[Left ventriculoplasty for ischemic cardiomyopathy with a left ventricular aneurysm]

We report 3 cases of left ventriculoplasty (LVP). They were chosen according to classification of the preoperative left venticle (LV) shape; an apex type and anteroseptal type. We think that an apex type has an indication for a Dor operation and the treatment of an anteroseptal type should be chosen between the following 2 methods. One is an overlapping method. It has the advantage of having to use no intracardiac patch which would remain akinetic area. It is therefore suitable for relatively small LV aneurysms without involvement of the proximal diagonal branches. However, it has the disadvantage of having to cut some distal diagonal branches in order to perform the volume reduction. The other method is a septal anterior ventricular exclusion (SAVE) operation. It is suitable for larger LV aneurysms which involve the proximal diagonal branches due to its advantage of being able to perform the LVP without cutting the diagonal branches. However, it has the disadvantage of leaving an akinetic area that corresponds to the intracardiac patch. We believe that choice of the LVP method according to the preoperative LV shape will bring about a better postoperative LV function and shape.

Clinical evaluation of a new enzyme immunoassay for hepatitis B virus core-related antigen; a marker distinct from viral DNA for monitoring lamivudine treatment

We aimed to assess the clinical performance of a newly developed chemiluminescence enzyme immunoassay (CLEIA) for the detection of hepatitis B virus (HBV) core-related antigen (HBcrAg) in patients with chronic HBV infection. A total of 82 patients with chronic HBV infection and 167 HBV-negative controls were studied. HBcrAg was measured by CLEIA with monoclonal antibodies to hepatitis B e antigen (HBeAg) and hepatitis B core antigen (HBcAg), and HBV DNA was measured by transcription-mediated amplification assay (TMA) and in-house real-time detection polymerase chain reaction (RTD-PCR). The HBcrAg assay detected viremia in 189 of 216 samples (88%) collected from 72 patients whilst the TMA assay detected viremia in 178 of the 216 samples (82%) (P = 0.019). The HBcrAg concentration correlated linearly with the HBV DNA concentration (P < 0.001) over a range which varied 100 000-fold. The accuracy in the measurement of the patients' HBV load obtained using the HBcrAg assay was not affected by the absence of hepatitis B e antigen from the serum or the presence of precore mutations in the HBV genome. In patients without anti-viral drugs, changes in their serum HBcrAg concentration over time corresponded to their HBV DNA concentration. In six additional patients who were later treated with lamivudine, HBV DNA concentration declined more rapidly than their HBcrAg concentration. Three months after treatment commenced, the ratio of HBcrAg: HBV DNA had increased in all six patients (P = 0.031). The HBcrAg assay is a sensitive and useful test for the assessment of a patient's HBV load. When monitoring the anti-viral effect of lamivudine, HBcrAg provides a viral marker which is independent of HBV DNA.

Long-term follow-up of hepatitis C virus infection: HLA class II loci influences the natural history of the disease

Hepatitis C virus (HCV) causes various grades of chronic liver disease, ranging from an asymptomatic state to cirrhosis. To assess genetic factors of disease severity, we selected two HCV patient groups according to the following stringent criteria: (i) asymptomatic carrier state (ASC) defined by HCV infection for more than 20 years, normal alanine aminotransferase levels for the past 5 years as well as normal liver histology and/or shape and (ii) liver cirrhosis (LC) as diagnosed by clinical symptoms, liver biopsy and/or ultrasonography. A total of 103 chronically infected Japanese HCV patients (43 ASC and 60 LC) were analyzed. HLA class I and II alleles were established using low resolution DNA typing. HLA-DRB1 and DQB1 genotypes were inferred upon polymerase chain reaction-restriction fragment length polymorphism analysis. Two hundred and one anti-HCV-negative ethnically matched controls were included. The frequencies of DRB1*12 (*1201 and *1202), DQB1*0301 and DRB3*03 alleles were higher in patients with ASC than in those with LC (odds ratio (OR) 11.23, OR 4.25, and OR 3.22, respectively). The frequency of DQB1*0503 were lower in ASC patients compared to LC patients (OR 0.05). No significant differences between groups were observed for age, sex, source of infection, HCV genotype or viral loads. Our findings establish that certain HLA class II alleles strongly influence disease progression following HCV infection.

Association between SEN virus infection and hepatitis C in Japan

There is a strong association between 2 SEN virus (SENV) variants (SENV-D and SENV-H) and transfusion-associated non-A-E hepatitis. In total, 200 subjects from a Japanese region where hepatitis C virus (HCV) is highly endemic and 194 persons from a contiguous area where HCV is not endemic were tested for SENV-D and SENV-H DNA by polymerase chain reaction. SENV DNA was detected equally in subjects from each area (56% prevalence in the area of high endemicity vs. 61% in the nonendemic area). Age-specific prevalence of SENV was similar to that of TT virus, with equal distribution at all ages in both areas; HCV was predominant in the elderly population. Alanine aminotransferase levels were significantly associated with HCV viremia but not with SENV viremia. SENV is a common infection that appears to have transmission routes and age-related prevalence that are distinct from those of HCV. No evidence was found that SENV caused hepatitis or worsened the course of hepatitis C.

Relationship between hepatitis C virus infection and schistosomal liver disease: not simply an additive effect

BACKGROUND

To study the association, clinical significance, and impact of hepatitis C virus (HCV) co-infection in patients with schistosomal liver disease (SLD).

METHODS

A total of 240 patients with chronic liver diseases encountered consecutively were enrolled in the study. Fifty volunteer blood donors were enrolled as controls. HCV antibody determination (enzyme-linked immunosorbent assay), qualitative and quantitative HCV RNA assay (reverse transcriptase polymerase chain reaction), and HCV genotyping (line probe assay) were performed.

RESULTS

Twenty-eight patients had SLD alone, 60 had both SLD and chronic hepatitis C (CH-C), 120 had CH-C alone, and 32 had other liver diseases. The positivity rates for HCV antibody (76% vs 20%; P < 0.001) and HCV RNA (59% vs 10%; P < 0.001) were significantly higher in the patients with SLD (n = 88) than in the volunteer blood donors (n = 50). Complications of liver cirrhosis were more common in patients with concomitant SLD and CH-C than in those with either SLD or CH-C alone. The mean levels of alanine aminotransferase (77 +/- 42 vs 93 +/- 55 IU/l; P = 0.049) and HCV RNA concentrations (3.5 +/- 1.0 vs 4.2 +/- 1.0 log copy/ml; P < 0.001) were significantly lower in patients with concomitant SLD and CH-C than in those with CH-C alone. HCV genotype 4 predominated in both these groups (93% and 98%).

CONCLUSIONS

SLD in Egypt is significantly associated with HCV infection, with the predominance of genotype 4. Concurrent HCV infection and SLD result in much more severe liver disease than that seen with either disease alone. However, the activity of HCV infection seems to be partially suppressed in patients with SLD.

Acyl-CoA thioesterases belong to a novel gene family of peroxisome proliferator-regulated enzymes involved in lipid metabolism

Acyl-CoA thioesterases hydrolyze acyl-CoAs to the corresponding free fatty acid plus coenzyme A. The activity is strongly induced in rat and mouse liver after feeding the animals peroxisome proliferators (PPs). To elucidate the role of these enzymes in lipid metabolism, the authors have cloned the cDNAs corresponding to the inducible cytosolic and mitochondrial type I enzymes (CTE-I and MTE-I), and studied tissue expression and nutritional regulation of expression of the mRNAs in mice. The constitutive expression of both mRNAs was low in liver, with CTE-I expressed mainly in kidney and brown adipose tissue, and MTE-I expressed in brown adipose tissue and heart. As expected, the expression in liver of both the CTE-I and MTE-I mRNAs were strongly induced (> 50-fold) by treatment with clofibrate. A similar level of induction was observed by fasting and a time-course study showed that the CTE-I and MTE-I mRNAs were increased already at 6 h after removal of the diet. Refeeding normal chow diet to mice fasted for 24 h normalized the mRNA levels with a T1/2 of about 3-4 h. Feeding mice a fat-free diet further decreased the expression, possibly indicating repression of expression. The strong expression of MTE-I and CTE-I in the heart was increased about 10-fold by fasting. To further characterize these highly regulated enzymes, the authors have cloned the corresponding genes and promoter regions. The structures of the two genes were found to be very similar, consisting of three exons and two introns. Exon-intron borders conform to general consensus sequences, and, especially, the first exon appears to be highly conserved. The promoter regions of both the CTE-I and MTE-I genes contain putative PP response elements, suggesting an involvement of PP-activated receptors in the regulation of these genes.

Seroepidemiological study of hepatitis E virus infection in Japan using a newly developed antibody assay

PURPOSE

A seroepidemiological study of hepatitis E virus (HEV) infection was conducted in Japan, where HEV infection is not considered endemic.

METHODS

IgG and IgM class antibodies to HEV were measured with a newly developed enzyme-linked immunosorbent assay in which recombinant virus-like particles were used as an antigen. A total of 1253 individuals (401 males and 852 females; age range, 6-89 years) were enrolled from two different areas: area 1 (n = 478), in which hepatitis C was endemic; and area 2 (n = 775), in which it was not endemic.

RESULTS

The HEV antibody (IgG class) positive rate was 6.7% in area 1 and 4.6% in area 2. Similarly, the HAV antibody (IgG class) positive rates were 65.3% and 72.3%. The age- and sex-specific prevalence of both HAV and HEV antibodies was quite similar in the two areas, and the HAV antibody positive rate clearly increased with age in both males and females. On the other hand, the HEV antibody positive rate showed a slight tendency to increase with age in males, but not in females. None of the 32 individuals with the HEV antibody who were interviewed had a history of visiting countries in which hepatitis E was endemic. In both areas, the mean age, percentage of males, and HAV antibody positive rate were significantly higher in the group of individuals with the HEV antibody than in the group of those without it, according to conventional statistical analyses. Of the three factors age, male sex, presence of HAV antibody, and the area factor, only male sex was statistically significant (P < 0.001) on multivariate logistic regression analysis. Two (0.2%) of the total of 1253 individuals were positive for the IgM class antibody to HEV.

CONCLUSIONS

Our results suggest the possibility that HEV infection is circulating in Japan at a low level. HEV infection was associated with male sex, but not with HAV infection.

Persistent infection mechanism of GB virus C/hepatitis G virus differs from that of hepatitis C virus

OBJECTIVE

Changes in the deduced amino acid sequence of the envelope 2 (E2) region of the GB virus C/hepatitis G virus (GBV-C/HGV) were analyzed to investigate whether or not the region contributes to persistent infection with the virus.

METHODS

Eight patients with acute hepatitis C and 1 patient with acute hepatitis of unknown etiology were included in the study. GBV-C/HGV RNA was detected in 6 patients, including the patient with hepatitis of unknown origin. The nucleotide sequence of the E2 region of hepatitis C virus (HCV) and GBV-C/HGV was determined by direct sequencing of polymerase chain reaction products in 5 patients with HCV infection and in 6 patients with GBV-C/HGV infection twice during the period of early infection and several months or years later in each patient.

RESULTS

The mean substitution rate of the deduced amino acid sequence in the E2 region was over 100 times lower (p < 0.001) in GBV-C/HGV (0.01 +/- 0.04/month/100 sites) than in HCV (2.4 +/- 1.7/month/100 sites). The amino acid sequence of the loop domain of GBV-C/HGV-E2 did not change in any of the 6 patients. On the other hand, the sequence of the hypervariable region of HCV-E2 changed remarkably (5.9 +/- 4.3/month/100 sites). No amino acid substitution in the loop domain was observed in 7 additional patients who showed persistent GBV-C/HGV viremia for more than 2 years.

CONCLUSION

These results indicate that changes in the amino acid sequence of the E2 region are not involved in the mechanism of persistent GBV-C/HGV infection.

Myopathic form of very-long chain acyl-coa dehydrogenase deficiency: evidence for temperature-sensitive mild mutations in both mutant alleles in a Japanese girl

In a 14-year-old Japanese girl, manifested recurrent myalgia with elevated serum creatine kinase after moderate exercise became evident, and she was diagnosed as having a myopathic form of very-long chain acyl-CoA dehydrogenase deficiency. Her first clinical symptom of the disease was evident when she was 6 y of age. She had never had hypoglycemic attacks, and hepatomegaly and cardiomyopathy were absent. The diagnosis was suspected on the basis of the urinary organic acid profile after a 36-h fast, long-chain fatty acid-loading test, and the blood acylcarnitine profile. Acyl-CoA dehydrogenase activity with palmitoyl-CoA as a substrate was severely decreased in her fibroblasts, and the amount of very-long chain acyl-CoA dehydrogenase protein was reduced. She was a compound heterozygote of A416T from her father and R450H from her mother. Transient expression of mutant A416T cDNA retained a significant residual acyl-CoA dehydrogenase activity of 10% and 20% normal at 37 degrees C and 30 degrees C, respectively. Specific activity of A416T mutant protein was calculated to be one fifth that of control. In the case of R450H mutant expression, a low residual acyl-CoA dehydrogenase activity of 5% normal was detected at 30 degrees C although significant activity was absent at 37 degrees C. The R450H protein was not detected at 37 degrees C but was clearly detected at one fourth the normal amount at 30 degrees C. These results indicate that both mutations were temperature-sensitive mild mutations, the result being the mildest phenotype of very-long chain acyl-CoA dehydrogenase deficiency.

Clinical impact of genotype 1 TT virus infection in patients with chronic hepatitis C and response of TT virus to alpha-interferon

BACKGROUND

The relationship between genotype 1 TT virus (TTV) infection and the status of chronic hepatitis C was studied.

METHODS

A total of 52 patients with chronic hepatitis C who were treated with interferon (IFN)-alpha were enrolled in the present study. Of those, 12 were infected with genotype 1 TTV and 40 were uninfected.

RESULTS

Clinical backgrounds, including mean age, sex, blood transfusion history, serum alanine aminotransferase (ALT) level, and the results of liver biopsy did not differ between patients with and without genotype 1 TTV infection. The distribution of hepatitis C virus (HCV) genotypes did not differ between the two groups of patients, but TTV-infected patients tended to have a lower serum HCV-RNA level than uninfected patients (median (range) 26.0 (< 1-460) vs 135 (1.2-740) kilo copies/mL, respectively; P = 0.065). Patients with a sustained response of HCV to IFN-alpha were significantly more common in TTV-infected than -uninfected patients (58 vs 23%, respectively; P = 0.018). Multivariate logistic regression analysis revealed that patients with a sustained response of HCV correlated significantly with the serum HCV-RNA level (P = 0.006), but not with the presence or absence of genotype 1 TTV infection (P = 0.161). Serum TTV-DNA decreased with IFN-alpha therapy in all 12 patients and remained negative in six patients even after treatment. There was no correlation between patients with a sustained response of HCV and the same of TTV. Serum ALT levels correlated with changes in the status of HCV viremia, but not with changes in the status of TTV viremia.

CONCLUSIONS

An opposing relationship between HCV and TTV proliferation was suggested, but coinfection with genotype 1 TTV did not affect the status of chronic hepatitis C.

Clinical impact of genotype 1 TT virus infection in patients with chronic hepatitis C and response of TT virus to alpha-interferon

BACKGROUND

The relationship between genotype 1 TT virus (TTV) infection and the status of chronic hepatitis C was studied.

METHODS

A total of 52 patients with chronic hepatitis C who were treated with interferon (IFN)-alpha were enrolled in the present study. Of those, 12 were infected with genotype 1 TTV and 40 were uninfected.

RESULTS

Clinical backgrounds, including mean age, sex, blood transfusion history, serum alanine aminotransferase (ALT) level, and the results of liver biopsy did not differ between patients with and without genotype 1 TTV infection. The distribution of hepatitis C virus (HCV) genotypes did not differ between the two groups of patients, but TTV-infected patients tended to have a lower serum HCV-RNA level than uninfected patients (median (range) 26.0 (< 1-460) vs 135 (1.2-740) kilo copies/mL, respectively; P = 0.065). Patients with a sustained response of HCV to IFN-alpha were significantly more common in TTV-infected than -uninfected patients (58 vs 23%, respectively; P = 0.018). Multivariate logistic regression analysis revealed that patients with a sustained response of HCV correlated significantly with the serum HCV-RNA level (P = 0.006), but not with the presence or absence of genotype 1 TTV infection (P = 0.161). Serum TTV-DNA decreased with IFN-alpha therapy in all 12 patients and remained negative in six patients even after treatment. There was no correlation between patients with a sustained response of HCV and the same of TTV. Serum ALT levels correlated with changes in the status of HCV viremia, but not with changes in the status of TTV viremia.

CONCLUSIONS

An opposing relationship between HCV and TTV proliferation was suggested, but coinfection with genotype 1 TTV did not affect the status of chronic hepatitis C.

Reevaluation of spiral CT cholangiography: basic considerations and reliability for detecting choledocholithiasis in 80 patients

PURPOSE

The purpose of this work was to reevaluate the characteristics and diagnostic accuracy of spiral CT cholangiography (CTC) for detecting biliary calculi.

METHOD

Spiral CTC was performed in 133 patients with suspected biliary or pancreatic diseases. All source images were reviewed by two radiologists who were unaware of final diagnoses. Attenuation values of bile were correlated with biochemical data and visualization of anatomic detail. The statistical measures in detecting the presence of choledocholithiasis were calculated in 80 patients with confirmed diagnoses.

RESULTS

Statistically significant correlations were found between the degree of biliary enhancement and both serum bilirubin and alkaline phosphatase levels. Of the 80 patients, 18 (23%) had choledocholithiasis and 62 did not. Observers diagnosed them with a sensitivity of 89% and a specificity of 98%. A mild adverse reaction to contrast material was observed in three (2.3%) patients.

CONCLUSION

Spiral CTC is a reliable, noninvasive, and accessible technique for detecting choledocholithiasis.

Aneurysm of the left sinus of Valsalva causing aortic, mitral regurgitation and myocardial ischemia

An aneurysm of the left sinus of Valsalva producing aortic and mitral regurgitation with myocardial ischemia was treated successfully by reconstructing the left coronary sinus while preserving the aortic cusp combined with coronary artery bypass grafting. Aortic and mitral regurgitation occurred due to distortion of the left aortic cusp by a huge aneurysm that also compressed and obstructed the main trunk of the left coronary artery. The postoperative course was uneventful and follow-up showed aortic and mitral regurgitation to be absent and the coronary graft to be patent. Aortic valve-sparing surgery thus proved to be an appropriate procedure for this case.

Clinical significance of TT virus infection in patients with chronic liver disease and volunteer blood donors in Egypt

Clinical significance of TT virus (TTV) infection was investigated in Egyptian patients with chronic liver disease and volunteer blood donors by a cross sectional analysis. TTV DNA in serum was assessed by a semi-nested polymerase chain reaction. The prevalence of TTV DNA did not differ among patients with chronic hepatitis B (11/24, 46%), chronic hepatitis C (22/72, 31%), or schistosomal liver disease (14/39, 36%). No difference in prevalence was found between blood donors (32/109, 29%) and each of the patient groups. Clinical background including mean age, sex distribution, history of blood transfusion, and mean level of alanine aminotransferase did not differ between TTV DNA-positive and -negative individuals in any of the study groups. Ultrasonographic evidence of liver cirrhosis was similar between TTV-positive and -negative patients in each of the chronic liver disease groups. TTV infection was not associated with hepatitis B or C virus infection in blood donors. The only significant difference observed was the lower concentration of serum HCV RNA in TTV DNA positive compared with negative patients with chronic hepatitis C (3.0 +/- 1.4 vs. 4.0 +/- 0.9 log copies/ml, P <. 001). In conclusion, TTV infection was not associated with either past history of blood exposure or infection with bloodborne hepatitis viruses in Egypt. No clinical significance of TTV was found in the present study. However, a reciprocal interaction was suggested between TTV and HCV replication.

[Primary ciliary dyskinesia treated with living-donor lobar lung transplantation]

We report a case of primary ciliary dyskinesia in which a living-donor lobar lung transplant was performed. A 24-year-old woman with a diagnosis of primary ciliary dyskinesia and bronchiectasis was admitted to Shinshu University Hospital because of persistent dyspnea and pyrexia over a period of 4 months. Although she was given various antibiotics, neutrophilia, elevated plasma C-reactive protein (CRP) levels, and respiratory failure persisted. Chest roentgenograms and computed tomography disclosed severe bronchiectasis and diffuse infiltrative shadows in both lung fields. Pseudomonas aeruginosa was detected in a sputum culture. Although a variety of conventional therapies were administered, the patient's oxygenation progressively deteriorated. She was intubated and assisted by mechanical ventilation. The patient and her family proposed lung transplantation, and we concluded that a living-donor lobar lung transplant would be a suitable treatment for her disease. We transported the patient to Okayama University Hospital by helicopter 10 days after intubation. A living-donor lobar lung transplant was successfully performed with lung tissues donated by the patient's mother and sister for each transplant site.

[Non A-G chronic hepatitis in Japan]

It is clear that certain patients with viral hepatitis are also seronegative for types A, B, C, D, and E. Although hepatitis G virus was discovered recently, this virus has been reported to be non-contributing or only slightly conductive to liver dysfunction. In this article, epidemiological studies regarding patients seronegative for types A to G chronic hepatitis in Japan are reported. Among 1089 patients with chronic liver disease, twenty-five patients (1.8%; 14 chronic hepatitis, 4 cirrhosis, 2 hepatocellular carcinoma) were diagnosed as non A-G hepatitis (negative for HbsAg, HCV-Ab, and HGV RNA). Only 3 of 25 these patients had histories of blood transfusion. The levels of transaminase in the patients with chronic non-A to G hepatitis (without hepatocellular carcinoma) was as the same as those in patients with chronic hepatitis type B and C. Our results indicated a low prevalence of non-A to G chronic hepatitis, yet a few cases were progressive to cirrhosis or HCC, and this may be due to another unknown agents for non-A to G hepatitis.

Transmission of and liver injury by TT virus in patients on maintenance hemodialysis

To study the prevalence and clinical significance of TT virus (TTV) infection in hemodialysis patients, we tested for TTV DNA in serum, using the nested polymerase chain reaction. The prevalence of TTV DNA in 352 hemodialysis patients was 32%, significantly higher than that in 50 healthy blood donors (12%). The prevalence increased with age (P = 0.0098): it was 20% (22/110) in patients aged less than 49 years, 37% (69/188) in those aged 50-69 years, and 41% (22/ 54) in those aged over 70 years. Other clinical features and the prevalence of other hepatitis viral markers tested did not differ between patients with TTV DNA and those without it. The detection rate of hepatitis C virus (HCV) and hepatitis G virus (HGV) viremias increased with duration of hemodialysis and with the number of blood transfusion units, but the prevalence of TTV viremia did not. Twenty-nine of 91 patients followed for 5 years were initially positive for TTV DNA. Of these 29 patients, 17 (59%) carried this viremia for at least 5 years. Fourteen of the 62 patients (23%) who were initially negative for TTV DNA acquired TTV viremia. Serum alanine aminotransferase (ALT) levels were elevated in patients with HCV viremia but not in patients with HGV or TTV viremia. However, the mean ALT level in patients with all three viremias (HCV, HGV, and TTV) was significantly higher than that in patients with one or two of the viremias. More than 30% of the hemodialysis patients had TTV viremia and the carrier state was maintained for years. The hemodialysis procedures, including blood transfusion, did not seem to be crucial for the transmission of TTV. The pathogenic effects of TTV on hepatitis appear to be limited.

Metastatic small cell lung cancer causing biliary obstruction

We report a case with metastatic small cell lung cancer which first manifested with biliary obstruction due to metastasis. Prognosis of patients presenting with jaundice due to hepatic parenchyma involvement is thought to be poor. However, the patient was successfully treated with percutaneous transhepatic biliary drainage and combination chemotherapy with reduced dosage. We believe this to be the first such case report, despite the frequency of metastasis to the liver from small cell lung cancer.

Early experience of minimally invasive valve surgery

In this paper we report on our early results of minimally invasive cardiac valve surgery. A series of 6 consecutive patients with valvular disease underwent valve repair and valve replacement via a right parasternal incision; aortic valve replacement 3, mitral valve replacement 1, mitral valve repair 2. There were no intraoperative complications requiring median sternotomy. Five patients had no blood transfusion. There was only one postoperative event; this patient had a sudden massive bleeding from the chest tube after extubation of the endotracheal tube, an immediate re-suture of the aortotomy was performed. The reoperative course was uneventful. Minimally invasive cardiac surgery for aortic and mital valves is an excellent option for most patients affected by isolated valvular disease.

Two patients with acute hepatitis B with suspected sexual transmission of hepatitis G virus

Two patients with acute hepatitis B with suggested sexual transmission of hepatitis G virus (HGV) are reported. A total of 18 patients with community acquired acute hepatitis B were analyzed in this study. Two of the 18 patients (patients 1 and 2) were positive for serum HGV RNA at the initial consultation. Both patients had had sexual contact with prostitutes several weeks before the onset of acute hepatitis, and hepatitis B virus (HBV) was suggested to be infected through the sexual contacts. These patients showed no other history of exposure to possible transmission routes for blood-borne hepatitis viruses. Patient 1 was diagnosed as with acute HGV infection because the antibody to HGV envelope-2 protein seroconverted to positive during the course of acute hepatitis. HGV RNA was negative in a serum sample collected from patient 2 before the onset of acute hepatitis, also suggesting acute HGV infection. These results indicate that in patients 1 and 2 HGV was infected along with HBV through sexual contact. The clinical manifestations of acute hepatitis in the two patients with HGV co-infection did not differ from those in the 16 patients with HBV infection alone.

Prevention of postoperative pericardial adhesions with a defibrinogenating agent

Pericardial adhesions pose a major problem during re-operative cardiac surgical procedures. The purpose of this study was to determine the effect of Batroxobin, a fibrinogen depleting agent, on the incidence of experimental pericardial adhesions. Twenty-four rabbits were divided into 3 groups of 8 rabbits each and pericardial mesothelial injury was induced by abrasion. Group A included rabbits receiving no further treatment, Group B included rabbits receiving intrapericardial injection of Ringer's solution, and Group C included rabbits receiving intrapericardial injection of Batroxobin. Three weeks after surgery, the incidence of adhesions in Groups B and C was compared with that in Group A. Pericardial adhesions found in 80% of the rabbits in Groups A and B. However, only 14% of the rabbits in Group C had pericardial adhesions (p < 0.05). Our findings demonstrated that intrapericardial Batroxobin reduced the incidence of pericardial adhesions in an animal model.

[Mantle cell lymphoma with multiple extranodal involvement]

A 79-year-old male was admitted to our hospital because of general fatigue and night sweat. Physical examination showed generalized superficial lymphadenopathy, marked splenomegaly, and tumors in the conjunctiva and the abdomen. Chest X-ray and computed tomography (CT) revealed pleural effusion and intrathoracic lymphadenopathy. Abdominal ultrasonography and CT showed hepatosplenomegaly and intraperitoneal tumors. Upper gastrointestinal fiberscopy revealed multiple polypoid lesions and ulcers in the duodenum and the stomach. Involvement of relatively small-sized lymphocytes with cleaved nuclei was identified in each biopsied specimen from a cervical lymph node, a tumor in the conjunctiva, gastrointestinal polypoid lesions, and the bone marrow. Surface marker analysis of abnormal lymphocytes in the bone marrow revealed that CD5, CD19, and CD20 were strongly positive, but CD23 was weakly positive. Although (11:14)(q13:q32) translocation was not identified by chromosome analysis of bone marrow cells, Northern blot analysis of bone marrow cells revealed overexpression of the PRAD1 oncogene. Diagnosis of mantle cell lymphoma (MCL) was made. Combination chemotherapy by cyclophosphamide and vincristine was not effective, but etoposide perorally given at a dose of 50 mg per day was effective. In MCL, extranodal involvement of a digestive tract and bone marrow is well known. This case suggests that involvement of multiple organs including lacrimal glands and pleura could be characteristic of MCL cells.

Mutation analysis of very-long-chain acyl-coenzyme A dehydrogenase (VLCAD) deficiency: identification and characterization of mutant VLCAD cDNAs from four patients

Very-long-chain acyl-coenzyme A dehydrogenase (VLCAD) deficiency is a newly identified disease. A 105-bp deletion in the VLCAD cDNA in two patients has been reported, and detailed molecular characterization of this disease has remained to be done. We report here five mutations identified in four patients: a 135-bp deletion encompassing bases 343-477, a C-1837-to-T transition (R613W), 3-bp deletions at the nucleotide positions 388-390 (E130del) and 895-897 (K299del), and an A-1144-to-C transversion (K382Q). Sequencing of genomic DNA amplified by PCR revealed a 135-bp deletion caused by exon skipping due to a 1-bp deletion in a 3' splice site of an intron. In cDNA expression experiments using Chinese hamster ovary (CHO) cells, we found that each of the mRNAs derived from E130del and K299del clones were unstable and that translation products from R613W, E130del, K299del, and K382Q clones were labile. Each of R613W, E130del, K299del, and K382Q proteins expressed in CHO cells appeared abnormal in dimer assembly, as shown in gel-filtration analysis. VLCAD activity was not detected in mutants' transfectants. Thus, we verified that all five mutations identified in these four patients were disease-causing alterations.

Dependence of the thymidylate synthase inhibition rate on the interval after the last administration of tegafur in sigmoid colon cancer patients

The thymidylate synthase (TS) inhibition rate was measured after tegafur (FT) administration (1.5 g/day, at least 10 days) in 7 sigmoid colon cancer patients. The TS inhibition rate decreased as the interval between the time of the last administration and the time of the tumor resection increased longer. This study provides basic data for considering methods of drug administration and assessment of modification, for example, by leucovorin.

[Histopathological evaluation of the radiosensitizing effects of an intratumoral injection of BrdU for rectal cancer]

We delivered preoperative radiotherapy with intratumoral injection (ITI) of radiosensitizer, 5-bromodeoxyuridine for patients with locally advanced cancer originating in lower rectum. We identified immunohistochemically the tumor cells that incorporated BrdU, and evaluated the radiosensitizing effect of BrdU histopathologically. (1) BrdU-labeled nuclei of cancer cells were identified in twenty-three cases out of 24 (96%). Mean labeling index was 18.5%, and tended to decrease as time progressed. (2) The parameters representing volume of residual tumor nests (Tumor Nest Index) or degrees of tumor extension (Depth of Extramural Tumor and Depth of Extramural Fibrosis) for patients with ITI were compared to those for patients without ITI. Those parameters tended to decrease when ITI was combined with radiotherapy. However, the difference was not significant statistically. Intratumorally injected BrdU can incorporate with cancer cells, but a methodological invention is required for yielding clinically measurable radiosensitization.

[Computed tomographic evaluation of thickness of perirectal fascia in rectal cancer treated by preoperative radiotherapy--diagnostic value for prediction of local recurrence]

Perirectal fascia was examined by computed tomography before and after preoperative radiotherapy in thirty-six patients with rectal cancer. CT measurement showed that perirectal fascia tend to increase in thickness during preoperative radiotherapy in proportion to tumor extension into perirectal fat tissue. The fascial thickening more than 7 mm after preoperative radiotherapy was suggestive of local recurrence to develop. Preoperative or intraoperative boost irradiation would be recommended for such high-risk patients.

Schmidt syndrome due to idiopathic accessory nerve paralysis

A patient with Schmidt syndrome due to idiopathic accessory neuropathy has had paralysis of soft palate and larynx as well as trapezius and sternocleidomastoid muscles, reflecting involvement of cranial and spinal roots, respectively. In addition to vocal cord paralysis on the laryngoscopy, videofluoroscopy confirmed diminished mobility of the soft palate. Electrodiagnosis showed accessory neuropathy at the proximal segment. Furthermore, the accessory nerve innervated not only upper but also middle and lower portions of the trapezius muscles.

Resection combined with intraoperative radiation therapy (IORT) for stage IV (TNM) gallbladder carcinoma

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty-seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT) +/- postoperative external radiotherapy (ERT), and 1 had postoperative ERT. The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n = 2), hepatic segmentectomy (SIVb, SV) plus HBR (n = 9), hepatic segmentectomy (SIV, V, VI) with HBR (n = 1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n = 3), PD plus HBR (n = 1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n = 3), and cholecystectomy plus HBR (n = 3), and cholecystectomy (n = 4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall. A single dose of 20-30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients. The three-year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16, 13, and 4 months after tumor resection followed by IORT plus ERT.

Effects of preoperative radiotherapy on rectal cancer. Preliminary report on combining radiation with intratumor injections of peplomycin and bromodeoxyuridine

Between 1976 and 1983, 61 patients with advanced rectal cancer underwent Miles' operation at the authors' institution. All lesions were located 10 cm or less from the anal verge. Of these patients, 25 were treated by surgery alone and 36 were given preoperative radiotherapy. The total dose was 42.6 Gy, (30.6 Gy [1.8 Gy/fr x 5/week]) delivered to the entire pelvis plus an additional 12 Gy (3.0 Gy/fr x 4/week) delivered to the primary tumor. Of 36 patients, 21 were administered intratumor injections of peplomycin and bromodeoxyuridine at the time of boost radiation and 15 were treated without intratumor injections. During the follow-up period (3 to 9 years), in the groups of patients who underwent radiation, there was only one local failure (2.8 percent). In contrast, in the group of patients treated by surgery alone, eight local failures occurred (32 percent). The intratumor injection significantly enhanced the effect of radiation on tumor regression. The incidence of positive lymph nodes was higher in patients in the surgery alone group than it was in the groups treated with radiation. There was no difference in the rate of distant metastasis among the three treatment groups. The five-year survival rate for the radiation with intratumor injection group, radiation alone group, and surgery alone group, was 77.8, 69.2, and 56.0 percent, respectively. No severe complication was experienced.

Recurrence factors studied by percutaneous transhepatic portography before and after endoscopic sclerotherapy for esophageal varices

High recurrence and rebleeding rates have been reported when endoscopic sclerotherapy has been performed on patients with esophageal varices. We studied the relationship between embolization range and recurrence rate in 26 patients in whom percutaneous transhepatic portography was carried out before and after sclerotherapy. Patients were divided into complete and incomplete embolization groups. The complete embolization group consisted of 16 patients whose esophageal varices had disappeared and in whom embolization of the feeders to the varices had occurred. The incomplete embolization group consisted of 10 patients whose esophageal varices had disappeared, but no embolization had occurred. Recurrence rates within 2 yr after the treatment were compared between complete and incomplete embolization groups. The recurrence rates in the respective groups were 6.7% (1 of 15) and 70.0% (7 of 10), indicating a significant difference between the two groups (p less than 0.05) and indicating that embolization of both esophageal varices and their feeders is essential to lower the recurrence rate after sclerotherapy.

[Electrophysiological monitoring of the brainstem function in impending brain death--serial changes of blink reflex and brainstem auditory evoked potential]

Serial changes of EEG, BR and BAEP recordings were obtained over a period of two days on two patients who had suffered massive cerebral hemorrhage while their clinical condition evolved from coma with evidence of preserved cerebral and brainstem functions to a state meeting the criteria of brain death. As clinical evidence of deteriorating brainstem function became apparent in case 1, first wave IV and V components of BAEP disappeared while waves I to III were normal. Finally, when clinical criteria of brain death were fulfilled, the BAEP response was restricted to wave I with small amplitude to stimulation of left ear only. These serial changes were likely consistent with gradual dissolution of brainstem function in a rostrocaudal direction. By contrast, in case 2, the BAEP response was restricted to waves I and II and was stationary in the whole process of impending brain death in no association with some preservation of cerebral and brainstem function. The changes of BAEP was not parallel to the progressive deterioration of EEG and BR. After meeting clinical criteria of brain death, complete abolition of waves II and I was sequential in that order, and then Babinski sign besides withdrawal and deep tendon reflexes may revive in the extremities. Monitoring of serial electrophysiological changes is helpful in the course of impending brain death to determine whether revival of Babinski sign is due to recovery of cerebral-brainstem dysfunction or due to establishment of spinal autonomy.

Intense accumulation of indium-111 leukocytes in peritonitis carcinomatosa

In order to detect the infectious foci in a case of terminal recurrent cancer of the sigmoid colon with intense inflammation, In-111 oxine leukocyte scintigraphy was performed. Leukocytes labeled with In-111 oxine quickly localized within the region of peritonitis carcinomatosa and could be imaged after 4 hours. With time, high activity appeared in this area. And 48 hours after injection, the large intestine was clearly seen. However, no activity was seen in the main recurrent tumor. This suggested that the labeled leukocytes had accumulated in regions of inflammation rather than in malignant tissue. When performing In-111 leukocyte scintigraphy for diseases in which tumor cells and inflammation are mixed, distinguishing the two components is particularly important, and time-sequential scanning is very useful.

[Electrophysiological study of congenital facial paralysis]

The common cause of neonatal facial asymmetry is facial nerve paralysis or "asymmetric crying facies syndrome". In the not uncommon later the lower lip, symmetrical at rest, becomes tilted to the so-called normal side when the patient is smiling or crying, as the congenital hypogenesis of sublabial muscles fail to pull down the lower lip in the opposite side. The electrophysiological differentiation between the two diseases has been performed by orbicularis oculi and oris reflexes with mechanically glabellar and supralabial tapping stimulation, respectively, in addition to needle and/or surface EMG recording. In the facial nerve paralysis of the case 1, R1 and R2 were absent in the orbicularis oculi and oris reflexes. EMG activity was completely lacking over the M. orbicularis oculi and oris innervated by facial nerve. On the contrary, the orbicularis oculi and oris reflexes were normal in the asymmetric crying facial of the case 2. EMG activity was absent only in the sublabial muscles including M. depressor anguli oris and/or M. depressor labii inferioris. Furthermore, needle EMG disclosed no spontaneous activity at rest, which was suggestive of no denervation in the sublabial muscles. It was, however, not possible to determine exactly which muscle the needle was inserted, the M. deprossor anguli oris or the M. depressor labii inferioris. The case 3 might be a variant of asymmetric crying facies with hypogenesis of M. orbicularis oris and/or oculi as well as the sublabial muscle, since the latency was normal but the amplitude was significantly attenuated in the components of orbicularis oculi and oris reflexes.(ABSTRACT TRUNCATED AT 250 WORDS)

Villous adenoma in the large bowel following ureterosigmoidostomy: a case report and review of the pertinent literature

This report presents a case of colonic adenoma which developed after ureterosigmoidostomy. A 71-year-old man was initially treated by total cystectomy and ureterosigmoidostomy for transitional cell carcinoma of the bladder in 1970. In 1983, a routine checkup revealed urinary occult blood. A barium enema x-ray showed a polypoid lesion in the sigmoid colon. Colonoscopy confirmed the presence of the polyp adjacent to the ureteral stoma. The biopsy findings were interpreted as villous adenoma with severe atypia. This tumor was removed endoscopically. This is the seventh case report of neoplasia occurring in the sigmoid colon after ureterosigmoidostomy in Japan. Review of the pertinent literature indicates that patients who have undergone this type of urinary diversion have an increased risk of development of large bowel neoplasia. Adequate and regular surveillance of these patients has been suggested in order to help in early detection.

Lithotomy of intrahepatic and choledochal stones with Yag laser

Eight patients with intrahepatic bile duct stones and three with choledochal stones were treated by Yag laser using a choledochofiberscope. A choledochoscope was inserted through a T-tube fistula in five patients or a percutaneous transhepatic cholangiodrainage fistula in six patients. In one patient, right partial lobectomy of the liver was performed after most of the stones were withdrawn, since some stones in the extremely narrow bile duct had not been removed. Most of the intrahepatic bile duct stones and choledochal stones will be withdrawn using the Yag laser and a choledochofiberscope, when they were bilirubin stones.

Injection sclerotherapy of esophageal varices for patients undergoing emergency and elective surgery

From October 1977 to September 1981, 68 patients with esophageal varices (30 emergency cases of bleeding and 38 elective cases) were treated by injecting 5% ethanolamine oleate into varices, using an esophagofiberscope. Esophageal bleeding was successfully controlled in 29 of 30 patients who had emergency surgery. None of the 38 patients who underwent elective operation had bleeding after treatment. When recurrence occurred 1 or 2 years after treatment, the same procedure was repeated. Pleuritis occurred in one of the patients who had emergency surgery, and bleeding (300 to 400 ml) from the esophagocardial junction occurred in two patients who underwent elective operation. These patients were treatment conservatively.

[Tissue concentration of 5-FU following pre-operative administration of FT-207]

Forty patients with gastric cancer and 30 patients with colon cancer were administered FT-207 prior to the operation. The relation between a total dose (4-88g) and tissue concentration of 5-FU was investigated and the following results were obtained. (5-FU concentration was measured with the method of Gas chromatography mas fragmentography) 1) The relation between total doses of FT-207 (x) and concentration of 5-FU in the tissue (y) was demonstrated by the formula: y = 0.00317x + 0.025 (gastric cancer) r = 0.519, p = 0.0001 y = 0.0019x + 0.043 (colon cancer) r = 0.641, p = 0.0001 2) In most of the patients with rectal cancer who received radiation therapy prior to the operation, 5-FU concentration in the tissue was extremely low. 3) 5-FU concentration showed no difference between the normal and metastatic lymph nodes, or among the lymph node groups. Administration methods (oral intake or suppository) had no influence on the concentration of 5-FU. 4) Among the organs, 5-FU concentration was higher in the following orders: liver, normal mucosa, lymph node, tumor, normal serosa. 5) In five autopsy cases, 5-FU concentration of the tissue show a great difference among them, and some cases showed 10 times as high concentration as others in the tissue of every organ.

Choledocholithotomy by Yag laser with a choledochofiberscope: case reports of two patients

The Neodymium-Yag laser was successfully used with a choledochofiberscope for choledocholithotomy in two patients. The bile duct stones were crushed with the Yag laser and removed or pushed into the duodenum without causing any injury. This procedure is highly recommended for treatment of some patients with bile duct stones.