[Late surgical results of operation in partial atrioventricular canal defect]

Twenty-three patients underwent repair of a partial atrioventricular canal defect and have been followed for a mean of 9.4 years. The patients were divided into two groups according to the management of mitral cleft. Mitral cleft was not repaired in seven patients and directly sutured or repaired by valvuloplasty using pericardium in sixteen patients. In seven patients untreated mitral cleft left, two patients have required mitral valve replacement because of progressive severe mitral regurgitation. In sixteen patients mitral cleft repaired, no patients have required re-operation. However, one patient using pericardium in valvuloplasty, mitral regurgitation was in progress recently due to calcification and degeneration of the pericardium. The peak flow velocity, pressure gradient, pressure half time, and valve area in the mitral valve were measured by echo-doppler study. We recognized no statistical difference among two groups about hemodynamic performance in the mitral valve.

IN CONCLUSION

1) As concerns post-operative mitral regurgitation, the mitral cleft should be repaired. 2) After mitral cleft closure, the mitral flow pattern was not disturbed. 3) Autologous pericardium should not be adapted for valvuloplasty, because calcification and degeneration of the pericardium may cause progressive incompetency of the mitral valve.

[The physician executive and laboratory tests]

Sera Central Hospital was founded in 1953 as Sera District Medical Center under the auspices of the neighboring five towns. At that time, the hospital had 3 doctors, 10 nurses, and 20 beds. But now in 1992, we have 12 doctors, 53 nurses and 110 beds. The present medical specialists are physician (4), surgeon (2), orthopedist (3), pediatrician (1), clinical laboratory physician (1), and dentist (1). Although the yearly income and expenditures were well balanced until 1989, thereafter the income began to decrease insidiously and expenditures began to increase year by year. In this symposium titled "Suggestions for Clinical Laboratory Medicine by Experienced Hospital Directors," I must refer to the issue of "Clinical Laboratory Medicine Administrator's Standpoint". Recently, the unaccustomed phrase "Physician Executive" is occasionally heard as the details of medical care become more numerous and more intricate and economic efficiency is strictly persued. From this perspective, the clinical laboratory physician is responsible for managing the laboratory department with well disciplined knowledge and technique. Therefore, training as "Physician Executive" has developed naturally within the field of Clinical Laboratory Medicine. So, I cannot help coming to the conclusion that the management of a hospital, as a matter of course, will be entrusted to a doctor including clinical laboratory physician who can do his best for the citizens, for the patients, and ultimately for ourselves.

Acute interstitial nephritis with symmetric enlargement of the lacrymal and salivary glands and systemic lymphadenopathy

We describe a 40-year-old man who developed symmetric enlargement of the lacrymal and salivary glands and systemic lymphadenopathy. Laboratory findings included eosinophilia, polyclonal hypergammaglobulinemia, elevated circulating immune complexes, hypocomplementemia, and renal insufficiency. The lymph node pathology was atypical of angioimmunoblastic lymphadenopathy with disproteinemia (AILD), in that it lacked a prominence of arborizing small vessel proliferation. Despite extensive examinations, the cause of the atypical AILD process has not been identified. However, a flow-cytometric analysis of immunophenotypes of lymphoid cells from the lymph node revealed a predominance of activated helper/inducer T cells, indicating a hyperimmune state. Acute interstitial nephritis was secondary to the renal propagation of the atypical AILD process. Thus, atypical AILD can be a new cause of acute interstitial nephritis. A course of combined steroids and immunosuppressive treatment resolved those pathologic disorders for 5 years.

Cerebrospinal fluid corticotropin-releasing hormone and ACTH, and peripherally circulating choline-containing phospholipid in senile dementia

Cerebrospinal fluid (CSF) levels of corticotropin-releasing hormone (CRH) and ACTH, plasma levels of ACTH and cortisol, and serum levels of phospholipid and its fractions were determined in samples taken simultaneously from patients with senile dementia of the Alzheimer type (SDAT), multi-infarct dementia (MID) or dementia following a cerebrovascular accident (CVD), and the borderline-to-normal control subjects. CRH levels in CSF were significantly reduced in patients with SDAT and CVD but not with MID compared to the borderline-to-normal controls. ACTH levels in CSF were significantly reduced in SDAT compared to MID. The levels of circulating lecithin (phosphatidyl-choline) were depressed in a similar fashion to the levels of CRH in CSF in the SDAT patients and the group of severe dementia. Dementia and its severity did not affect the morning plasma levels of ACTH and cortisol. CSF CRH was positively correlated with CSF ACTH, while CSF ACTH was negatively correlated with plasma cortisol. No significant correlations were found between serum lecithin and CSF CRH or ACTH. These findings suggest that: 1) abnormalities in the extrahypothalamic CRH system play a role in the pathophysiology of senile dementia, which may not be specific to SDAT; 2) the CRH system and the ACTH system correlate with each other within the brain; 3) CSF ACTH is subject to the feedback inhibition by circulating cortisol; and 4) in the SDAT patients and the severe dementia group CSF CRH and serum lecithin are reduced probably via independent mechanisms.

[A case report of pulmonary embolectomy for acute pulmonary embolism]

In recent years, case reports of the pulmonary thromboembolism which had been comparatively less in our country, have been gradually increasing. However, this disease is more often reported in the chronic stage, and case reports of severe cases in the acute stage are still less. The case reported here was admitted to our hospital by emergency ambulation with severe chest pain. On the second day after the admission, respiratory standstill developed suddenly following recurrent chest pain, which necessitated cardiopulmonary resuscitation. The patient was intubated and the IABP was instituted because of hemodynamic instability. An emergent cardiac catheterization under the mechanical ventilation and the IABP supported displayed massive shadow defect on the pulmonary arteriogram, which was indicating acute pulmonary embolism. The pulmonary pressure was 58/18 mmHg despite of the shock state (the aortic pressure: 60/28 mmHg). Subsequently, a pulmonary thrombectomy was carried out under the emergency cardiopulmonary bypass. The cardiac catheterization performed two weeks after the operation. Revealed that the pulmonary pressure returned to the almost normal volume (38/18 mmHg) in association with the aortic pressure of 113/72 mmHg. The venogram of lower extremities revealed thrombi in the deep veins, suggesting the cause of the thromboembolism in the pulmonary arteries. The Bird's nest filter was inserted for the prevention of recurrence of pulmonary embolism. This patient is doing well 10 months postoperatively.

Transient bullous dermolysis of the newborn. Retention of anchoring fibril- and basal lamina-like structures in keratinocytes and evidence of collagenolysis

In a freshly induced blister from transient bullous dermolysis of the newborn, we found in epidermal basal cells structures similar to anchoring fibrils and lamina densa, often in combination. In the upper dermis, collagenolysis and phagocytosis of degenerated collagen fragments were observed. It is concluded that the stellate inclusions previously reported in this disease are prematurely assembled anchoring fibrils and lamina densa. A disturbance of delivery mechanism of precursor materials for anchoring fibrils and lamina densa may cause the deficiency of these structures which are essential for the integrity of dermo-epidermal adhesion. The presence of many normal anchoring fibrils and lamina densa in perilesional skin and their prompt degeneration after rupture of the inclusions previously led us to conclude that lytic enzymes are involved in the formation of blisters in this disease. The new finding of collagen phagocytosis in the lesional dermis seemed to support this contention.

Activation of phospholipases in platelets by polyclonal antibodies against a surface membrane protein

In a previous paper we demonstrated using immunochemical techniques that propolypeptide of von Willebrand factor was present on the surface of resting platelets. In the present paper we show that polyclonal antibodies against propolypeptide of von Willebrand factor induce activation of phospholipase(s) in platelets and lead to platelet aggregation. The antibody-stimulation of platelets induced the synthesis of thromboxane A2 (TXA2). Furthermore, the aggregation was inhibited by aspirin and an antagonist of TXA2. Aspirin inhibited not only the aggregation but also the activation of arachidonic acid liberation from phospholipids, but the effect of aspirin on arachidonic acid liberation was cancelled by the combined effect of the antibodies and a TXA2 mimetic agonist, which itself did not activate arachidonic acid liberation. The antibody-induced activation of arachidonic acid liberation and the aggregation were blocked by cytochalasin B. All these results obtained with antibodies were quite similar to the results obtained with collagen.

Papular mucinosis (scleromyxoedema) complicating diffuse systemic sclerosis: clinical features and electron microscope observations

Papular mucinosis (scleromyxoedema) is an uncommon disorder characterized by generalized papular eruption and cutaneous induration, which may be associated with a variety of extracutaneous manifestations. Although scleroderma and papular mucinosis share many features, they are clinically and histologically distinct entities. We report here a patient with diffuse scleroderma who developed superimposed papular mucinosis. Degranulating mast cells were a prominent ultrastructural finding in the involved skin. The occurrence of scleroderma and papular mucinosis, two uncommon cutaneous indurative diseases, in the same patient has not been described previously.

[A case of successful surgery for tetralogy of Fallot with single atrium, azygous connection and partial anomalous pulmonary venous drainage in atrio-visceral heterotaxic syndrome]

A 2-year-old girl of heterotaxia associated with complex anomalies was reported. Major cardiac anomaly was tetralogy of Fallot (TOF), which associated with the interruption of the inferior vena cava, persistent left superior vena cava (PLSVC), common atrium and partial anomalous pulmonary venous drainage (PAPVD) to the coronary sinus. The two dimensional echocardiogram displayed the characteristic views of TOF and the additional interesting abnormalities near the mitral ring. The markedly enlarged and protruded coronary sinus by the association of PLSVC and PAPVD overlay along the posterior mitral leaflet and the abnormal muscular septum surrounded immediately above the anterior mitral leaflet. These structures created a sort of supramitral ring structure, although this was not important hemodynamically because of the association of single atrium and TOF preoperatively. At the operation the coronary sinus roof was resected along the posterior mitral leaflet as well as the abnormal muscular flange. The atrial septum was created with a porcine pericardium and the left superior vena cava was ligated. The postoperative course was not eventful.

Polymorphism of coagulation factor XIII B subunit: further occurrence of FXIIIB*15 in Japanese and phenotyping in bloodstains

The polymorphism of FXIIIB was investigated in 555 unrelated Japanese individuals using isoelectric focusing and immunoblotting. Five common phenotypes and a rare variant type FXIIIB 15-3 were observed. The allele frequencies were FXIIIB*1 = 0.3063, FXIIIB*2 = 0.0162, FXIIIB*3 = 0.6766 and FXIIIB*15 = 0.0009. Phenotyping was also possible from bloodstains stored at 37 degrees C for up to 4 months and from bloodstains stored at room temperature and at 4 degrees C for over 6 months. The FXIIIB system can provide a new powerful genetic marker for the medicolegal grouping of bloodstains.

The role of growth factor in wound healing

A pig wound healing model was developed to study the morphological processes involved in incisional and excisional wound healing, the immunohistochemical localization of TGF-alpha in wound healing, and the latter's relevance. In incisional wounds, a few layers of epidermis were regenerated after only 32 hours. In contrast, several layers of epidermis were regenerated on day 7 in excisional wounds. In general, the incisional wound model is useful for evaluating tensile strength, while the excisional wound model is suitable for evaluating epidermal regeneration. Immunohistochemical study showed that keratinocytes migrating from wound edges expressed TGF-alpha very faintly, while TGF-alpha was present prominently in the upper several layers of the epidermis adjacent to the wound, which resembled normal epidermis and showed no changes during the wound healing process.

[Adult T-cell leukemia/lymphoma, histologically presenting Ki-1 positive anaplastic large cell lymphoma]

A 48-year-old woman was admitted with neck tumors and cutaneous nodules. On the histological basis of the skin nodule biopsy, a metastatic anaplastic carcinoma was suspected. Immunohistochemical studies showed the presence of Ki-1 antigen, IL-2 receptor antigen, leukocyte common antigen (LCA), CD3 and CD4 on the tumor cells compatible with Ki-1 positive anaplastic large-cell lymphoma. This case was, however, finally diagnosed as adult T cell lymphoma (ATL) of a helper/inducer phenotype. She was born in Kagoshima. The serum anti-ATL associated antigen (ATLA) was positive. Southern blot analysis on the DNA extracted from the skin tumor cells showed a monoclonal integration of HTLV-1 proviral DNA. The results suggested that Ki-1 positive lymphomas may include a subset of ATL with a large-cell histology.

The growth regulation of keratinocytes

Taken together, all these results suggest that TGF-alpha and amphiregulin are the major growth factors for positive growth control, although we don't know which plays the central role. For negative growth control, TGF-beta is the major factor. However, it remains to be solved which isoform of TGF-beta is naturally involved in keratinocyte growth regulation.

Effects of a new antiarrhythmic drug, SD-3212, on canine ventricular arrhythmia models

The antiarrhythmic effects of a new antiarrhythmic agent, SD-3212, (-)-(S)-3,4-Dihydro-2-[5-methoxy-2-[3-[N-methyl-N-[2-[(3,4- methylene dioxy)phenoxy]ethyl]amino]propoxy]phenyl]-4-methyl-3-oxo-2H-1, 4-benzothiazine hydrogen fumarate, were investigated using canine models of ventricular arrhythmias, i.e. spontaneously occurring digitalis-, two-stage coronary ligation- and adrenaline-induced arrhythmias. SD-3212 suppressed adrenaline-induced arrhythmia and showed some antiarrhythmic effect on digitalis- and 48 hr coronary ligation-arrhythmias. These results indicate that SD-3212 has antiarrhythmic effects common among class IV antiarrhythmic drugs and also has additional efficacy common among class I antiarrhythmic drugs, thus when considering the level of experimental arrhythmias it somewhat resembles propafenone. It may therefore become a clinically useful antiarrhythmic drug among typical class I or class IV antiarrhythmic drugs.

[Hyperresponsiveness of TSH and prolactin and impaired responsiveness of GH in Japanese patients with isolated ACTH deficiency]

Two hundred and forty-one cases of isolated ACTH deficiency have been reported in Japan since 1969. Pituitary hormone responsiveness to stimulation tests before and after hydrocortisone supplementation was investigated in these cases. Plasma ACTH level showed no or little change in response to lysine vasopressin, metyrapone, CRF or insulin-induced hypoglycemia in 97.3-100% of the cases. Serum GH level changed little or not at all in response to GRF, insulin-induced hypoglycemia, glucagon, 1-dopa and arginine in 26.9, 29.3, 40.0, 50.0 and 56.1%, respectively. Serum TSH and prolactin (PRL) levels showed hyperresponse to TRH in 34.7 and 35.6%, respectively. After hydrocortisone therapy, GH secretion was more responsive than before therapy in 78.9% of the cases. After supplementation, TSH level was less responsive to TRH stimulation than before therapy in 59.3% of the cases. After hydrocortisone supplementation, TSH response to TRH decreased in 75% of ACTH-deficient patients without primary hypothyroidism but did not decrease in more than half of those with primary hypothyroidism. TSH response to TRH decreased after supplementation in 76.5% of the patients with TSH hyperresponsiveness before therapy, and increased after therapy in 66.7% of those with normal TSH responses before therapy. After supplementation, PRL response to TRH was less than that before therapy in 43.5% of ACTH--deficient patients, and greater than that before therapy in 30.4%. PRL response to TRH decreased after therapy in 66.7% of the patients with PRL hyperresponsiveness before therapy, and increased in 63.6% of those with normal PRL response before therapy. Primary hypothyroidism and Hashimoto's thyroiditis were complicated in 21.6 and 11.6%, respectively, of the 241 patients with isolated ACTH deficiency. In patients who had TSH hyperresponsiveness and/or high basal TSH levels and PRL hyperresponsiveness and/or high basal PRL levels, primary hypothyroidism was complicated in 58.4 and 42.3%, respectively. Hashimoto's thyroiditis was complicated in 29.8 and 20.5%, respectively, of these patients. Pituitary cell antibody (PCA) was detected in 36.6% of ACTH-deficient patients who were examined. Pituitary cell surface antibody (PCSA) to AtT-20 cells and GH3 cells was detected in 50.0 and 28.0% of the examined cases, respectively. The prevalence of PCA and PCSA did not differ between TSH-hyperresponsive patients and those with normal TSH basal levels and response, whereas PCA and PCSA were significantly more prevalent in PRL-hyperresponsive patients than in those with normal PRL levels and response. An empty sella was found in 30.2% of the examined case.(ABSTRACT TRUNCATED AT 400 WORDS)

[Bilateral pneumothorax and rupture of dissecting aortic aneurysm following a mitral valve replacement in Marfan syndrome: a case report]

A 12-year-old girl with Marfan syndrome was referred to our department because of severe mitral regurgitation. The patient was pale and in a pre-shock condition. The echocardiogram revealed a chordae rupture of the posteromedial papillary muscle at the posterior leaflet. A moderate dilatation of the aortic annulus (30 mm) and the ascending aorta (45 mm) without aortic regurgitation was also observed. Emergent mitral valve replacement was performed without replacement of the aortic valve or the ascending aorta. After two months, the patient developed bilateral pneumothorax, which was resistant to continuous suction therapy and finally required surgical treatments. Despite the relatively uneventful recovery, a lethal rupture of dissecting aortic aneurysm into the pericardial cavity, developed four months after the initial operation. We discussed the desired surgical approaches and respiratory problems in patients with connective tissue disorder.

[Flow karyotyping and chromosome sorting]

For flow karyotyping and sorting, chromosomes are stained in suspension with appropriate DNA fluorochromes, and passed singly through a beam of laser light. The emitted pulses of fluorescence and scattered light are measured and stored in the form of a histogram displaying the number of pulses versus fluorescence or scattered light intensity. A data processing system was devised to remove signals from cell debris or chromosome fragments. A selective window was set in a dot plot of fluorescence versus scattered light intensities and a program was made to count pulses from the gated area only. As application of chromosome fractionation, flow cytometry has been used for karyotype analysis, gene mapping, and chromosomal DNA library construction.

Juvenile colloid milium: clinical, histological and ultrastructural features

We report the clinical, histological and ultrastructural features of juvenile colloid milium affecting a brother and sister. In this rare condition, translucent papules develop on sun-exposed areas of skin, with onset in childhood. Histologically and ultrastructurally, the papules consist of amyloid-like material derived from epidermal keratonocytes. A review of the literature suggests a possible genetic abnormality that leads to sun-induced degeneration of keratinocytes.

Alteration of pulmonary blood flow in tetralogy of Fallot: pre- and postoperative study with macroaggregates of 99mTc-labeled human serum albumin

The pulmonary blood distribution was examined in 17 patients with tetralogy of Fallot (TOF) pre and postoperatively with macroaggregates of 99mTc-labeled human serum albumin. Most of the patients with TOF demonstrated an abnormal preoperative distribution pattern. The abnormalities included not only an unbalanced distribution between the right and left lungs but also a maldistribution of peripheral vessels in each lung. The Right/Left lung counts ratio and Pulmonary Peripheral Index (calculated in order to express the severity of peripheral maldistribution) correlated neither to the diameter nor the cross-sectional area of either right or left pulmonary arteries which were measured angiographically. Postoperatively, the pulmonary blood was shunted toward the developed side of the lung which further contributed to maldistribution of blood flow and unbalanced pulmonary growth. Since the patients with an unbalanced pulmonary blood distribution demonstrated a higher right ventricular pressure one year after the operation, a palliative operation facilitating the growth of the underdeveloped side of the lung might be considered as an effective procedure to precede intracardiac repair.

Spinal arachnoid cyst in a newborn infant

A male infant was born with asphyxia following a prolonged breech delivery at 39 weeks of gestation. He had a chylohemothorax from birth. Soon after birth he exhibited flaccid paraplegia with an absence of deep tendon reflexes in the lower extremities. At 17 days of age, magnetic resonance imaging (MRI) disclosed a hypodense area in the thoracic cord between C7 and Th4 in T1-weighted images, and spinal sonography revealed an echo-free space compressing the spinal cord in the same region observed with MRI. A spinal cyst was removed surgically at 24 days of age. The cyst was confirmed by pathology to be a true arachnoid cyst between C7 and Th4. The cause of this cyst may have been a spinal cord injury during the perinatal period.

Review of operative indication and prognosis in gastric cancer with hepatic cirrhosis

Prognosis following surgery for gastric cancer has markedly improved as a result of early diagnosis, advances in operative techniques, and perioperative management. However, gastrointestinal surgery in patients with hepatic cirrhosis has continued to be associated with a high operative morbidity and mortality. On the basis of a detailed classification of the preoperative hepatic conditions into three risk groups, we have established a preoperative means of assessing surgical indication. Depending on the preoperative assessment, 40 gastric cancer patients with hepatic cirrhosis underwent surgical exploration. Thirty-seven patients (92.5%) received gastric resection, while 3 patients (7.5%) were non-resectable. Postoperative complications occurred in only 8 patients (20%), and no anastomotic leakage occurred; the overall operative mortality was zero. The five-year-survival rate following a curative resection, as calculated by Kaplan-Meier statistical analysis, was 51.4% (n = 30).

[Cell kinetic effect of carcinostatic agents using BrdU and its monoclonal antibody]

We have investigated the cell kinetic effect of four carcinostatic agents (MMC, CDDP, ADR and 5-FU) on the human gastric cancer cell line (KATO-III; signet ring cell carcinoma) by means of flow cytometry (FCM), using bromodeoxyuridine (BrdU) and its monoclonal antibody. Cancer cells in the S phase were first labelled with BrdU and then the bivariate DNA/BrdU distribution was examined to analyze the effect on the cell cycle. Furthermore, cells were reincubated at 24 hours after labelling to evaluate the cell turnover during FCM. MMC, CDDP and ADR assembled the cells into late S phase and G2M phase, while 5-FU assembled them into S phase. after 24 hours, cells with cessation of cell cycle had inhibited their proliferation. We conclude that this technique can be usefully applied as a susceptibility test of carcinostatic agents, since it could define the phase where carcinostatic agents acted on cancer cells.

[Urinary N-acetyl-beta-D-glucosaminidase and gamma-glutamyl-transpeptidase activities for evaluation of renal disturbance in patients with multiple myeloma]

The activities of N-acetyl-beta-D-glucosaminidase (NAG), gamma-glutamyl-transpeptidase (gamma-GTP) and NAG isoenzyme were measured in the urine of 20 patients with multiple myeloma (IgG/IgA type/Bense Jones type; 15/1/4 cases) and 25 healthy controls to evaluate these activities as indicators of renal disturbance in multiple myeloma. NAG isoenzyme fractions in urine were measured by agarose electrophoresis-m-cresol sulfonphthaleinyl-NAG reaction. Mean urinary NAG activity in the patients with myeloma was significantly higher than that in the controls (20.1 +/- 3.3 vs 4.3 +/- 0.3U/g. cr; p < 0.001). Urinary NAG activity in these patients correlated positively with the dose (mg/g. cr) of urinary protein (r = 0.755; p < 0.01), most of which were considered to be light chain protein, but not with creatinine clearance. Each urinary NAG isoenzyme fraction (NAG-1, -2, -3) was higher in the patients than that in the controls, and especially NAG-2 fraction (A form) showed a highly positive correlation with the dose of urinary protein. Urinary gamma-GTP activity in the patients did not differ from that in the controls, but urinary NAG/gamma-GTP ratio was higher in the patients, and reversely correlated with creatinine clearance (r = -0.721; p < 0.01). It is suggested that the elevation of urinary NAG activity results from the damage of lysosome in proximal tubular cells by urinary light chain protein and its degradation products. Therefore, urinary NAG activity may be a good index for proximal tubular disturbance, and NAG/gamma-GTP ratio may be an index for the extensive damage of nephrons in addition to the damage of tubular cells in multiple myeloma.

Effects of benzylpiperazine derivatives on the neurotoxicity of 3,4-methylenedioxymethamphetamine in rat brain

The neurotoxicity of 3,4-methylenedioxymethamphetamine (MDMA) in rat brain was attenuated significantly by coadministration of several benzylpiperazines (p-nitrobenzylpiperazine, p-chlorobenzylpiperazine and 1-piperonylpiperazine), which were weak inhibitors for [3H]6-nitroquipazine binding to the 5-hydroxytryptamine (5-HT) transporter in rat brain. These results suggest that these benzylpiperazines may inhibit the MDMA-induced neurotoxicity by a novel neuropharmacological effect other than 5-HT uptake inhibition.