[A large nontuberculous mycobacterial granuloma mimicking lung cancer; report of a case]

A 45-year-old woman with no immunodeficiency or clinical symptoms presented to our hospital for treatment of an enlarging spherical lung tumor in 4.0-cm-diameter. Chest radiography 8 years ago had shown a 1.5-cm-diameter tumor. Chest computed tomography (CT) showed the solitary tumor, located in the right apical segment, to have an irregular margin without satellite lesions or cavitations. Mycobacterium avium complex (MAC) was cultured in tumor specimens incised during transbronchial biopsy. Right upper lobectomy was performed because of resistance to 6-month antituberculosis treatment. Pathological findings showed a MAC-infected granuloma with caseous necrosis. Postoperative course was uneventful and she had no recurrence 3 years after surgery. These findings suggest that nontuberculous mycobacterial granuloma can enlarge without clinical manifestations or any satellite lesions and cavitations, leading to a misdiagnosis of lung cancer.

[Chest wall epithelioid sarcoma]

Two relatively rare cases of epithelioid sarcoma located in the chest wall are reported herein. The first was a tumor, 3.8 x 5.5 x 2.4 cm in size, originating in the left erector spinae muscle of a man 64 years of age. He experienced local recurrence 3 times even after wide resections, and he died of systemic metastasis 22 months after the initial surgery. The second was a tumor, 2.2 x 2.0 x 1.5 cm in size, originating in the left seventh intercostal muscle of a woman 24 years of age. A metastatic tumor occurred in the same muscle, and wide resection including the seventh and eighth intercostal muscles was performed. There has been no recurrence for 1.5 years since surgery. Metastasis of chest wall epithelioid sarcoma in the muscle in which the primary lesion resides should be considered, even if the primary lesion is small.

[Clinicopathologic features of small-sized peripheral lung cancer; is intentional limited resection appropriate for selected patients?]

We sought to determine the eligibility of patients with early peripheral lung cancer for intentional limited resection. The clinicopathologic features of 103 patients who underwent lobectomy and mediastinal nodal dissection for early stage peripheral lung cancer measuring 2 cm or less in maximum dimension between 1992 and 2002 were examined retrospectively. The lymph node metastasis and residual cancer after thoracoscopic partial resection were analyzed by the following categories. Three groups were divided by maximum dimension of the primary lesion in the resected specimen; 10 mm or less (n = 11), 15 mm or less (n = 33), and 20 mm or less (n = 59). Two groups were divided by lesion histology; bronchioloalveolar adenocarcinoma (BAC) [n = 42] and invasive lung cancer (n = 61). Residual cancer was found in the residual lobe after thoracoscopic partial resection in 3 of 43 patients who had no diagnosis preoperatively. Their maximum dimensions were 15 mm or less. No lymph node metastasis was detected in the patients with tumor measuring 10 mm or less, and BAC. Intentional limited resection without mediastinal nodal dissection is appropriate for patients with tumor measuring 10 mm or less and BAC. Further investigation associated with partial resection is necessary.

[Traumatic laceration of the right middle lobar bronchus; report of a case]

We described the rare case of 26-year-old woman with a traumatic laceration of the right middle lobar bronchus. The patient suffered blunt chest trauma in a traffic accident. Chest roentgenography showed bilateral pneumothorax, right multiple rib and clavicle fractures and emphysema in the subcutaneous and mediastinal lesions. Bilateral thoracic drainages were performed under controlled mechanical ventilation. Massive air leakage from the right chest tube was observed. Bronchofiberscopy 2 days after the accident revealed laceration of the right middle lobar bronchus. A right middle lobectomy was performed via thoracotomy. The patient was discharged on hospital day 51. In terms of the rare bronchial laceration is discussed.

Successful reconstruction of extensive laryngotracheal strictures after inhalation burn injury: report of a case

We report a rare case of long segmental laryngotracheal stenosis following inhalation burn injury. The patient presented 2 months after his injury with progressive stridor and dyspnea necessitating tracheostomy. A computed tomographic scan of the neck revealed stenosis extending from the vocal cords to the top of the sternum. Repair was successfully carried out with multiple surgical procedures employing hinge-flap closure tented with autogenous tissue.

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis

BACKGROUND

Surgical treatment of chronic necrotizing pulmonary aspergillosis is hazardous and controversial.

METHODS

Ten patients (8 men, 2 women; mean age, 50 years) with chronic necrotizing pulmonary aspergillosis underwent pulmonary resection between 1989 and 2000. Single segmentectomy or lobectomy, pneumonectomy, or bilobectomy and multisegmentectomy were performed. Clinicopathologic features of these patients were reviewed to clarify the role of surgical intervention for chronic necrotizing pulmonary aspergillosis.

RESULTS

The mean time from the onset of clinical symptoms to operation was 5.3 years. Surgical intervention was undertaken because of prolonged illness in 4 patients and hemoptysis in 6 patients. All patients survived. Three major complications (1 late empyema, 2 bronchopleural fistulas) occurred in the large dead space in the right pleural cavity. All survivors were free of aspergillosis at a mean follow-up time of 4.8 years, and only 1 patient required antifungal drugs for relapse during the follow-up period.

CONCLUSIONS

Aggressive pulmonary resection in chronic necrotizing pulmonary aspergillosis should be considered when patients have prolonged illness or frequent hemoptysis. Empyema and bronchopleural fistula are the main complications. Concomitant thoracoplasty or intrathoracic transposition of the chest wall musculature is recommended in cases involving a large residual pleural cavity on the right side.

[Clinical analysis of intrapulmonary lymph nodes]

We encountered 12 cases (9 men, 3 women) of intrapulmonary lymph nodes, discovered by chest radiography or chest CT and identified by thoracoscopic lung biopsy (in 10 cases), open lung biopsy (1 case) or lobectomy (1 case). We also studied the literature related to intrapulmonary lymph nodes in Japanese. Many intrapulmonary lymph nodes were found in the lower lung field, few in the upper lung field. All intrapulmonary lymph nodes were spherical and were located under the pleura, but we were not able in some cases to differentiate them from malignancies by the CT scanfindings. We could not diagnose them or rule out malignancy before surgery. Pathological findings revealed that all of them showed anthracosis. Silicotic changes were found in three cases. We consider that thoracoscopy is useful in making a definite diagnosis if peripheral pulmonary lesions cannot be diagnosed. We emphasize that intrapulmonary lymph nodes should be taken into consideration in differential diagnoses of small nodular lesions in the lung.

Symptomatic accessory cardiac bronchus

Symptomatic accessory cardiac bronchus is rare. A 52-year-old woman with an accessory bronchus, who had had frequent episodes of hemosputum for 6 years, suffered from empyema complicated by a right lower lung abscess infected with Pseudomonas aeruginosa. Resection of the anomalous cardiac bronchus after open drainage of the pleural cavity was successful.

Late pleuropulmonary aspergillosis after the treatment of pneumothorax: report of three cases

A bullectomy for spontaneous pneumothorax is often combined with pleurodesis to prevent recurrence. A recurrent or progressive residual bullous lung beneath adhesive pleura neovascularized from the chest wall may be affected by aspergillosis. Of the 12 patients with pulmonary aspergillosis secondary to bullous lung disease treated surgically at our hospital since 1974, 3 underwent a bullectomy with pleurodesis for spontaneous pneumothorax. The presenting symptoms in all cases were hemosputum. Aspergillus lesions affected the patients in the right upper lobe, the left apical segment, and both apical segments at 16, 9, and 13 years, respectively, after a bullectomy. Angiograms demonstrated hypervascularization in the intercostal and internal thoracic arteries, as well as in the bronchial branches. Catheter embolization for airway bleeding was not effective in 1 patient. Four operations, including an emergency procedure for massive intrapulmonary bleeding, were performed. These included a right upper lobectomy followed by a left upper segmentectomy at second-look operation in 1 patient who required bilateral chest wall resections. All patients survived the operations. Intraoperative bleeding ranged between 700 and 3 500 ml (1 543 ml on average), and bleeding foci were mainly from the chest wall, with hypervascularization stemming from the ipsilateral chest wall. Postoperative complications included pleural space hemorrhaging and a bronchopleural fistula, both of which required additional chest wall resections. Patients with bullous lung disease late after a bullectomy with pleurodesis may thus be associated with complex pleuropulmonary aspergillosis, which requires surgical therapy concomitant with a chest wall resection.

[Adaptation of dental home care--report number 1: Limitation of dental home care]

In 1985, we established a home care team which treats elderly and handicapped patients who cannot easily come to our clinic for treatments. The demand for home care is increasing, and 70% of this demand is related to dentures-i.e., adjusting dentures or making new dentures. Through the use of portable equipment, the home care team is able to cope effectively with this demand. However, some patients who experience difficulty eating as a result of their dental conditions require immediate attention. Furthermore, some patients require frequent follow-up. In such cases, time becomes more of an issue. Cases which were found to be difficult for the home care team include: treatments involving existing teeth where more than one tooth was involved, severe cares requiring surgical treatment, and cases requiring close monitoring of a patient's physical conditions. From our experience we know there is a great demand for home care, especially among elderly and handicapped patients; we also know that the risk factors increase and that there are limitations to the kind of care we can effectively deliver. Therefore in order to ensure the patient's safety and conduct effective treatment, it is critical that we evaluate each patient's condition carefully and thoroughly. Furthermore, it is important to develop a treatment plan and to conduct treatment while comprehensively monitoring the patient's condition.

[Adaptation of dental home care--report number 2: Attempt at a new system of dental home care]

In the first report we revealed some problems in visiting dental treatment, and concluded that a new dental care system should be constructed for the solution of those problems. Therefore, we started a new system which included dental treatment under hospitalization in our dental hospital. For home patients this system aims at treating, managing smoothly and providing better dental treatment, due to the choice of hospitalization, outpatient care, or home visits in the medical process. In the period from March, 1993, when our dental hospital was established, until December, 1998 treatment was given 1,527 times with 420 patients under this system, and 127 of these patients chose dental treatment under hospitalization. Dental treatment under hospitalization is the management method not found in usual dental treatment, but it is indispensable to our system. When we decide hospitalization, we must make an overall estimate of the patient's general condition, contents of treatment, eating function and nutritional condition, background, and the wishes of the patient and family. In principle, visiting dental treatment is intended for a patient who has finished dental treatment. When treatment is necessary, it should be limited to simple treatment, first aid and maintenance. The oral care of many home patients under the present circumstances is not practiced sufficiently, and cooperation of medical and welfare workers is required to improve such conditions.

[Mucosa-associated lymphoid tissue lymphoma with Sjögren's syndrome]

A 68-year-old woman presented with Sjögren's syndrome. Chest X-ray films disclosed consolidated shadows in the right S2 and an infiltration shadow in the right S8 with small nodules. Pathological examination of transbronchial lung biopsy (TBLB) specimens revealed lymphocytic infiltrations that stained positive with UCHL-1 and L 26 in immunohistochemical studies. Lung tissue specimens obtained by video-assisted thoracic surgery showed lympho-epithelial lesions with dense lymphocytic infiltration. Southern blot hybridization and polymerase chain reaction (PCR) assays demonstrated monoclonality and immunoglobulin heavy chain gene rearrangement. These findings yielded a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma. The detection of rear-ranged genes encoding for immunoglobulin heavy chains is useful for the diagnosis of primary pulmonary lymphoproliferative disorders, especially malignant lymphomas.

Helical computed tomographic minimum-intensity projection of a slit in an airway obstruction

We treated a 54-year-old man with an anastomotic obstruction after a right upper sleeve lobectomy. By using minimum intensity projection images that were generated from helical computed tomographic data sets that indicated a twisted slit enhanced with air a few millimeters in length, through anastomosis to the distal bronchus, we successfully treated the obstruction by bronchoscopic balloon dilatation.

Pulmonary histoplasmosis in a Japanese male: report of a case

A case of pulmonary histoplasmosis, which is rare in Japan, is reported herein. A 43-year-old man who had worked in Mexico for 2 years and had come back to Japan 3 months earlier, presented at our hospital because of an abnormal shadow on his chest roentogenogram with no symptoms. His chest roentogenogram as well as chest computed tomograms revealed a 2-cm-diameter nodule in the anterior basal segment of his right lung and an enlargement of the subcarinal lymph node. Although these pictures seemed to indicate an advanced lung cancer, no malignant cells were found based on the brushing cytology findings after bronchoscopy. An exploratory thoracoscopic tumor resection and biopsy of the enlarged lymph node led to a histological diagnosis of an abscess due to histoplasma. The hospital course was uneventful. Postoperatively, amphotericin B was administered for 1 year. This is the eighth case of pulmonary histoplasmosis reported in Japan. A pulmonary nodule together with mediastinal lymphoadenopathy seems to be characteristic in these patients. Histoplasmosis should therefore be considered in the differential diagnosis, since overseas travel has now become common-place for the Japanese.

Subcarinal neurogenic tumor: report of a case

We present herein the rare case of a 63-year-old man in whom a subcarinal tumor, demonstrated by enhanced chest computed tomograms (CT), was subsequently confirmed to be a neurilemmoma by histological examination following tumor resection through a diagnostic thoracoscopy. Magnetic resonance imaging (MRI) and transesophageal ultrasonogram findings excluded the possibility of malignant lymphoadenopathy. As the patient was also found to have an elevated level of the squamous cell carcinoma (SCC) tumor marker which did not resolve postoperatively, close follow-up will be required.

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

BACKGROUND

Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial.

METHODS

Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases.

RESULTS

The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy.

CONCLUSIONS

The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior medisatinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.

[Cardiac tamponade caused by diffuse pericardial mesothelioma]

A 75-year-old woman was admitted to our hospital because of dyspnea and fever. A chest roentgenogram obtained on admission showed cardiomegaly. An echocardiogram, a computed tomogram, and a magnetic resonance computed tomogram revealed a pericardial tumor and a large pericardial effusion. A tumor biopsy was done under echocardiographic guidance, and sarcomatous mesothelioma was diagnosed on the basis of histological and immunohistological studies of biopsy specimens. Pericardial fenestration followed by tumor resection gave relief from cardiac tamponade. The postoperative course was good, and the patient was discharged from the hospital on the 19th postoperative day. Four months later the pericardial mesothelioma recurred and the patient died of constrictive pericarditis. Palliative resection was useful in this case because it allowed the patient to resume activities of daily living by relieving the cardiac tamponade.

Successful surgical treatment of a complete traumatic tracheal disruption

We report a case of a survivor who suffered a complete traumatic disruption of the cervical trachea associated with multiple organ injuries. She underwent an emergent operation including end-to-end anastomosis of the disrupted trachea with pedicled omental coverage to prevent dehiscence and mediastinitis. The postoperative course was uneventful, with hospital discharge on day 36. She returned to her previous lifestyle.

[Diagnosis and treatment of pulmonary nodules by video-assisted thoracoscopic surgery--surgeons' view]

We reviewed 48 cases of pulmonary nodules in which video-assisted thoracoscopic surgery was done at Jichi Medical School Hospital from 1992 through 1995. The pulmonary nodules comprised 14 malignant tumors (9 lung cancers and 5 pulmonary metastases), 10 benign tumors (7 hamartomas, 2 localized mesotheliomas and 1 tumorlet), 19 granulomas (8 inactive infectious tumors, 7 active infectious tumors, and 4 granulomas as sequelae of other diseases), 4 intrapulmonary lymph nodes, and 1 pulmonary cyst. Conventional operations for lung cancer were done in 7 cases, and 6 were found to be ST-I. Tumor resection by video-assisted thoracoscopic surgery allowed diagnosis of rare diseases and treatment of benign lung tumors and of lung metastases. We conclude this procedure is very useful for diagnosis and treatment of indeterminate pulmonary nodules.

[Chest wall reconstruction, relation between reconstruction method and infection]

We have operated 52 cases of chest wall resection in these 20 years. Twenty five cases in it were reconstructed by unabsorbable artificial materials such as Marlex mesh, Gore-Tex sheet and some others (Group 1). Eleven cases were covered with the net knitted by absorbable threads or muscle flaps (Group 2). Resting 16 cases have not received any definitive renovations (Group 3). Group 1 has suffered from such severe postoperative complications as acute empyema (8%) and chronic empyema (8%). Few cases in Group 2 has had infectious complication and ventilatory disturbance. Rate of postoperative vital capacity in Group 3 was the lowest value among three groups, though they had the smallest chest wall defects. We obtained following conclusions from this study. Every chest wall defect should be repaired by some way even if the defect were small. Chest wall defect in compromised host should be repaired by absorbable artificial material and muscle flap. Unabsorbable artificial materials are now indispensable for the reconstruction of large chest wall defect, however we must fully take care of postoperative infections in cases of its use.

The effectiveness of transesophageal ultrasonography in preoperatively diagnosing an esophageal cyst in a 75-year-old woman: report of a case

We present herein the unusual case of a 75-year-old woman in whom an esophageal cyst was preoperatively identified with the aid of transesophageal ultrasonography. She underwent successful extirpation and has remained well since her discharge from hospital. The transesophageal ultrasonogram was shown to be a powerful diagnostic tool for the identification of a mediastinal mass located adjacent to the esophagus.

[Clinical study on transfer into lung tissue of cefminox]

Nineteen patients who underwent pulmonary resection due to lung diseases were administered with 2 g of cefminox (CMNX) by intravenous drip infusion just before surgery. CMNX levels in the serum and lung tissue were determined and pharmacokinetic parameters were derived. The obtained results are summarized as follows: 1. Pharmacokinetic parameter (K1/K2) derived from serum and lung tissue concentrations using deconvolution method was 0.46. 2. CMNX was useful for prophylaxis of postoperative infections with lung resection.

[Open lung biopsy in an 11 year old boy with %FVC 11%]

Anesthesia was administered to an 11 year old boy with %FVC 11%. The patient had dyspnea and severe constrictive pulmonary disorder with an almost normal chest radiograph. Open lung biopsy was performed and the patient was weaned in the first postoperative morning without any problem. Pulmonary fibrosis was caused by anti-cancer drugs given in his infancy. He died of cardiorespiratory failure 14 months postoperatively.

[Contact time of red blood cells with alveolar air]

The contact time between red blood cells and alveolar air is one of the most important factors affecting red blood cell oxygenation in the lungs. Many methods have been presented for contact time measurement, however, no work, evaluating it by tracing red blood cell movement through the pulmonary capillary network has been reported. In this study, the contact time was measured by tracing red blood cells, stained with fluorescein isothiocyanate (FITC-RBC), with a fluorescent microscope in living rat lung. It was assumed that the transit time of red blood cells through the pulmonary capillary network was equivalent to the contact time. The flow patterns of red blood cells were complicated, namely, FITC-RBC discharged from one arteriole flowed into several venules through many routes in the pulmonary capillary network, and those ejected from several arterioles pored into one venule. Furthermore, the FITC-RBC flow rate changed many times in the pulmonary capillary network. The contact time varied from 0 to 1.2 seconds. The measurement was performed in each classified route by the straight distance between arteriole and venule, in order to simplify the various capillary networks. The results revealed that the contact time was 0.3, 0.4, 0.5, 0.7, 0.7 and 0.7 seconds on the average respectively in the routes of 101--150, 151--200, 201--250, 251--300 and 301--350 microns straight distance. The frequencies of the above distance routes were 5, 8, 15, 23, 26 and 21%, respectively. As a result, the total lung contact time calculated using these frequencies was 0.7 +/- 0.2 seconds (mean +/- standard deviation) on average.

[Two cases of re-expansion pulmonary edema]

A 62-year-old man and 26-year-old man with re-expansion pulmonary edema (RPE) after thoracic drainage as a treatment for pneumothorax are presented. Blood cell counting and biochemical serum analysis were performed throughout their treatment in both patients, and biochemical sputum analysis was in one patient. The results showed transient marked leukocytosis just after RPE. Total protein and albumin concentrations of sputum approximated to those of serum. The above results suggested that RPE is based on pulmonary microvascular injury, which may introduce leukocytosis.

[An injury of the liver caused by ischemia-reperfusion in rat liver. Report 2: Relationship between the damage of the liver and during the period of reperfusion]

Liver injury by 30-min ischemia following reperfusion was examined biochemically and histopathologically. A greater increase in the level of LDH was observed after 1-hr reperfusion. However, the level of LDH decreased in proportion to the period of reperfusion, while the levels of GOT and GPT were also increased rapidly and reached its peak at 12 hr following reperfusion and were almost restored to the control level by 48 hr. A similar increase was obtained in the lipid peroxides of the liver. In addition, cyt. P-450 content and NADPH cyt. c reductase activity decreased in proportion to the period of reperfusion up to 12 hr and then recovered by 96 hr. On the other hand, heme oxygenase activity was significantly increased by ischemia-reperfusion. The ischemia-reperfused liver resulted in various morphological changes with the period of reperfusion. The destruction of Disse's space, vacuolization of the cytoplasm and nonviable hepatocytes were observed after 12-hr reperfusion. These results indicate the greatest damages of the liver induced by 30-min ischemia following reperfusion is observed after 12-hr or 24-hr reperfusion. The liver injury by ischemia-reperfusion could be a useful experimental model to develop for future studies.

[Delayed sternal closure after cardiac surgery]

Following cardiac surgery, approximation of sternum will produce systemic hypotension or elevation of left atrial and central venous pressures. A new criteria for delayed sternal closure is proposed. Sternal closure has to be delayed when mean left atrial or central venous pressures increased over 2 mmHg at the tentative closure. In seven cases (3.5%) of consecutive 201 patients was delayed the sternal closure under the above mentioned state, all survived and received the successful closure later. One of them died of congestive heart failure four months after the operation and one died of the rupture of the ascending aortic pseudoaneurysm eleven months after the initial operation. Microbiological examination of the mediastinal and pericardial contents obtained at the final sternal closure were negative in all cases. Comparing the total cardiopulmonary bypass time, ventricular fibrillation time, and myocardial ischemic time between in the secondary closure group and in the primary closure group, the total bypass time and the ventricular fibrillation time of the former were significantly longer than the latter, but the ischemic time revealed no difference. In conclusions, persistent elevation of left atrial or central venous pressures after cardiac surgery at the tentative sternal closure seems the reliable predictor for the delayed closure of the sternum. Careful post-operative management prevents serious mediastinal infection. Delayed sternal closure is preferable procedure for the patient with brittle hemodynamics after open heart surgery.

[Two cases of Marfan syndrome, surgically treated for complicating spontaneous pneumothorax]

Two cases of spontaneous pneumothorax in the patients of Marfan Syndrome were reported. Nine and 13-year-old girls were admitted to our hospital complaining of chest pain and dyspnea for the first time. Tension pneumothorax was confirmed by the chest radiograph. Both of them had the physical stigmata of Marfan Syndrome including cardiovascular abnormalities. The drainage tube was inserted into the thoracic cavity. As the drainage was ineffective, the surgical treatment was undertaken. The thoracic cavity was opened though axillary incision and bullae were resected. The patient of pneumothorax with the Marfan Syndrome should be examined preoperatively about cardiovascular abnormality using chest computed tomography and echocardiography. As far as the surgical intervention was concerned, the axillary approach is preferred to the median sternotomy, as such patient highly probably require cardiovascular operation in future.

[Effects of kamikihi-to, a Chinese traditional medicine, on various cholinergic biochemical markers in the brains of aged rats]

The effects of kamikihi-to (EK-49) on various cholinergic biochemical markers, muscarinic receptors, acetylcholinesterase (AChE), choline acetyltransferase (CAT) and choline uptake, in aged rat brains were examined. Administration of kamikihi-to in daily doses of 200 mg/kg, p.o. for 4 weeks to aged rats (24-months-old) significantly increased the density of muscarinic receptors (Bmax) for 3H-QNB (quinuclidinyl benzilate), but did not affect the apparent dissociation constant (Kd). After repeated administration of kamikihi-to to aged rats, AChE activity and choline uptake were not significantly different in the kamikihi-to treated aged rats as compared with the control aged rats. However, administration of kamikihi-to for 4 weeks resulted in a significant increase in Vmax values of CAT in kamikihi-to treated aged rats as compared with those of the control rats. These results indicate that long-term treatment with kamikihi-to enhances both the Bmax and Vmax for QNB binding and CAT activity in aged rats, respectively.

[Angiosarcoma of the chest wall with chronic empyema--a case report]

A 65-year-old man admitted to our hospital with a complaint of painful tumor of chest wall. By preoperative aspiration cytology and biopsy, the tumor was diagnosed as a sort of sarcoma. Tumor, empyema cavity and lower lobe of the right lung was resected en bloc. Pathological diagnosis was angiosarcoma originated from the chest wall with chronic empyema. Chest wall angiosarcoma is a rare disease, and its prognosis is grave. One of the causes of chest wall sarcoma with chronic empyema is considered to be repeated chronic inflammation.

[A severe respiratory distress in a new born infant with double aortic arch without cardiac anomalies]

A 39-day-old girl underwent operation for double aortic arch. She required endotracheal intubation at 23-day-old because of severe respiratory distress. Echocardiography, esophagography and angiocardiography revealed double aortic arch without other cardiac anomalies. At the operation the lesser arch and ductus arteriosus were divided. Soon after the operation her respiratory distress disappeared and fiberbronchoscopic examination showed rapid recovery of the deformed trachea.

A comparative study on the concentrations of polychlorinated biphenyls (PCBs) and polychlorinated quaterphenyls (PCQs) in the blood and hair of "Yusho" patients and inhabitants of Nagasaki Prefecture

The relationship between polychlorinated biphenyl (PCB) and polychlorinated quaterphenyl (PCQ) concentrations in the blood and hair was investigated. The materials in this study consisted of 49 blood samples and hair obtained from 27 patients with PCB poisoning (Yusho) and 22 normal controls. The alkaline decomposition method described in the official standard analytical methods for the isolation of PCB and PCQ fractions was used. In the blood of the control group, the mean concentration of PCBs was 2.25 ppb, while the concentration of PCQs was too low to be detected by our analytical method. On the other hand, the mean concentration of PCBs in the Yusho group was about 2.8 times higher than that in the control group. The mean concentration of PCQs in the blood was 0.61 ppb in the Yusho group, but PCQs were not detectable in the control group. In the hair, the mean concentration of PCBs was 25.85 ppb and 9.41 ppb in the Yusho group and control group respectively. The mean concentration of PCQs in the hair of Yusho patients was 0.44 ppb, but PCQs were not detected in the control group. The PCB level in the hair was higher than that in the blood, but the PCQ level in the hair was lower than that in the blood. These results suggest a difference of excretory system among polyhalogenated compounds such as PCBs or PCQs. We consider that PCBs display a greater affinity than PCQs for the pilosebaceous system of the human skin.(ABSTRACT TRUNCATED AT 250 WORDS)

[A young female case with simultaneous bilateral spontaneous pneumothorax operated upon submammarian incision for median sternotomy]

One of the characteristics of pneumothorax in female is considerably complicated with menses, histiocytosis X, diffuse pulmonary hamartoangiomyomatosis. So during thoracotomy, the thoracic cavity must be examined, as well as the hole of the diaphragm. And especially in female aesthetic attention is also required. A transverse submammarian skin incision with median sternotomy was used in a 18-year-old female with simultaneous bilateral pneumothorax. This approach was useful for the median sternotomy as well as more excellent aesthetics.

Effects of aprotinin on prostaglandin metabolism and platelet function in open heart surgery

The effects of the protease inhibitor, aprotinin, on plasma prostaglandin levels and platelet function during and after cardiopulmonary bypass (CPB) were studied in a group of 23 patients which consisted of 11 untreated patients (control group) and 12 aprotinin-treated patients (aprotinin group). Thromboxane B2 (TXB2, a stable metabolite of thromboxane A2) and beta-thromboglobulin levels in the control group increased significantly during CPB compared with preoperative values. These increases were significantly suppressed in the aprotinin group. 6-Keto-PGF1 alpha (stable metabolite of prostacyclin) increased significantly during CPB in both groups, and there was no significant difference between the two groups. In the aprotinin group, the TXB2/6-Keto-PGF1 alpha ratio decreased significantly during CPB compared with the preoperative value, whereas no significant decrease was observed in the control group. Platelet counts decreased significantly during and after CPB in both groups. Platelet aggregability decreased significantly during CPB in the control group, whereas no significant decrease was found in the aprotinin group. In conclusion, aprotinin treatment improved prostaglandin metabolism and preserved platelet function during open heart surgery.

[A case report of chest wall reconstruction utilizing microvascular surgery]

A 62-year-old man underwent left chest wall reconstruction after resection of the chest wall including 4-6th ribs for the metastatic tumor of squamous cell carcinoma of the left lung. The chest wall defect measuring 15 x 10 cm was reconstructed with double Marlex mesh in skeletal chest and covered with pedicled free mucocutaneous flap of tensor fasciae latae which was implanted by the vascular anastomoses to the thoracodorsal artery and vein using microvascular surgical technique. The flap was attached well and its blood supply was excellent on postoperative angiography.

Inhibition of MAO activity, 3H-imipramine binding, 3H-paroxetine binding and 3H-5-HT uptake by human cerebrospinal fluid

Addition of small amount of human cerebrospinal fluid (CSF) inhibited both types of MAO in monkey brain mitochondria. The specific binding of 3H-paroxetine decreased remarkably with increasing CSF volumes, while 3H-imipramine binding was slightly inhibited. Scatchard analysis of 3H-paroxetine binding in the presence and absence of CSF indicated that the inhibitory effect was associated with a decreased Bmax without an appreciable change in Kd. Addition of CSF induced an inhibition of uncompetitive 3H-5-HT uptake to monkey cerebral membranes. These results indicate that the materials in human CSF inhibit 3H-paroxetine binding, and modulate the uptake system for 5-HT.

Preservation of pancreatic beta cell function with pulsatile cardiopulmonary bypass

Pancreatic islet cell function and tissue metabolism were studied during and after cardiopulmonary bypass in 38 patients undergoing an open heart operation. Twenty patients were operated on with pulsatile cardiopulmonary bypass (group I) and 18, with nonpulsatile cardiopulmonary bypass (group II). Hyperglycemia was observed during and early after operation in both groups. In group I during cardiopulmonary bypass, the immunoreactive insulin and c-peptide levels and the insulin to glucagon molar ratio increased significantly compared with the preoperative values, but in group II, these variables did not alter significantly. An hour postoperatively, the immunoreactive insulin (71 +/- 34 muIU/mL) and c-peptide (8.3 +/- 3.0 ng/mL) levels and the insulin to glucagon molar ratio (11.0 +/- 5.2) in group I were significantly higher than those in group II (immunoreactive insulin, 29 +/- 20 muIU/mL; c-peptide, 4.8 +/- 1.8 ng/mL; insulin to glucagon molar ratio, 3.4 +/- 2.6). The blood lactate level in group I (41 +/- 22 mg/dL) was significantly lower than that in group II (78 +/- 30 mg/dL) an hour postoperatively. In conclusion, pulsatile cardiopulmonary bypass is quite effective in preserving pancreatic beta cell function and tissue metabolism during and early after open heart procedures.

CD3-negative lymphoproliferative disease of granular lymphocytes containing Epstein-Barr viral DNA

Lymphoproliferative disease of granular lymphocytes (LDGL) is a heterogeneous disorder and the pathogenesis is likely to be complex. Some patients with chronic active EBV (CAEBV) infection also have LDGL. To investigate the relationship between EBV infection and the pathogenesis of LDGL, we conducted a survey for EBV DNA sequences by Southern blot analysis of DNA obtained from the peripheral blood of seven patients with LDGL, including one with CAEBV infection. Interestingly, EBV DNA was detected in the sample from the patient with CAEBV infection, and in the samples from four other patients with CD3-LDGL. Moreover, a single band for the joined termini of the EBV genome was demonstrated in two samples, suggesting a clonal disorder of those LDGL. These findings strongly suggest that EBV may play a pathogenic role in some cases of LDGL.

A comparative study on polychlorinated biphenyls (PCB) and polychlorinated quaterphenyls (PCQ) concentrations in subcutaneous fat tissue, blood and hair of patients with yusho and normal control in Nagasaki prefecture

The relationship between PCB and PCQ concentrations in the blood, subcutaneous fat tissue and hair was investigated in this study. PCB and PCQ concentrations in twenty four patients with PCB poisoning (yusho) and 59 normal controls were analyzed. The alkaline decomposition method described in the official standard analytical methods for the isolation of PCB and PCQ fractions was used. The mean value of PCB concentrations was 2.43 ppb, CB% ratio was 0.69 and the PCQ concentration in the blood of the control group was too low to be detected by our analysis. On the other hand, the PCB concentration and CB% ratio in the yusho group were two times higher than those in the control group. The mean value of PCQ concentration was 1.34 ppb in the yusho group although it was below the level of detection in the control group. The mean PCB concentration in the hair of patients with yusho was 28.92 ppb, and 8.06 ppb in the control group. CB% ratio in the hair of patients with yusho was two times higher than that in the control group. The mean value of PCQ concentration in the hair of patients with yusho was 0.55 ppb although it was not detected in the control group. The PCB and PCQ concentrations in the hair were not greatly elevated when compared with those in the subcutaneous fat tissue. However, the hair is an excellent sample for the detection of these chemicals because it can be collected simply without operation.