51, 34.65 and 417.14 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. Overall mortality and morbidity were higher in emergency anesthetics than in elective anesthetics. ASA-PS correlated well with overall mortality and with morbidity, regardless of etiology. The incidences of cardiac arrest totally attributable to anesthesia were 0.24, 0.45, 1.47, 8.38, 0.36, 1.75, 2.43 and 11.34 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The incidences of all critical events totally attributable to anesthesia were 4.92, 8.81, 14.74, 20.95, 4.34, 11.40, 15.80 and 22.67 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The mortality rates after cardiac arrest totally attributable to anesthesia were 0.00, 0.00, 0.61 and 4.53 in patients with ASA-PS of I-IV, I E-II E, III E, and IV E, respectively. The overall mortality rates totally attributable to anesthesia were 0.00, 0.04, 0.18, 0.00, 0.00, 0.61 and 4.53 in patients classified to ASA-PS of I, II, III, IV, I E-II E, III E, and IV E, respectively. Only one death, due to overdose of anesthetics, was reported among patients with good physical status (ASA-PS of I, II, II E and II E). Anesthetic management was mainly responsible for critical events in patients with good physical status, while co-existing diseases were in those with poor physical status. The major co-existing diseases or conditions leading to critical events were heart diseases in elective anesthetics, and hemorrhagic shock in emergency anesthetics. We reconfirmed that ASA-PS is beneficial to predict perioperative mortality and morbidity. It also seems likely that we should make much more efforts to reduce anesthetic morbidity in patients with good physical status, and to improve preanesthetic assessment and preparation of cardiovascular conditions in those with poor physical status.

Low-dose dobutamine electrocardiograph-gated myocardial SPECT for identifying viable myocardium: comparison with dobutamine stress echocardiography and PET

The identification of severely dysfunctional but viable myocardium is of particular importance for the selection of patients with depressed left ventricular function who will benefit from coronary revascularization. Assessment of inotropic reserve with dobutamine has recently been used for this purpose. This study compared the accuracy of low-dose dobutamine stress gated myocardial SPECT (DS SPECT) with the accuracy of dobutamine stress echocardiography (DSE) and resting perfusion SPECT for the identification of viable myocardium in patients with previous myocardial infarction.

METHODS

Resting and low-dose dobutamine (7.5 microg/kg/min) gated (99m)Tc-tetrofosmin SPECT and echocardiography and resting (18)F-FDG PET were prospectively studied in 23 patients with previous myocardial infarction and severely depressed regional function. Twenty-one of them were successfully studied with each technique. The left ventricular wall was divided into 14 segments to assess wall motion using a 5-point scale. PET viability was defined as FDG uptake >/= 50% of the maximum uptake in a region with normal wall motion. For DS SPECT and DSE studies, viable myocardium was defined as hypokinetic areas with > or = 1 point improvement in wall motion. For resting perfusion SPECT, viable myocardium was defined as hypokinetic areas with a relative uptake > or = 50% of the maximum uptake.

RESULTS

Of a total of 294 segments, 55 had severe resting dyskinesis. Thirty-four segments were identified as viable on FDG PET, and 21 segments were identified as nonviable. Eleven segments were inadequately visualized with DSE, including 5 segments in the apex. Sensitivities (78% vs. 76%) and specificities (94% vs. 100%) were similar for DSE and DS SPECT, with a concordance of 86% (kappa = 0.72). DS SPECT and perfusion SPECT did not significantly differ with respect to sensitivities (76% vs. 85%, respectively). However, specificity was significantly higher for DS SPECT than for perfusion SPECT (100% vs. 52%, respectively, P < 0.05).

CONCLUSION

This study indicated that DS SPECT correlates well with DSE in the assessment of viability. In addition, gated SPECT can evaluate regional wall motion, even in areas inadequately assessed by echocardiography. DS SPECT may also provide additional information for identifying viable myocardium, which is often overestimated by routine perfusion scans.

Indication for histological examination of endometrium in breast carcinoma patients receiving tamoxifen therapy

OBJECTIVE

To investigate the effects of tamoxifen on the uterine endometrium and define the indications for histological examination of endometrium on the thickness of uterine endometrium and on the duration of tamoxifen therapy.

METHODS

The endometrial thickness was measured on the transvaginal ultrasonogram in 40 postmenopausal breast carcinoma patients receiving tamoxifen (tamoxifen group), and control group. Endometrial histological examination was carried out. Receiver operating characteristic (ROC) curve analysis was carried out.

RESULTS

Endometrial thickness in the tamoxifen group was 11.2 +/- 5.1 mm, and that of the control group was 3.8 +/- 2.1 mm. The incidence of endometrial abnormalities in the tamoxifen group was greater than that in control group. The cut off values derived from the ROC curve analysis were 9 mm for endometrial thickness, and 24 months for duration of tamoxifen therapy.

CONCLUSION

The histological examination of endometrium should be carried out if the endometrial thickness is more than 9 mm, or the duration of tamoxifen therapy is more than 24 months even if the patients do not have any symptoms.

A DAF-1-binding protein BRA-1 is a negative regulator of DAF-7 TGF-beta signaling

We have identified homologs of a human BMP receptor-associated molecule BRAM1 in Caenorhabditis elegans. One of them, BRA-1, has been found to bind DAF-1, the type I receptor in the DAF-7 transforming growth factor-beta pathway through the conserved C-terminal region. As analyzed using a BRA-1GFP (green fluorescent protein) fusion gene product, the bra-1 gene is expressed in amphid neurons such as ASK, ASI, and ASG, where daf-1 is also expressed. A loss-of-function mutation in bra-1 exhibits robust suppression of the Daf-c phenotype caused by the DAF-7 pathway mutations. We propose that BRA-1 represents a novel class of receptor-associated molecules that negatively regulate transforming growth factor-beta pathways.

Altered expression of occludin and tight junction formation in psoriasis

In simple epithelia, tight junctions are well developed and have barrier and fence functions. On the other hand, tight junctions are less developed in stratified epithelia. In the rodent epidermis, only maculae occludentes (i.e. focal strands or spot tight junctions) are observed in the most superficial zone of the granular cell layer. Occludin is an integral membrane protein, and is localized at tight junctions in simple epithelia. In normal epidermis, occludin is expressed at the maculae occludentes in the granular cell layer, indicating that it is associated with keratinocyte differentiation. Thus, we examined occludin expression in psoriasis, in which differentiation of keratinocytes is impaired. In psoriasis, occludin was expressed more broadly in the upper epidermis than in normal epidermis. In addition, immunoelectron microscopy showed occludin to be concentrated on the maculae occludentes in the spinous layer of psoriatic skin. These findings indicate that occludin and the formation of tight junctions are related to the proliferation and differentiation of keratinocytes, and to the pathogenesis of psoriasis.

Pre-emptive renal transplantation in children

BACKGROUND

Renal transplantation is a definitive therapeutic modality in end-stage renal disease (ESRD). Most ESRD patients in Japan experience dialysis prior to renal transplantation. The present study was undertaken to examine the usefulness of pre-emptive renal transplantation (PET).

METHODS

Between 1987 and 1998, 255 renal transplantations were carried out by the authors. Among those consecutive cases, 10 were cases of PET. In nine pediatric cases, demographics, graft and patient survival, height growth and benefits from successful transplantation were studied and compared with age-matched dialyzed transplantation controls.

RESULTS

All transplantation was living-related. There was a disparity of causes of ESRD between the two groups. In PET, acquired renal deterioration due to a congenital lower urinary tract disorder was the major cause. Graft and patient prognosis was favorable in both groups. Growth retardation in PET patients under 15 years of age was significantly less apparent at the time of transplantation and after 3 years compared to the control. The benefits from transplantation were different in the two groups. Most PET patients felt an improvement of their physical condition; however, all of the control patients felt that the major boon was the freedom from the restriction of the daily diet and time for dialysis.

CONCLUSION

In pediatric renal transplantation, short-term preceding dialysis does not have a detrimental effect, but PET could benefit ESRD patients by maintaining their quality of life. Moreover, PET minimizes the production of renal dwarfism in prepubertal children. Thus, PET should be taken into consideration in the choice of renal replacement therapy.

Clinical advantages of interictal SPECT coregistered to magnetic resonance imaging in patients with epilepsy

PURPOSE

The aim of this study was to investigate the clinical value of coregistration of interictal SPECT and magnetic resonance imaging (MRI) in patients with partial epilepsy.

MATERIALS AND METHODS

Seventeen patients with partial epilepsy were examined with I-123 IMP or Tc-99m ethyl cysteinate dimer SPECT during the interictal phase. The SPECT images were automatically coregistered to axial T1 weighted MRIs. Asymmetry indexes (AIs) were calculated in both nonregistered images and coregistered images.

RESULTS

SPECT images showed areas of decreased tracer uptake in 12 patients. In two patients, the relation between the tumor and the extent of decreased uptake became more accurate in the coregistered images. In five cases, the coregistered images clearly showed that the decreased uptake was located in the sulcus. The AIs were significantly reduced from 14.29 +/- 7.23 to 5.86 +/- 3.48 (P < 0.001) after the images were coregistered in these cases. In five cases, the coregistered images indicated that the decreased areas were in agreement with the cortical findings. No significant differences in the AIs were observed in these cases (16.50 +/- 6.19 versus 17.83 +/- 4.45). Thus, the coregistered images were useful not only to differentiate actual hypoperfusion from artificial hypoperfusion resulting from partial volume effects but also to improve the accuracy of AIs.

CONCLUSION

The coregistration of interictal perfusion SPECT and MRI is useful not only to provide precise functional and anatomic mapping but also to improve the accuracy of calculations of the semiquantitative analysis of regional cerebral blood flow parameters during the interictal state of epilepsy.

[Indications for and clinical outcome of the Ross procedure: a review]

The Ross procedure has been used increasingly to treat aortic valve disease in children and young adults. The primary indication for the Ross procedure is to provide a permanent valve replacement in children with congenital aortic stenosis. More recently, it has been extended to young adults with a bicuspid aortic valve and small aortic annulus, especially women wishing to have children. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus. Conversely, Marfan syndrome is considered to an absolute contraindication, and this procedure should be used with caution in patients with rheumatic valve disease and a dysplastic dilated aortic root because of the higher associated incidence of autograft dysfunction. The technique of total aortic root replacement has become the preferred method of autograft implantation, because it carries the lowest risk of pulmonary autograft failure. In patients with marked graft-host size mismatch, either concomitant aortic annulus reduction and fixation or aortic annulus enlargement (i.e., the Ross-Konno procedure) should be performed. The Ross Procedure International Registry data document that in the modern era (post-1986) the early and late mortality rate is 2.5% and 1%, respectively. Excellent long-term results have been reported, and the benefits of this procedure include optimal hemodynamics, low risk of endocarditis, resistance to infection in patients with active endocarditis, and nonthrombogeneicity and therefore few anticoagulation-related complications. The Ross procedure can be performed with acceptable early and mid-term mortality and excellent autograft durability. Further long-term follow-up will confirm the role of this procedure in patients with various types of aortic valve disease.

Rap1 is involved in cell stretching modulation of p38 but not ERK or JNK MAP kinase

Mechanical force or mechanical stress modulates intracellular signal pathways, including the mitogen-activated protein kinase (MAP kinase) cascades. In our system, cell stretching activated and cell contraction inactivated all three MAP kinase pathways (MKK1/2-extracellular signal-regulated kinase (ERK), MKK4 (SEK1)-cJun N-terminal kinase (JNK) and MKK3/6-p38 pathways). However, little is known about the molecular mechanisms that link the mechanical force to the MAP kinase cascades. To test whether Ras and Rap1 are possible components in the stretch-activated MAP kinase pathways, we examined if Ras and Rap1 were activated by cell stretching and if inhibition of their activity decreased the stretch-enhanced MAP kinase activity. Rap1 was activated by cell stretching and inactivated by cell contraction, whereas Ras was inactivated by cell stretching and activated by cell contraction. Rap1GapII and SPA-1, downregulators of Rap1 activity, decreased the stretch-enhanced p38 activity, whereas a dominant-negative mutant of Ras (RasN17) did not inhibit the stretch-initiated activation of MAP kinases. Furthermore, overexpression of Rap1 enhanced p38 activity but not ERK or JNK activity. These results indicate that Rap1 is involved in transducing the stretch-initiated signal to the MKK3/6-p38 pathway, but not to the MEK1/2-ERK or the MKK4 (SEK1)/MKK7-JNK pathway. Thus, Rap1 plays a unique role in force-initiated signal transduction.

Delayed infection of a lymphocele following mastectomy with immediate breast reconstruction: report of a case

We report herein a rare case of delayed infection of a lymphocele following mastectomy with immediate breast reconstruction. A 38-year-old woman presented to our hospital 7 months after undergoing a left-modified radical mastectomy with an immediate breast reconstruction, following the sudden development of a giant mass in the left thoracoabdominal region as well as a high fever and shivering. Ultrasonography and a computed tomographic scan revealed massive fluid retention extending from the left axilla to the lower abdominal region. Puncture drainage was performed three times and the injection of an antibiotic directly into the cyst resulted in resolution of the fluid. This massive retraction of fluid was considered to have resulted from a delayed infection of an axillary lymphocele.

Effect of facial affect stimuli on auditory and visual P300 in healthy subjects

This study investigated whether or not P300 components are influenced by emotional affect such as sadness and pleasure in twenty healthy subjects and whether or not the P300 effects of facial affect stimuli are influenced by auditory and visual stimulus modalities. Written informed consent was taken from each subject before the study. Each subject was asked to stare at a simple picture of a facial expression (crying or smiling faces) during the auditory and visual oddball tasks. P300 amplitude and area were significantly larger when viewing a crying face (sadness) than a smiling face (pleasure) under both conditions with auditory and visual stimulus. P300 latency was significantly longer while viewing sadness than while viewing pleasure only with auditory stimuli. Reaction time was not changed by facial stimuli. Amplitude and area of P300 were significantly larger in women than men in their modalities, but the effects of facial affect on P300 amplitude and area in women were similar to those in men. These results suggest that amplitude and area of P300 with both modalities recorded while viewing sadness may induce larger attentional resource than pleasure. Gender was a less potent influence of facial expression on P300 parameters. The influence of facial emotion may be important to investigate the recognition processes of subjects.

Electroencephalographic changes and their regional differences during pediatric cardiovascular surgery with hypothermia

Monitoring brain function by EEG is an important means of preventing cerebral insults in pediatric cardiovascular surgery. We studied intraoperative EEG changes and their regional differences associated with hypothermia and brain ischemia. The subjects of this study consisted of 13 children ranging in age from 4 months to 4 years and 6 months. Multi-channel EEGs were recorded using a portable digital EEG system, and the EEG changes were examined by visual inspection and computerized analyses. The results were as follows. (1) During cooling, a discontinuous EEG pattern was transiently observed in four patients, and this phenomenon indicated rapid suppression of cerebral function and subsequent adaptation. (2) Regarding the patterns of change in equivalent potentials induced by hypothermia, there were two different patterns depending on the degree of hypothermia, and the borderline rectal temperature was found to be around 32 degrees C. (3) During cooling, regional differences in the changes in equivalent potentials were observed in nine patients. A decrease in slow waves was marked in the occipital head area, and a decrease in fast waves was prominent in the anterior head area. (4) Arterial hypotension caused transient EEG abnormalities. Of them, bilaterally synchronous rhythmic high voltage slow waves were remarkable and exhibited bifrontal or bicentral dominance. (5) The EEG changes induced by hypothermia were influenced not only by the rectal temperature itself, but also by the rate of change in rectal temperature, and we speculated that this phenomenon was a result of adaptation. In intraoperative EEG monitoring, these findings constitute the basis for early detection of a cerebral hypoxic-ischemic state during pediatric cardiovascular surgery.

Interleukin-6 production in lung tissue after transthoracic esophagectomy

BACKGROUND

The mechanisms of the reported high increase in interleukin-6 (IL-6) levels after esophagectomy are unclear. We investigated the influence of an intrathoracic procedure, esophagectomy, on IL-6 production in lung tissue.

STUDY DESIGN

Fourteen paired lung tissue samples were obtained from patients before and after they underwent transthoracic esophagectomy for esophageal cancer. IL-6 levels in the lung were measured with enzyme-linked immunosorbent assay, and IL-6 mRNA expression was determined with real-time quantitative reverse transcription-polymerase chain reaction. Immunohistochemical staining was used to localize IL-6, and circulating levels were also measured.

RESULTS

IL-6 protein and mRNA were significantly increased in lung tissue after this intrathoracic procedure (p < 0.05). Peak levels of plasma IL-6 after surgery were correlated with IL-6 levels in lung tissues obtained after the procedure (p < 0.05). Immunohistochemical staining revealed IL-6 production from alveolar and bronchial epithelial cells but not from alveolar macrophages.

CONCLUSIONS

Transthoracic esophagectomy causes an increase in IL-6 production from airway epithelial cells, secondary to increased expression of IL-6 mRNA. Local response of lung tissue may be one source of increased serum IL-6 after this procedure.

Comparison of (18)F-FDG, (131)I-Na, and (201)Tl in diagnosis of recurrent or metastatic thyroid carcinoma

There are several reports about the usefulness of (18)F-FDG PET in thyroid cancer. However, few studies have compared FDG PET with (131)I and (201)Tl scintigraphy. The aim of this study was to evaluate the clinical significance of whole-body FDG PET in differentiated thyroid cancer and to compare the results with those obtained from (131)I and (201)Tl scintigraphy.

METHODS

Whole-body FDG PET was performed on 32 patients (10 men, 22 women; age range, 30-77 y; mean age, 54 y) with differentiated thyroid cancer (5 cases of follicular cancer and 27 of papillary cancer) after total thyroidectomy. An overall clinical evaluation was performed, including cytology, thyroglobulin level, sonography, MRI, and CT, to allow a comparison with functional imaging results for each patient. Metastatic regions were divided into five areas: neck, lung, mediastinum, bone, and other. Multiple lesions in one area were defined as one lesion. The tumor-to-background ratio (TBR) was measured for the lesions that were positive for both (201)Tl uptake and FDG PET uptake.

RESULTS

The number of lesions totaled 47. Forty-one (87%) were detected by all scintigraphic methods. FDG uptake was concordant with (131)I uptake in only 18 lesions (38%). FDG uptake was concordant with (201)Tl uptake in 44 lesions (94%). Only one lesion was negative for FDG uptake and positive for (201)Tl uptake, and two lesions were positive for FDG uptake and negative for (201)Tl uptake. A significant correlation was seen between the TBR of (201)Tl and that of FDG (r = 0.69; P<0.05).

CONCLUSION

These data indicate that for detecting metastatic lesions, FDG PET and (131)I scintigraphy may provide complementary information, whereas FDG PET may provide results similar to those of (201)Tl scintigraphy. Thus, the combination of (131)I scintigraphy and FDG PET (or (201)Tl scintigraphy) is the method of choice for detecting metastatic thyroid cancer after total thyroidectomy.

Chlorophyll derived from Chlorella inhibits dioxin absorption from the gastrointestinal tract and accelerates dioxin excretion in rats

We investigated the effects of chlorophyll derived from Chlorella on gastrointestinal absorption of seven types of polychlorinated dibenzo-p-dioxin (PCDD) and 10 types of polychlorinated dibenzofuran (PCDF) in Wistar rats. Twenty-eight rats were randomly distributed into seven groups (n = 4). After overnight food deprivation, rats were given 4 g of the basal diet or 4 g of the chlorophyll diet containing 0.01-0.5% chlorophyll one time on day 1; each diet also contained 0.2 mL PCDD and PCDF standard solutions. The amounts of fecal excretion of PCDD and PCDF congeners from days 1 to 5 in the group fed 0.01% chlorophyll were 64.8% for 1,2,3,7,8-pentaCDD, 78.6% for 1,2,3,4,7,8-hexaCDD, 73.5% for 1,2,3,6,7,8-hexaCDD, 58.5% for 1,2,3,7,8,9-hexaCDD, 33.3% for 1,2,3,4,6,7,8-heptaCDD, 85.7% for 1,2,3,7,8-pentaCDF, 77.3% for 2,3,4,7,8-pentaCDF, 88.6% for 1,2,3,4,7,8-hexaCDF, 78.0% for 1,2,3,6,7,8-hexaCDF, 62.5% for 1,2,3,7,8,9-hexaCDF, 84.1% for 2,3,4,6,7,8-hexaCDF, 41.7% for 1,2,3,4,6,7,8-heptaCDF, and 40.0% for 1,2,3,4,6,7,8-heptaCDF greater (p < 0.01) than those of the control group, respectively. The fecal excretion of PCDD and PCDF congeners was remarkably increased along with the increasing dietary chlorophyll. The amounts of PCDD and PCDF congeners in rats on day 5 administered dioxin mixtures were lower in the 0.01% chlorophyll group than in the control group, ranging from 3.5 to 50.0% for PCDD congeners and from 3.7 to 41.7% lower for PCDF congeners, except for 2,3,7,8-tetrachlorodibenzofuran. The amount of PCDD and PCDF congeners in rats was remarkably decreased along with the increasing dietary chlorophyll. These findings suggest that chlorophyll is effective for preventing dioxin absorption via foods.

Combination therapy of percutaneous mitoxantrone injection, percutaneous ethanol injection, and transcatheter arterial embolization for intrahepatic hepatocellular carcinoma and adrenal metastasis

We treated a 63-year-old man who had recurrent large hepatocellular carcinomas (> 5 cm in diameter) and left adrenal metastasis with the combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization. He received repeated transcatheter arterial embolization and percutaneous ethanol injection combination therapy for intrahepatic hepatocellular carcinomas, which controlled his disease for 6 months from the first treatment. After that, left adrenal metastasis was detected by biopsy specimen. Therefore, we repeated more transcatheter arterial embolization and percutaneous ethanol injection to the liver and left adrenal gland, but this combination therapy could not control the hepatocellular carcinomas in these organs. With the patient's consent, he was treated with the combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization for hepatocellular carcinomas of the liver and left adrenal gland. After this combination therapy, we followed-up the viable lesions by color Doppler ultrasonography and computed tomography examination. However, we could not detect these viable lesions of hepatocellular carcinomas in his body until one month before he died. When the degree of hepatic failure worsened due to the natural course of cirrhosis, this combination therapy was stopped 7 months before he died. He died of pulmonary tumor emboli from metastasis of inferior vena cava 24 months after the combination therapy started. However, on autopsy there was almost no remaining hepatocellular carcinoma found in the main lesions of liver and left adrenal gland. We suggest that a combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization may be indicated in elderly cases of intrahepatic large hepatocellular carcinoma and adrenal metastasis, which are not under control only by transcatheter arterial embolization and percutaneous ethanol injection.

Quantitative analysis of regional wall motion and thickening by quantitative gated SPECT: comparison with visual analysis

PURPOSE

Electrocardiograph-gated myocardial SPECT permits a quantitative assessment of global and regional functions by quantitative gated SPECT software. To validate quantitative indexes of wall motion and wall thickening, the authors compared these indexes with visual scores.

MATERIALS AND METHODS

Gated myocardial SPECT was performed 60 minutes after the administration of Tc-99m sestamibi at rest in 42 patients with coronary artery disease. Regional wall motion (measured in millimeters and wall thickening (expressed as a percentage) were calculated by quantitative gated SPECT software in nine left ventricular myocardial segments and the results were compared with the five-point visual score interpretations of cinematic display.

RESULTS

A high correlation of wall motion was observed between the quantitative and visual analyses (r = 0.810; P < 0.001). In addition, a high but somewhat less significant correlation of wall thickening was observed between the quantitative and visual analyses (r = 0.606; P < 0.001).

CONCLUSIONS

In conclusion, regional wall motion and wall thickening can be evaluated quantitatively by electrocardiograph-gated myocardial SPECT and quantitative gated SPECT software. This will be useful for functional assessments made with various interventions.

Role of Egr-1 in cAMP-dependent protein kinase regulation of the phenylethanolamine N-methyltransferase gene

The molecular mechanism by which cAMP activates the rat phenylethanolamine N-methyltransferase (PNMT) gene was examined by transient transfection of the wild-type rat PNMT promoter-luciferase reporter gene construct pGL3RP893 into PC12 cells. Forskolin treatment (10 microM) of the transfected cells for 3--6 h maximally induced luciferase threefold. Induction by forskolin was mimicked by the cAMP analog, 8-Br-cAMP, and prevented in PC12 cells pretreated with the protein kinase A (PKA) inhibitor H-89 or co-transfected with an expression construct for PKI, a polypeptide inhibitor of PKA. Furthermore, forskolin did not activate the PNMT promoter when the 893 bp PNMT promoter-reporter gene construct was transfected into the PKA-deficient cell line, A126. Detailed examination of the forskolin responsiveness of PNMT constructs harboring > or = 60 bp and < 893 bp of PNMT promoter demonstrated that the cAMP-responsive element(s) lay between < 392 bp and > or =60 bp. Within this region of the promoter lies a functional binding element for Egr-1, a transcriptional activator of the PNMT gene. Forskolin treatment of PC12 cells also rapidly increased nuclear levels of Egr-1 and the catalytic subunit of PKA (PKA-C), with the rise in PKA-C preceding that of Egr-1. Mutation of the --165 bp Egr-1 site markedly decreased forskolin activation of the PNMT promoter. These findings demonstrate that the rat PNMT gene promoter can be activated via the cAMP-PKA signal transduction pathway, mediated by the immediate early gene transcription factor, Egr-1.

Thalamic asymmetry on interictal SPECT in patients with frontal lobe epilepsy

BACKGROUND

Interictal brain single photon emission computed tomography (SPECT) is useful for the detection of seizure focus. Recent reports indicate a hypoperfusion in the ipsilateral thalamus as a seizure focus on interictal SPECT in temporal lobe epilepsy. In frontal lobe epilepsy (FLE), however, the alteration of perfusion in the thalamus has not been well documented. This study aimed to assess whether perfusion analysis on the thalamus may add useful information for the detection of epileptic foci in patients with FLE.

METHODS

Interictal brain SPECT was performed in 11 patients with FLE. The asymmetry index for the thalamus and frontal area in the SPECT image was calculated in order to compare the laterality of the seizure foci.

RESULTS

Thalamic asymmetry was seen in seven patients (64%), while cortial asymmetry was seen in six patients (55%). The concordance with the lateralization of the seizure foci was 6/7 (86%) in the thalamus, and 4/6 (67%) in the frontal area. Four patients showed only thalamic asymmetry. Concordance with the lateralization of the seizure focus was found in all of them.

CONCLUSION

These preliminary results suggest that hypoperfusion in the thalamus may have a complementary role to lateralize the epileptic foci in patients with FLE.

Relation between initial blood distribution volume and propofol induction dose requirement

BACKGROUND

Propofol induction dose is variable and depends on many factors, including initial volume of distribution and early disposition. The authors hypothesized that preadministration blood distribution volumes, cardiac output (CO), and hepatic blood flow (HBF) could be examined to establish a propofol induction dose.

METHODS

Propofol dose required to reach loss of consciousness, when infused at infusion rate per lean body mass (LBM) of 40 mg x kg(-1) x h(-1), was determined in 75 patients aged 11-85 yr. CO, blood volume (BV), central blood volume (CBV), and HBF were measured with indocyanine green pulse spectrophotometry. Univariate least squares linear regression analysis was used to individually analyze the relation between propofol induction dose and patient characteristics, including LBM, baseline distribution volumes, CO, and HBF. Stepwise multiple linear regression models were used to select important predictors of induction dose.

RESULTS

Although there was a significant correlation between the induction dose and each of the eight variables of age, sex, LBM, hemoglobin, CO, BV, CBV, and HBF, only factors of age (partial r = -0.655), LBM (partial r = 0.325), CBV (partial r = 0.540), and HBF (partial r = 0.357) were independently associated with the induction dose (R2 = 0.85) when all variables were included in a multivariate model.

CONCLUSIONS

At a constant propofol infusion rate of 40 mg x kg(-1) x h(-1) as a function of LBM in patients with American Society of Anesthesiologists physical status I or II, the induction dose can be determined from four variables: age, LBM, CBV, and HBF.

Pulmonary thromboembolism after one and a half ventricle repair. Successful catheter-directed thrombolysis

Acute pulmonary thromboembolism in a patient who had undergone bidirectional Glenn anastomosis was treated by percutaneous selective intravascular thrombolysis. A 20-year-old woman was diagnosed with pulmonary stenosis and right ventricular hypoplasia, complete occlusion of the left pulmonary artery secondary to a Blalock-Taussig shunt, and atrial septal defect. The patient developed thromboembolism of the subsegmental branches of the right pulmonary artery resulting in critical hemodynamic deterioration 2 weeks after undergoing one and a half ventricle repair (bidirectional Glenn shunt). The patient was treated with tissue plasminogen activator administered directly into the right pulmonary artery via an intravascular catheter. Progressive recanalization of the obstruction began immediately. Pulmonary angiography 3 months after thrombolytic therapy demonstrated patent subsegmental vessels. Early detection of the pulmonary thromboembolism and prompt intervention are crutial to relieving this fatal complication after a Fontan operation.

Fatal bleeding from a residual vein at the esophageal ulcer base after successful endoscopic variceal ligation

Endoscopic variceal band ligation (EVL) is now one of the accepted treatment options for esophageal varices, and the safety of this procedure has been proved. However, we experienced a patient who had a fatal massive bleeding after successful EVL for ruptured esophageal varix. Postmortem study revealed a residual vein at the base of the esophageal ulceration associated with the ligation, which was believed to be the site of the fatal bleeding. His platelet counts and prothrombin time were not very impaired. Our case indicates that fatal massive bleeding can occur in patients after successful EVL without specific risk factors and indicates the importance of the awareness of the possibility of these complications.

Pedunculated basal cell epithelioma which is not Pinkus tumor

A 33-year-old female with pedunculated basal cell epithelioma was reported. She had noticed a cutaneous tumor on the scalp for two years before admission. It developed gradually and clinically resembled fibroma or pigmented nevus. Total resection was performed, and its histopathology revealed the solid or cystic type of basal cell epithelioma.

Angiosarcoma of the scalp: absence of vascular endothelial cadherin in primary and metastatic lesions

A 73-year-old man with angiosarcoma of the scalp died about 1 year after disease onset, despite systemic and topical administration of recombinant interleukin-2. Histopathology showed typical changes of endothelial cells with very sparse lymphocytic infiltration into the tumour. An autopsy revealed that the primary site penetrated cranial bone and invaded vertically into the subarachnoid space. Multiple metastases to lung, chest wall, vertebrae and ribs were also found. On immunofluorescence staining, the expression of vascular endothelial cadherin, which is present in normal endothelium, was absent from both primary and metastatic sites. This may have promoted local invasion and metastasis.

Nerve growth factor down-regulates the expression of norepinephrine transporter in rat pheochromocytoma (PC12) cells

Functional expression of norepinephrine transporter (NET) and its regulation were examined in rat pheochromocytoma cell line, PC12. Nerve growth factor (NGF) decreased [3H]-norepinephrine (NE) uptake in association with a decrease in NET mRNA levels. On the other hand, levels of tyrosine hydroxylase mRNA increased in PC12 cells treated with NGF for 4-24 h, while Oct-2 mRNA levels decreased at 4 h with NGF then recovered for 8-24 h in the presence of NGF. Both bFGF and EGF reduced [3H]NE uptake, although they failed to affect NET mRNA levels. To examine the NET transcriptional regulation, we identified the 5'-noncoding region of rat NET mRNA by the rapid amplification of cDNA end (RACE) method and cloned the 5'-flanking region of NET gene. The newly identified exon encodes the untranslated region of rat NET mRNA upstream of the known 5'-region including ATG start codon. Constructs having green fluorescent protein (GFP) as reporter were made with the cloned NET gene, and promoter activity was examined in CHO and SK-N-SH cells transiently transfected and in PC12 cells stably transfected with NET-GFP constructs. The results indicate that the 2.1 kb NET flanking region displays promoter activity and is responsible for the NGF-induced down-regulation of NET expression.

Gender differences of exploratory eye movements: a life span study

Exploratory eye movements of normal subjects (39 male and 39 female) were recorded using an eye-mark recorder. Four parameters mean gazing time, total number of gazing points, mean scanning length, and total scanning length) were analyzed. Subjects were divided into three life spans as prepuberty (boys and girls), adult, and postpuberty. The mean gazing time of adult women was significantly longer than that of age-matched adult men, but not between men and women in prepuberty or postpuberty (postmenopausal older women and age-matched older men). The total number of gazing points of women was significantly smaller than that of men, but not significantly different between men and women in both prepuberty and postpuberty. Both the mean scanning length and total scanning length of adult women were shorter than those of age matched adult men, but no significant differences were found between men and women in both prepuberty and postpuberty. Furthermore, the mean gazing time of adult women was longer than that of men in prepuberty and postpuberty. The total scanning length of adult men was longer than that of women in both prepuberty and postpuberty. These findings suggest that gender differences of exploratory eye movements are observed only during the adult phase, which indicates that visual information processing may be regulated by gonadal hormones in humans.

[Alternating chemoradiotherapy for oropharyngeal cancer]

To evaluate the usefulness of chemoradiotherapy for oropharyngeal cancer, we retrospectively analyzed disease-free survival (DFS) and acute toxicities of the patients treated with this therapy. Between 1990 and 1998, 15 patients were treated with alternating chemoradiotherapy (CRT). Chemotherapy (CT) mainly consisted of 5-fluorouracil 700 mg/m2 (i.v.) on days 1-5 and nedaplatin 100-140 mg/m2 (i.v.) on day 6. Chemotherapy was administered before the beginning of radiotherapy. One cycle of this treatment consisted of CT and a subsequent 27 to 36 Gy of radiotherapy, as a general rule, two cycles were performed. Radiotherapy was delivered in single daily fractions of 1.8 to 2 Gy, to a total dose of 54 to 75 Gy for local lesions and 45 to 86.3 Gy for nodal metastases in the neck. As a historical control, 52 patients treated with curative radiotherapy between 1971 and 1990 were analyzed and compared with the CRT group in terms of DFS. The complete response rate with CRT was 100%. The three-year DFS were 87% and 38% with CRT and RT, respectively. There was a significant difference between the two groups (p = 0.0081). The most frequent and severe acute toxicity was mucositis, with grade 3-4 occurring in 47%. Acute hematologic toxicities were mild. Therefore, this CRT is considered to be an effective and tolerable treatment, and is expected to improve survival for oropharyngeal cancer patients.

Color Doppler sonography for evaluating response to transcatheter arterial embolization and percutaneous ethanol injection therapy and for detecting recurrence of hepatocellular carcinoma

Eighty-six patients (mean age, 63 years) with 92 hepatocellular carcinomas (2.0 cm or greater in diameter; mean +/- SD, 3.5 +/- 1.6 cm) underwent color Doppler sonography before and after transcatheter arterial embolization and after subsequent percutaneous ethanol injection for (1) identification of pulsatile flow in the residual tumor area after transcatheter arterial embolization, (2) evaluation of therapeutic effectiveness of combined transcatheter arterial embolization and percutaneous ethanol injection, and (3) detection of recurrence during follow-up evaluation. Before and 2 weeks after transcatheter arterial embolization, color Doppler sonography revealed pulsatile flow in 76 (82.6%) and 43 (46.7%)lesions, respectively. After percutaneous ethanol injection, tumor stains in these lesions completely disappeared on digital subtraction angiography (gold standard). During follow-up study (3 to 45 months), digital subtraction angiography revealed recurrence in 73 patients (38 local recurrences and 19 new lesions [2.0 cm or greater]), whereas color Doppler sonography revealed pulsatile flow in 76.3% (local) and 63.2% (new) (not significant). Color Doppler sonography was useful for complying with our three objectives, especially for detecting local recurrence during follow-up evaluation.

A combination therapy of continuous superselective intraarterial carboplatin infusion and radiation therapy for locally advanced head and neck carcinoma. Phase I study

BACKGROUND

To improve the treatment result for locally advanced head and neck carcinoma, the authors used a combination of radiotherapy with superselective continuous intraarterial therapy using carboplatin. The dose limiting toxicity (DLT), maximum tolerated dose (MTD), and treatment effectiveness were tested in Phase I and II protocols. PATIENTS AND METHODS. Thirty-five patients were entered into the study from August 1992 to May 1997. The target arteries were the lingual artery in 18 cases, facial artery in 5 cases, maxillary artery in 11 cases, and external carotid artery initially changing to lingual artery in 1 case. Escalating daily carboplatin doses were tested, starting from 10 mg/m(2) (total dose, 360 or 400 mg/m(2)) to 15 mg/m(2) (total dose, 405 or 450 mg/m(2)) and then 20 mg/m(2) (total dose, 460 or 500 mg/m(2)). Radiotherapy was administered using a 6-megavolt linear accelerator to a total dose of 50-60 grays. Interstitial radiotherapy boost also was used for carcinoma of the tongue.

RESULTS

Excluding 3 patients who discontinued treatment, the treatment results of 32 patients were complete response in 21 cases, partial response in 10 cases, and no change in 1 case. Neutropenia was the DLT, and the MTD was 500 mg/m(2). The local control rate was 64%.

CONCLUSIONS

Superselective continuous intraarterial carboplatin and concurrent radiation therapy can be delivered safely with good efficacy for locally advanced carcinomas of the tongue and base of the tongue. Surgical treatment of these diseases usually incurs severe functional loss. This current approach may be a breakthrough in these cancers.

Relationship between cyclooxygenase-2 expression and K-ras gene mutation in colorectal adenomas

BACKGROUND AND AIMS

Cyclooxygenase (COX)-2 has a trophic effect on gastrointestinal epithelial cells and is associated with the progression of colorectal adenomas. Mutation of the K-ras gene is also associated with the progression of colorectal adenomas and has recently been suggested to play an important role in the induction of COX-2. In the present study, we investigated the relationship between COX-2 expression and K-ras mutation in colorectal adenomas.

METHODS

Twenty-nine colorectal adenomas were obtained from specimens resected by the use of surgery or endoscopic mucosal resection and analyzed clinicopathologically. Immunohistochemistry was performed to analyze COX-2 expression in the adenoma specimens. The K-ras codon 12 mutations were detected by using the polymerase chain reaction-restriction fragment length polymorphism method.

RESULTS

An increase of COX-2-positive cells in adenoma was observed in 11 (37.9%) lesions, 10 (90.9%) of which had a K-ras gene mutation, suggesting a significant correlation between COX-2 expression and K-ras gene mutation in colorectal adenomas. Morphologically, COX-2-positive adenomas (13.8 +/- 2.6 mm) were significantly larger than COX-2-negative ones (5.8 +/- 0.9 mm). In addition, the increase of COX-2-positive cells in the lesion was observed more frequently in tubulovillous (63.6%) than in tubular (36.4%) adenoma.

CONCLUSIONS

Cycloxygenase-2 expression in colorectal adenoma cells is strongly correlated with K-ras gene mutation, suggesting that COX-2 and mutated K-ras are connectively associated with the progression of colorectal adenoma.

[Four cases of the anomalous origin of the left coronary artery from the pulmonary artery]

We report perioperative management of 4 patients with anomalous origin of the left coronary artery from the pulmonary artery. This report involves with 3 infant cases and an adult. Two infants underwent coronary reimplantation procedure and Takeuchi's method was performed on the other infant. In all infant cases, mitral valve plasty was performed to correct mitral regurgitation secondary to papillary muscle dysfunction. The adult patient underwent CABG with ligation of LCA. General anesthesia was performed with high doses of fentanyl in all cases. We employed a relatively high PaCO2 and low FIO2 in order to maintain a high pulmonary vascular resistance. It aims to decrease the incidence of left to right shunt. We used epinephrine to wean one infant and the adult from cardiopulmonary bypass. Perioperative course was uneventful with the use of catecholamines and high doses of vasodilators for left ventricular dysfunction and coronary perfusion under mechanical ventilation.

Massive bleeding from a gastric erosion after transcatheter arterial chemoembolization for hepatocellular carcinoma in a patient with mild haemophilia A

We observed massive bleeding from a gastric erosion following transcatheter arterial chemoembolization (TAE) in a patient with mild haemophilia A. A 78-year-old haemophiliac (factor VIII level over 60%) received TAE with farmorubicin and spongel. Haematemesis and melena with loss of consciousness occurred 3 days [corrected] after TAE, and endoscopy revealed superficial erosions with oozing. Toxic effects of the anticancer drug in conjunction with the bleeding disorder may have caused the massive bleeding. We should always consider the possibility of unexpected complications in patients with bleeding disorders; gastrointestinal bleeding can develop during treatment for liver tumours.

A new dynamic myocardial phantom for the assessment of left ventricular function by gated single-photon emission tomography

Gated myocardial perfusion single-photon emission tomography (SPET) has been used for the measurement of left ventricular (LV) function and validated by means of comparison with other imaging modalities. We have designed a new dynamic myocardial phantom in order to validate the LV function as assessed by the use of gated myocardial perfusion SPET. The phantom consists of two half-ellipsoids (an endocardial surface and an epicardial surface) and a thorax. The myocardial space is filled with a radioactive solution. The endocardial surface moves continuously towards and away from the epicardial surface in the longitudinal axis to vary the LV volume [143 ml at end-diastole (ED), 107 ml at end-systole (ES)] and thickness (apex 8 mm at ED and 26 mm at ES, midplane 8 mm). The mean values of wall motion (WM) for the apical midplane region and the basal midplane region were 5 mm and 2 mm, respectively. Gated myocardial SPET was performed during 8 and 16 intervals. These projection data sets were processed using a Butterworth filter with an order of 5 and a critical frequency of 0.34 cycles/cm. LV function was calculated using the quantitative gated SPET (QGS) algorithm. The LV function values estimated by gated SPET during 16 intervals [22% for ejection fraction (EF), 3.7 mm for WM of the apical midplane, 1.7 mm for WM of the basal midplane] closely resembled actual LV functions [25% for EF, 5 mm for WM of the apical midplane, 2 mm for WM of the basal midplane]. However, the estimated values during 8 intervals were smaller than those during 16 intervals (19% for EF, 3.3 mm for WM of the apical-midplane, 1.1 mm for WM of the basal-midplane). The estimated LV volumes closely correlated with the actual volumes (r=0.99 for 16 intervals, r=0.95 for 8 intervals). Utilizing this phantom, LV function estimated using gated myocardial SPET can be compared with actual values.

Sonographically guided core-needle biopsy of focal splenic lesions: report of four cases

There are few published reports about the use of splenic needle biopsies in the investigation of focal splenic lesions. We report our experience with sonographically guided core-needle biopsies of splenic lesions in 4 patients. The biopsies resulted in the following diagnoses: sarcoidosis, malignant lymphoma, infarction, and scar tissue. Surgery was avoided in the 3 patients diagnosed with sarcoidosis, infarction, and scar tissue by ruling out the possibility of a malignant splenic tumor. None of the patients experienced significant complications. We conclude that splenic core-needle biopsy is a useful and safe diagnostic tool for the evaluation of focal splenic lesions.

Mediation by platelet-activating factor of 12-hydroxyeicosatetraenoic acid-induced cytosolic free calcium concentration elevation in neutrophils

12(R)-hydroxyeicosatetraenoic acid (HETE) shows biphasic increase in cytosolic free calcium concentration ([Ca2+]i) in rabbit and human neutrophils; the initial transient phase and the continuous falling phase. 12(S)-HETE was less potent in both species. BN50739, a platelet-activating factor (PAF) receptor antagonist, inhibited both phases of 12(R)-HETE-induced [Ca2+]i rise but did not affect leukotriene B4 (LTB4)-induced [Ca2+]i rise. N-tosyl-L-phenylalanine chloromethyl ketone (TPCK), a PAF synthesis inhibitor, and manoalide, a phospholipase A2 inhibitor, reduced 12(R)-HETE-induced [Ca2+]i rise. These blockers inhibited the continuous phase of [Ca2+]i rise induced by N-formyl-methionyl-leucyl-phenylalanine (FMLP) with little effect on the initial phase. It had no significant effect on LTB4-induced [Ca2+]i rise. SC-41930, a LTB4-receptor antagonist, did not block 12-HETE-induced [Ca2+]i rise. In 12(R)-HETE-, FMLP- and LTB4-stimulated cells, accumulations of cell-associated PAF and released PAF were detected but not in unstimulated cells. BN50739 did not affect the accumulation of cell-associated PAF and release of PAF in 12(R)-HETE-stimulated cells. These results suggest that 12(R)-HETE-induced and partially, FMLP-induced, but not LTB4-induced [Ca2+]i rise are mediated by PAF, which is produced and released by stimulation of the cells by 12(R)-HETE and FMLP, respectively.