Incidence of menstrual cycle abnormalities and polycystic ovary syndrome in female Japanese patients with type 1 diabetes mellitus. The role of androgens

Type 1 diabetes mellitus (T1DM) adversely affects gonadal function. This study aimed to define the characteristics and factors associated with menstrual cycle abnormalities and polycystic ovary syndrome (PCOS) in Japanese patients with T1DM. Our study enrolled 157 patients, including 55 with oligomenorrhea (prolonged menstrual cycle) and 102 without oligomenorrhea. LH/FSH ratio (p = 0.04) and total testosterone levels (p = 0.03) were significantly higher in the oligomenorrhea group than in the non-oligomenorrhea group. No significant differences were found between the two groups regarding age at menarche, age at T1DM diagnosis, treatment, glycated hemoglobin, or total daily insulin dose. Of the 55 patients in the oligomenorrhea group, 27 were diagnosed with PCOS based on the Rotterdam criteria. We concluded that female patients with T1DM, as well as abnormal menstrual cycles and hyperandrogenism, may suffer from undiagnosed PCOS and should be referred to a gynecologist for full assessment, diagnosis, and treatment.

Clinical and Genetic Characteristics of Patients with Mild Hyperphenylalaninemia Identified by Newborn Screening Program in Japan

Phenylketonuria (PKU) and hyperphenylalaninemia (HPA), both identified in newborn screening, are attributable to variants in PAH. Reportedly, the p.R53H(c.158G>A) variant is common in patients with HPA in East Asia. Here, we aimed to define the association between p.R53H and HPA phenotype, and study the long-term outcome of patients with HPA carrying p.R53H. We retrospectively reviewed the genotype in 370 patients detected by newborn screening, and identified the phenotype in 280 (117, HPA; 163, PKU). p.R413P(c.1238G>C) was the most frequently found (n = 117, 31.6%) variant, followed by p.R53H (n = 89, 24.1%). The odds ratio for heterozygous p.R53H to cause HPA was 48.3 (95% CI 19.410-120.004). Furthermore, we assessed the non-linear association between the phenylalanine (Phe) value and elapsed time using the follow-up data of the blood Phe levels of 73 patients with HPA carrying p.R53H. The predicted levels peaked at 161.9 μmol (95% CI 152.088-172.343) at 50-60 months of age and did not exceed 360 μmol/L during the 210-month long observation period. The findings suggest that patients with HPA, carrying p.R53H, do not need frequent Phe monitoring as against those with PKU. Our study provides convincing evidence to determine clinical management of patients detected through newborn screening in Japan.

Double pancreatic tumors in an adolescent: Imaging features

Insulinoma is generally identified as a single tumor and seldom occurs in children or adolescents. A 14-year-old girl with difficulty in waking was found to have hyperinsulinemic hypoglycemia. On abdominal ultrasonography two hypoechoic masses (8 and 12 mm in diameter) were seen in the pancreatic body: the larger mass was hypervascular, whereas the smaller one was hypovascular. Contrast-enhanced computed tomography showed enhancement of the larger mass, but did not delineate the smaller mass. On fat-suppressed T1-weighted magnetic resonance imaging, the larger mass was hypointense, but the smaller mass was hyperintense. Pathologically, the larger tumor was normal density, insulin positive, and rich in vascularity, whereas the smaller tumor was high density, insulin negative, and poor in vascularity. The present case suggests that difficulty waking should be considered as a potential etiology in insulinoma, and multiple suspected pancreatic insulinomas should be evaluated using a combination of imaging modalities to characterize each tumor.

FUS immunoreactivity of neuronal and glial intranuclear inclusions in intranuclear inclusion body disease

AIMS

Recent studies have shown that fused-in-sarcoma (FUS) protein is a component of 'neuronal' intranuclear inclusion bodies (INIBs) in the brains of patients with intranuclear inclusion body disease (INIBD). However, the extent and frequency of FUS-immunoreactive structures in INIBD are uncertain.

METHODS

We immunohistochemically examined the brain, spinal cord and peripheral ganglia from five patients with INIBD and five control subjects, using anti-FUS antibodies.

RESULTS

In controls, the nuclei of both neurones and glial cells were intensely immunolabelled with anti-FUS and neuronal cytoplasm was weakly positive for FUS. In INIBD, neuronal and glial INIBs in the brain and spinal cord were positive for FUS. FUS-positive INIBs were also found in the peripheral ganglia. The proportion of FUS-positive neuronal INIBs relative to the total number of inclusion-bearing neurones ranged from 55.6% to 83.3% (average 73.2%) and that of FUS-positive glial INIBs ranged from 45.9% to 85.7% (average 62.7%). The nucleus and cytoplasm of inclusion-bearing neurones and glial cells showed no FUS immunoreactivity.

CONCLUSIONS

These findings suggest that FUS is incorporated into INIBs in both neurones and glial cells and that loss of normal FUS immunoreactivity may result from reduced protein expression and/or sequestration within inclusions.

Linezolid versus vancomycin for the treatment of infections caused by methicillin-resistant Staphylococcus aureus in Japan

OBJECTIVES

To compare the efficacy and safety of linezolid and vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in Japan.

METHODS

Patients with nosocomial pneumonia, complicated skin and soft-tissue infections or sepsis caused by MRSA were randomized to receive linezolid (600 mg every 12 h) or vancomycin (1 g every 12 h).

RESULTS

One hundred patients received linezolid and 51 received vancomycin with outcomes evaluated at the end of therapy (EOT) and at the follow-up (FU), 7-14 days later. At EOT, clinical success rates in the MRSA microbiologically evaluable population were 62.9% and 50.0% for the linezolid and vancomycin groups, respectively; and microbiological eradication rates were 79.0% and 30.0% in the two groups, respectively (P < 0.0001). At FU, the clinical success rates were 36.7% for both groups and the microbiological eradication rates were 46.8% and 36.7%, respectively. Reversible anaemia (13%) and thrombocytopenia (19%) were reported more frequently in linezolid patients; laboratory analysis showed mild decrease in platelet counts with full recovery by FU. The mean platelet count in linezolid patients with thrombocytopenia was 101,000/mm(3). Significantly low platelet counts (<50,000/mm(3)) were observed more frequently in patients receiving vancomycin than in linezolid patients (6% versus 3%). Mean changes in haemoglobin levels between the two groups were not different.

CONCLUSIONS

Linezolid is as effective as vancomycin for the treatment of MRSA infections and may be more effective than vancomycin in achieving microbiological eradication. Haematological adverse events were reported more frequently in linezolid-treated patients; analysis of laboratory data showed a mild reversible trend towards lower platelet counts.

Comparative Clinical Study of Cefcapene Pivoxil and Cefteram Pivoxil in Chronic Respiratory Tract Infections by a Double-blind Method

In a double-blind study, the efficacy and safety of the novel cephem antibiotic cefcapene pivoxil (CFPN-PI; 450 mg/day) was compared with cefteram pivoxil (CFTM-PI; 600 mg/day) in 171 patients with chronic respiratory tract infections. There was no significant difference between the clinical efficacy of the two drugs (80.2% for CFPN-PI versus 78.9% for CFTM-PI). There was no significant difference in the rate of elimination of the causative bacteria (60.5% for CFPN-PI versus 65.9% for CFTM-PI). Side-effects were observed in 6.0% of patients treated with CFPN-PI compared with 6.4% of patients treated with CFTM-PI. There were no significant differences in incidence of abnormal laboratory findings following treatment with the two drugs (13.9% for each), and none of the side-effects was severe. We conclude that CFPN-PI (450 mg/day) was as effective and as well tolerated as CFTM-PI (600 mg/day) in the treatment of chronic respiratory tract infections.

Hyperthyroidism Causes Mechanical Insufficiency of Myocardium with Possibly Increased SR Ca2+-ATPase Activity

Hyperthyroidism is known to affect multiple organ functions, and thyroid hormone has been known to improve myocardial function in a failing heart. The purpose of this study is to elucidate the functional and metabolic effects of thyroid hormone on myocardium in a rat model exposed to long-term excess thyroid hormone, particularly focusing on the SR Ca(2+)-ATPase (SERCA2) function. 3,5,3'-Triiodo-L-thyronine (T3), or the vehicle, was subcutaneously given for 4 weeks (T3 and control [C] group). Bolus I.V. Thapsigargin (TG) was used to test the SERCA2 function (C-TG and T3-TG) in Langendorff perfused heart. Myocardial functions such as LV-developed pressure (LVDP; mmHg), +/- dP/dt (mmHg/s), tau (ms), and oxygen consumption (MVO(2); ml/min/g wt) were measured. SERCA2 and GLUT4 protein level were also evaluated by Western immunoblotting. Left ventricle to body weight (LV/BW) ratio was significantly higher in the T3 group. Both negative dP/dt and tau were significantly decreased by TG. It is interesting that the decrement of negative dP/dt and tau attained by TG was significantly larger in the hyperthyroid group (T3-TG) than in a normal heart (C-TG). SERCA2 and GLUT4 protein levels were not significantly different between control and the T3 group. We conclude that prolonged exposure to thyroid hormone causes hypertrophy of the myocardium and an augmentation of the SR Ca(2+) ATPase activity. Care must be taken in hyperthyroid heart during the ischemia-reperfusion process where the SRECA2 function is inhibited.

Cigarette smoking depletes cells spontaneously secreting Th(1) cytokines in the human airway

Cigarette smoking may modify the immune balance in the airway since it alters the course of diseases in which immune system has an important role. This study examined whether cigarette smoking could affect the distribution of cells secreting Th(1) or Th(2) cytokines in the human airway. We utilized cytokine ELISPOT assay to detect and quantitate the frequencies of cells spontaneously secreting cytokines in bronchoalveolar lavage fluid (BALF). BALF was collected from six non-smokers and four heavy cigarette smokers without clinical airway symptoms. Cytokine ELISPOT assay was performed to quantitate cells secreting interleukin (IL-)2, IL-4 and interferon (IFN-)gamma with or without phorbor 12-myristate 13-acetate (PMA) stimulation. There were no cells spontaneously secreting IL-2 detected in all samples from smokers whereas most of non-smokers had detectable IL-2-secreting cells. The number of IFN-gamma-secreting cells was also extremely decreased in smokers. Mitogen-stimulated Th(1) cytokine-secreting cells were again significantly decreased in smokers' airways. The frequency of IL-2-secreting cells and CD4/CD8 ratio in BALF had a weak positive correlation. IL-4-secreting cells were not detected in any samples from both groups. These results show that cigarette smoking depletes Th(1) cytokine-secreting cells in the human airway. It may explain the susceptibility of smokers to certain airway disease conditions such as viral or mycobacterial infections and allergic diseases.

Detection of pulmonary metastasis of low-grade endometrial stromal sarcoma 25 years after hysterectomy

Endometrial stromal sarcoma (ESS) is a rare uterine sarcoma. Low-grade ESS occasionally recurs or metastasizes after long disease-free periods, a fact that may complicate the diagnosis. Here we report a case of multiple lung metastases in a 68-year-old woman who had been disease-free for 25 years after hysterectomy for a uterine tumor. Biopsy revealed that the tumor was composed of oval cells with slight nuclear atypism but without mitotic figures, suggesting a low-grade neoplasm. Immunostaining for intermediate filaments revealed strong positivity for vimentin and weak positivity for alpha-smooth muscle actin. In addition, immunostaining for estrogen and progesterone receptors, performed under suspicion of low-grade ESS, was positive. The uterine tumor resected many years before had shown a similar morphology. Thus, it was demonstrated that the lung neoplasm was a metastatic low-grade ESS that had appeared after many disease-free years. A review of the literature revealed that this case had the longest recorded interval between the occurrence of the initial ESS and the development of distant metastases. When low-grade sarcoma appears in the lungs of female patients, it is important to consider the possibility of low-grade ESS. Detailed information on the past clinical history, together with immunostaining for estrogen and progesterone receptors, are important diagnostic keys.

Fatal aspiration of sardine fry in a patient with lung cancer

We report a fatal case of death due to unusual aspiration of sardine fry in an elderly Japanese man with lung cancer. The cause of death was sudden respiratory arrest while eating. Autopsy revealed peculiar materials with cell nests and pigmented particles, together with striated muscle and skin, in the ectatic bronchioles of the left lower lobe. Serial histologic sections suggested that the structures observed were the eyeballs of small animals that appeared to have been inhaled. The patient had habitually eaten sardine fry and rice gruel, which were also detected in the gastric contents. Therefore, the eyes were considered to be those of the fry, which is a popular food item in Japan. This was confirmed by histologic examination of fry that were obtained commercially.

[Usefulness of bronchoscopy for the diagnosis of atypical pulmonary mycobacteriosis]

In 14 subjects whose chest radiographs showed abnormal shadows during the two years from January 1995 until December 1996, no definite diagnosis could be obtained because sputum, smears and cultures all gave negative results for mycobacteria. Bronchoscopy was therefore performed, revealing atypical mycobacteria in cultures of the bronchial washing fluid for mycobacteria, and the significance of bronchoscopic examinations in cases diagnosed an atypical pulmonary mycobacteriosis was investigated. Most of the subjects (9) were women. Nine subjects had been informed that they had abnormal chest shadows; five had subjective symptoms; bloody sputum, 3 and cough, 2. The characteristics of the shadows were as follows: in the plain radiographs, the main shadows had a mottled or granular appearance in the majority of the patients (9) and there were infiltrative shadows in 3 patients and nodular shadows in another 3. In computed tomograms, the shadows in the vicinity of the pleura appeared as micronodular conglomerates in 12 patients, in 11 of whom bronchiectasis was also present near the shadows. Alveolar infiltrative shadows were present in four cases, and a cavity was seen in only one. Smears of the bronchial washing fluid for mycobacteria were positive in 7 patients, and cultures of this fluid yielded at least 100 colonies in 8 of the 14 subjects for whom the results were positive. By culture, Mycobacterium avium complex (MAC) was identified in 13 patients, but eleven of these in whom the bronchial washing fluid was concurrently tested for MAC by the polymerase chain reaction, only four were MAC-positive. Transbronchial lung biopsies were performed in 11 cases, in which the histological findings of mycobacterial infections showed granuloma in four, and caseation in three. Bronchoscopy is making possible initial-stage diagnosis, which are normally difficult, among the recently growing number of cases of the bronchial form of atypical pulmonary mycobacteriosis and is also useful for reaching definite diagnosis in the early stage.

Insufficient effectiveness of 5-hydroxytryptamine-3 receptor antagonists due to oral morphine administration in patients with cisplatin-induced emesis

PURPOSE

To compare the effect of 5-hydroxytryptamine-3 (5HT(3)) receptor antagonists in cancer patients receiving chemotherapy including cisplatin (CDDP), with or without sustained-release oral morphine (MS Contin; Shionogi Co, Osaka, Japan).

PATIENTS AND METHODS

We retrospectively studied 58 lung cancer patients given chemotherapy including at least 50 mg/m(2) CDDP with 5-HT(3) receptor antagonists between January 1996 and December 1997. Number of vomiting episodes, average proportions of hospital-supplied meals consumed (0 to 100%, as an index of appetite), and nausea severity scores (0 to 2 points, subjective patient judgment) were compared between oral morphine-administered (+) and morphine-free (-) groups.

RESULTS

Sixteen morphine(+) and 42 morphine(-) cases were used. In cases of acute emesis (within 24 hours after CDDP injection), morphine(+) and morphine(-) groups were significantly different in number of vomiting episodes (1.25 and 0.14, respectively; P <.0001), appetite (58.13% and 90.24%; P <.0001), and nausea severity scores (1.63 and 0.62; P <.0001). In delayed-emesis cases (24 to 120 hours after CDDP), these groups differed significantly in number of vomiting episodes (1.94 and 0.43, respectively; P =.0001), appetite (23.13% and 52.08%; P <.0001), and nausea severity (1.38 and 0.91; P =.009). There were no significant differences in sex, age, anticancer drugs concurrent with CDDP, CDDP dose, corticosteroid administration, clinical stage, or type of 5-HT(3) antagonist.

CONCLUSIONS

These data suggest that morphine can markedly reduce the effectiveness of 5-HT(3) receptor antagonists in patients receiving chemotherapy that includes CDDP. These results require confirmation by reinvestigation of clinical data on the efficacy of 5-HT(3) receptor antagonists and by extensive prospective analyses.

[Peripheral blood dendritic cell dysfunction in patients with Sjögren's syndrome]

The function of dendritic cell (DC), that has the strongest antigen-presenting ability, was investigated for the purpose of clarifying immune abnormalities in Sjögren's syndrome (SS) from the point of view of antigen-presenting cells. DCs were separated from peripheral blood of SS patients, and mixed lymphocyte reaction (MLR) with DCs was observed to examine the function of DC. Autologous MLR (AMLR), which was induced by mixed culture of DCs with autologous T cells, significantly decreased in SS patients (p < 0.01). Allogeneic MLR (alloMLR), which was induced by mixed culture of DCs with allogeneic T cells, also decreased in SS patients, suggesting the presence of DC dysfunction. Cell surface expression rates of HLA-DR, CD 80, and CD 83, which are a first signal of cell surface antigen presentation, a second signal, and a specific antigen of DC, respectively, were then examined. Among HLA-DR-positive cells, CD 80-positive cells and CD 83-positive cells increased in SS patients, compared with normal subjects (p < 0.0003 and p < 0.00009, respectively). From these results, it was inferred that SS patients have not only DC dysfunction, but abnormalities in cell surface antigens as well.

[Reoperative coronary artery bypass grafting without cardiopulmonary bypass]

Between October 1995 and February 1997, 2 men and 4 women aged 53 to 75 years (mean, 66.3) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex or intermediate artery bypass was performed through a left thoracotomy (n = 2), reoperative bypass to the left anterior descending coronary artery was performed through a median sternotomy (n = 3), and bypass to the right coronary artery was performed through an upper median laparotomy (n = 1). Single coronary bypass grafting utilizing arterial grafts (left internal thoracic artery: 3, right gastroepiploic artery: 3) was performed in all cases. There were no operative deaths. All cases required neither cathecolamine nor intraaortic balloon pumping). Peri/post operative blood transfusion was necessary in only one case. Postoperative coronary angiography revealed that the 6 arterial grafts were patent. Reoperative coronary artery bypass grafting without cardiopulmonary bypass can be performed with low perioperative morbidity and mortality, easy postoperative management, satisfactory graft patency, and good symptomatic improvement.

[Coronary artery bypass grafting without cardiopulmonary bypass]

From October 1995 until April 1996. CABG (coronary artery bypass grafting) was performed under the beating heart without CPB (cardiopulmonary bypass) in nine cases. They consisted of 7 males and 2 females ranging in age from 31 to 79 years old (mean 64.7 years). Single bypass grafting was performed in 6 cases, and double bypass grafting was done in 3 cases, involving 2 re-do cases. With regard to the major associated diseases, two patients had required chronic hemodialysis three time a week, four patients were administered with insulin for diabetes mellitus. There were other three patients with renal dysfunction not requiring hemodialysis, two patients had pulmonary problems, and one patient had Parkinson's disease. Further more two patients were older than 75th years in age. Graft anastomosis to the coronary artery was performed with 7-0 polypropylene. In one case, left thoracotomy was done to approach the heart for the anastomosis to intermediate artery, and in the other eight cases, median sternotomy was done. The grafts used in the nine cases were 4 right internal thoracic arteries, 6 left internal thoracic arteries, one gastroepiploic artery and one saphenous vein, 12 grafts in total. Subtotal gastrectomy for gastric cancer and cholecystectomy for cholecystitis was done in one patient for each. Heterologous blood transfusion was required two cases (22.2%). The postoperative course was very good in all cases. Eleven grafts in postoperative angiographed 8 cases were all patent, although presenting the string sign in one case, and angina pectoris disappeared in all cases. CABG under the beating heart without CPB was considered to be useful for the patients with considerable other diseases from the point of view of safety and ease of postoperative managements. We think that this procedure should be considered particularly for patients on chronic hemodialysis who required CABG.

[Bilateral internal thoracic artery-left descending artery anastomosis in pediatric for the Bland-White-Garland syndrome]

BWG syndrome, a rare congenital heart disease, is a prognostically unsatisfactory disease that causes many patients to die of the myocardial ischemia within one year. Recently in pediatric BWG patients, a two coronary-system established has been the accepted treatment. We experimented positive results with a patient who was convalescing after direct closure of the left coronary arterie's orfice in the pulmonary artery and the establishment of the two-coronary-system by bilateral internal thoracic artery-left descending artery anastomosis. We report this case as a possible effective method of surgical treatment for BWG syndrome in pediatric.

[Systemic-to-pulmonary artery shunt using the internal thoracic artery]

Systemic-to-pulmonary artery shunts may be useful for palliation of cyanotic congenital heart disease. We report the two cases of a 2-year-girl and a 5-year-girl in whom the internal thoracic artery was used to create a systemic-to-pulmonary artery shunt. This technic may have distinct advantages in selected cases and should be considered as an alternative during investigation of the older child who requires a systemic-to-pulmonary shunt.

[A case of extended surgery in acute aortic dissection by perfusion into extra anatomic bypass]

Total aortic arch replacement creates various problems involving surgical techniques, myocardial protection and perfusion methods. The most important problem during this procedure is cerebral ischemia. We developed a technique to prevent this problem by bypass grafting through the right axillo-left external carotid-left axillary artery and perfusing the brain continuously through the side branch attached to this bypass graft. A 62-year-old man with acute aortic dissection underwent ascending aorta and total aortic arch replacement using this alterative perfusion method. No cerebral dysfunction was seen in this case. The advantages of this method are as follows: there is no time limit required even for total aortic arch replacement; adequate and reliable anastomosis is possible; the dissecting aortic branches are not touched directly; it is possible to prevent cerebral infarction caused by mural thrombus and pieces of atherosclerotic plaque by clamping the aorta and aortic arch branches; and it is possible to prevent air embolism.

Infected aneurysms--clinical study of 5 cases

The infected aneurysm has been assumed to be a disease with a poor prognosis due to the occurrence of aneurysmal ruptures and sepsis, in contrast to the outcome of atherosclerotic aneurysms. In the present study, we conducted surgical treatment on five patients with infected aneurysms (infected abdominal aortic aneurysm in three cases and iliac artery aneurysm in two cases). In particular, two of the three patients suffering from infected abdominal aortic aneurysms underwent extra-anatomic bypass and the remaining one case underwent vascular graft replacement in situ. In the two patients who underwent an extra-anatomic bypass, an aneurysm was found at the site of aortic stump closure. In the patient who underwent in situ replacement, wrapping was carried out using the omentum after vascular graft replacement, and the postoperative course was uneventful. Accordingly, we consider that the optimum primary therapeutic intervention for infected aneurysms is in situ revascularization followed by wrapping with the omentum after removal of the aneurysm and debridement of the surrounding infected tissue to the maximum extent possible.

[CABG operation with sequential bypass using arterial grafts]

We evaluated 39 cases where sequential anastomoses had been performed using arterial graft (AG) in coronary artery bypass grafting (CABG). Fourty three AGs were used, and anastomosed to 87 coronary arterial branches. The details of these anastomoses were: 25 right gastroepiploic arteries (RGEA) to 51 branches; 10 left internal thoracic arteries (LITA) to 20 branches; 8 right internal thoracic arteries (RITA) to 16 branches. The interrupted suture was employed for all anastomoses. The proxymal site was initially anastomosed in the parallel way to a native coronary artery, and then, the distal anastomosis was done. In CABG using RGEA, the number of cases receiving anastomoses to RCA and LCX was the largest as in 13 cases, and the patent rate was favorable. There were also 8 cases of anastomoses to LAD and Dx and these GEA'S grafts were all patent. But, in the 2 cases of astomoses to RCA and LAD, the GEA's grafts between RCA and LAD were occluded. Therefore, this combination was thought to be inadequate for sequential hypass. On the other hand, in the 10 cases using LITA, these grafts were all anastomosed to LCA system, and were all patent. In the 8 cases using RITA, 4 in-situ grafts and 4 free grafts were employed. There were 3 anastomoses to LAD and D1 in the former, and 2 cases each of anastomoses to LAD and D1, and LCx (segment 12) in the latter. The patency was excellent, 100%. Although there were 1 case of post-operative early death (renal failure) and 1 case of remote death (cerebral infarction), they were found not due to arterial sequential bypass. In the 37 cases of post-operative angiography, patency was recognized in 40 AGs out of the 41 (97.6%) and 78 anastomosed branches out of the 83 (94.0%). These satisfactory findings indicate that it is possible and effective to perform sequential bypass in multivessel GABG using AG.

[CABG using Y arterial graft which consists of internal thoracic artery Y branched with inferior epigastric artery]

From December 1994 to April 1995, nine patients were submitted to myocardial revascularization using Y arterial graft, which consists of internal thoracic artery (ITA) Y branched with inferior epigastric artery (IEA). The age ranged 50 to 76 (mean age, 67.2 years); seven patients were male. Five patients had three vessel CABG and four patients had four vessel CABG. There was no operative mortality and no mechanical supports with IABP. Aortic clamping and operative time was not longer in this series. Early postoperative angiographic evaluation of Y arterial grafts showed that nine ITA grafts were patent (100%) and seven IEA grafts were patent (77.8%). Because of the low patency rate of IEA graft, Y graft using IEA appears to be an interesting alternative only in patients who have no other available conduits.

[The potential of anastomosis of the gastroepiploic artery to the left anterior descending artery in coronary artery bypass grafting]

It would be a great contribution in coronary artery bypass grafting (CAGB) using arterial graft (AG) if right gastroepiploic artery (GEA) could be grafted onto left anterior descending artery (LAD) in situ. In this study, we discussed 22 cases where anastomosis of GEA to LAD was made in situ. The subjects were limited to high stenotic cases of > 90% stenosis or more > 75% stenoses recognized in the proximal segment of coronary artery from the anastomosed site. The sex ratio of 18 (male): 4 (female) and the age varied from 40 to 78 years (the mean age: 58 years). The details were 2 cases of single CABG, 6 cases of double CABG, 11 cases of triple CABG and 3 cases of quadruple CABG and 22 GEA's were anastomosed onto 32 vessels. There was no operative death. Postoperative angiography performed on the 21 cases showed the patency of 95.2% (20/21). These finding indicate that the use of GEA is effective for multivessel CABGs in LAD.

[Surgical treatment of acute aortic dissections--a clinical study using a ringed intraluminal graft]

From 1984 to 1994, surgery was performed using a ringed intraluminal graft (RIG) in 75 patients with acute aortic dissection (DeBakey's type I in 37 cases, type II in 10 cases and type III in 28 cases). The operative death rate was 24% for type I, 30% for type II and 21% for type III. The average time from onset to surgery was short (47 +/- 67 hours for type I, 34 +/- 36 hours for type II and 47 +/- 77 hours for type III). The outcome of these cases indicated that this technique was effective for saving the lives of patients in the acute early stage of aortic dissection. No characteristic complications developed after this surgery. The postoperative course of patients was followed by using CT scans, MRI, angiography. No patients developed aneurysmal formation in the ligated area or dislocation of the RIG. There were no deaths directly attributable to the RIG. Patients who were autopsied in the late postoperative period showed no aneurysm of the ligated area or necrosis of the aortic wall. In conclusion, RIG surgery effectively saved the life of patients with acute aortic dissection and the RIG could be used as prosthetic graft for long-term periods.

[A case of secondary valve replacement caused by pulmonary bioprosthetic valve endocarditis]

A 42-year-old male with pulmonary bioprosthetic valve endocarditis accompanied by residual minor leakage through a previously closed patch for ventricular septal defect (VSD), underwent reoperation with a Carpentier-Edwards bioprosthetic valve. The patient had a history of pulmonary valve replacement and VSD in 1973. A massive vegetation on the pulmonary valve was demonstrated by echocardiography. Five repeated blood cultures yielded Eikenella corrodens. After medical treatment, reoperation was performed. The patient was free of complications after the procedure. Although bioprosthetic valves have potential problems of dysfunction and calcification in long-term use, these problems develop at a significantly slower rate in right-sided positions compared with left-sided positions and bioprosthetic valve thrombosis in the pulmonary position has apparently not been reported. Mechanical prostheses for pulmonary valve replacement have a poor prognosis, with a high incidence of valve thrombosis despite adequate anticoagulant therapy. For the replacement of prosthetic valves in right-sided positions (tricuspid and pulmonary), bioprosthetic valves are now our first choice.

Surgical treatment of infective endocarditis

From February, 1975 through October, 1990, 26 patients underwent surgical treatment for infective endocarditis at Tokai University Hospital. The overall operative mortality rate was 11.5% (3/26). The three patients who died were suffering from aortic prosthetic valve endocarditis (PVE) in the active stage. Among 16 patients in the active stage, the mortality rate was 18.7% (3/16) Among 10 patients with native valve endocarditis (NVE) in the healed stage, all survived. Among the total of 21 patients with NVE, the mortality rate was zero and among those with PVE, the rate was 60% (3/5). Various species of streptococci were the most common organisms encountered, followed by Staphylococcus epidermides. The two PVE patients with S. epidermides died. Nine of the 11 NVE cases in the active stage were of the localized type. Only one case of the localized type of PVE suffered from an infected mitral bioprosthetic valve. The 6 extensive-type cases had aortic valve endocarditis (2NVE, 4PVE). Three patients with the extensive type of PVE died. We conclude that patients with infective endocarditis who develop progressive congestive heart failure, recurrent embolization, or progressive sepsis despite antimicrobial treatments, should undergo prompt valve replacement within 7 days after institution of therapy.

[An evaluation study on arbekacin for MRSA-infectious diseases including pneumonia, septicemia and others]

Availability of arbekacin (ABK) was analyzed in the chemotherapy of 24 MRSA-infected patients with symptoms of pneumonia (12), sepsis (6) and others (6). Most patients had background diseases such as malignant tumors or cerebrovascular disorders. 47% (7/15) of them were immunologically abnormal. 17 of them had been previously treated with cephems, imipenem, minocycline or fosfomycin. The ABK therapy was performed with doses ranging 50-400 mg a day, divided into 1-3 times (mostly 100 mg x 2), and for 5-24 days. (18 patients were treated between 5 and 14 days). 14 patients (58%) received combined therapy with other antibiotics (mostly with beta-lactams, 12). The clinical efficacy rate of the ABK therapy was 62% (good, 13; fair, 4; ineffective, 4; unknown, 3). The bacteriological efficacies were: eradicated, 7 (44%); decreased, 4; no change, 5; unknown, 8. Side effects were found in 3 patients (oliguria, 2; eruption due to drug, 1) and one case resulted in serious renal disorder. Abnormal laboratory data were found in 7 cases. Above results have indicated that ABK is a useful antibiotic in chemotherapy of MRSA-infections.

[Surgical management for atrial septal defect secundum in aged patients]

Between 1989 and 1992, atrial septal defect secundum (ASD) were closed in 8 patients aged 51 to 77 years with the use of cardiopulmonary bypass. The notable characteristics in our cases were; 1) All but one had slight or moderate left to right shunt ratios. Although pulmonary hypertension was present, the obstructive pulmonary vascular change had not progressed so far. 2) Atrial fibrillation was present in 6 patients (75%) and some other cardiac lesions (atrioventricular insufficiency, ischemic heart disease, intracardiac anomaly) coexisted with ASD in a high frequency. And surgical procedures other than ASD closure were required in 5 patients. 3) We must take care to prevent cardiac complications (i.e., arrhythmia) as well as extracardiac malfunctions in postoperative care, because aged patients had some organic dysfunctions of respiratory, renal and hepatic systems. 4) Post-operative courses were satisfactory and there was no operative mortality. All patients obtained improvements in their quality of life. Consequently, we concluded that surgical closure is recommended even for aged patients with ASD, except for Eisenmenger's syndrome.

Right atrial myxoma developing 4 years following patch closure of an atrial septal defect: report of a case

We report herein the rare case of a 13-year-old boy in whom a right atrial myxoma developed 4 years following patch closure of an ostium secundum atrial septal defect, at which time no other atrial abnormality had been observed. The myxoma arose from the atrial septum in the area between the orifices of the coronary sinus and inferior vena cava. The suture line was not involved. Gross and histopathological findings were characteristic of atrial myxoma. Atrial myxomas are usually considered to be slow-growing neoplasms; however, this case demonstrates that the initial period of growth may be quite rapid in some cases.

Artificial valve replacement for congenital bicuspid aortic valves

The congenital bicuspid aortic valve functions almost normally provided degeneration does not occur, but complications of infective endocarditis and calcification of the cusps with aging are indications for surgical intervention. We compared 22 cases with an incompetent bicuspid aortic valve (14 cases with stenosis and eight with regurgitation) with 96 cases of acquired tricuspid aortic valve (30 cases with stenosis and 66 with regurgitation) who were treated by aortic valve replacement (AVR) during the same period. Compared with the stenotic tricuspid aortic valve cases, the stenotic bicuspid aortic valve cases: 1) were older at AVR (59.3: 51.7 years, P < 0.05), 2) had a smaller diameter of preoperative valve orifice (6.9: 9.2 mm, P < 0.05), 3) had a smaller valve ring diameter (23.0: 24.3 mm, P < 0.05), 4) used artificial valves of almost identical size (22.0: 22.5), and 5) included no operative deaths (0: 10%). In contrast, compared with the tricuspid aortic valve cases with regurgitation, the bicuspid aortic valve cases with regurgitation: 1) were younger at AVR (39.5: 45.8 years), 2) had a higher incidence of infective endocarditis (62.5: 19.6%, P < 0.02) as a complication, and 3) showed a higher operative death rate (25.0: 6.1%), although this difference was not statistically significant. Suture repair of the incised portion of the aorta must be performed meticulously in patients with prominent poststenotic dilatation of the ascending aorta.

[Transvenous pacemaker implantation for sick sinus syndrome with mirror-image dextrocardia]

A case of sick sinus syndrome with mirror-image dextrocardia which was associated with bilateral superior vena cava and an absent inferior vena cava with azygos continuation is reported. A 45-year-old woman was referred to our hospital with the chief complaints of dizziness and palpitation. The electrocardiogram showed a atrial fibrillation with a 4-second period of asystole. A permanent endocardial bipolar demand pacemaker was inserted through the left superior vena cava. Since anomaly of venous system is commonly associated with mirror-image dextrocardia, the angiogram is necessary prior to permanent pacemaker implantation.

Three-staged graft replacement for multifocal aortic aneurysms in the Marfan syndrome

A three-staged operation for multifocal aortic aneurysms was conducted over a period of 8 months in a 52-year-old woman with the Marfan syndrome. The aortic valve and ascending aorta, the abdominal aorta and the upper half of the descending thoracic aorta were replaced. As of 9 months after the third operation, the patient's course has been uneventful, but continuous follow-up will be needed in view of the character of this disease.

Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: report of a case

Mesenteric ischemia caused by obstruction of the superior mesenteric artery associated with acute aortic dissection was successfully treated by surgery in a 74-year-old man. The vein graft was effectively bypassed between the right common iliac artery and superior mesenteric artery on the day of onset of acute DeBakey type III b aortic dissection. He is currently well 1 year postoperatively on anti-hypertensive therapy.

[Bilateral coronary-pulmonary artery fistulas with a large saccular aneurysm: a case of cardiac tamponade following rupture of the coronary artery aneurysm]

A case of bilateral coronary-pulmonary artery fistulas with a large saccular aneurysm is reported as follows. The patient was a 72-year-old woman who was referred to our hospital with a complaint of abnormal shadow on chest X-ray and had the past history of cardiac tamponade. The fistula was ligated and the aneurysm was resected with the extracorporeal circulation. Her Postoperative course was uneventful. Coronary arteriography showed that bilateral coronary-pulmonary artery fistulas had completely disappeared.

Surgical treatment of non-penetrating injury to the aorta

During a 17-year period, eight cases of blunt traumatic injury to the aorta were surgically treated at our hospital. The locations of the lesions were the descending thoracic aorta in four cases, abdominal aorta in two cases, and traumatic DeBakey type IIIb dissection in two cases. Surgical repairs were carried out during the acute or subacute period in four cases and others were electively treated during the chronic period. One patient suffering from acute traumatic dissection of the aorta died of acute renal failure following acute ischemia in the lower extremities 10 days after surgery. Accordingly, the overall mortality rate was 12.5% in this series. We believe that elective operations should be carefully considered if they are possible.

Delayed hemolytic transfusion reaction with anti-Jkb erythrocyte antibody after open heart surgery

A patient suffering from delayed hemolytic transfusion reaction with anti-Jkb erythrocyte antibody after open heart surgery is reported on. On preoperation evaluation, a 42-year-old woman who had never been transfused exhibited a negative erythrocyte autoantibody. After the operation of aortic valve replacement and open mitral commisurotomy, she developed a severe hemolytic anemia with a positive rare anti-Jkb erythrocyte antibody on the 14th postoperative day. Precautions are discussed which need to be taken to distinguish delayed hemolytic transfusion reaction from mechanical hemolysis caused by extracorporeal circulation and prostheses.

[Combined medical and surgical treatment of 74 cases of acute type III aortic dissection]

In the early period up to 1986, our treatment of acute type III dissection was anti-hypertension drug therapy as a rule, and Collins operations were performed in two cases of progressive hemothorax. Among 21 patients receiving medical therapy, five died of rupture, and three operated cases died of multiple organ ischemia, and then the hospital mortality was 40%. Since 1987, we have selected hypotensive treatment of strictly maintaining blood pressure less than 120mmHg for the completely thrombosed type of the dissected lumen, and the emergency operation of ringed intraluminal graft insertion (RIG operation) for the blood-flow type and aneurysm formation type of the dissected lumen, diagnosed by the emergency cine-angiography. As the result, among 51 cases having hypotensive therapy, one died of respiratory failure. In the 23 operated cases, in which RIG operation and/or arterial reconstruction was performed, four died of multiple organ ischemia. The hospital mortality was 8%, which was significantly improved compared with that of the early period.

[Clinical evaluation of myocardial protection by oxygenated crystalloid cardioplegic solutions with DBcAMP]

Possible enhancement of myocardial protection by adding DBcAMP and oxygenation of a crystalloid cardioplegic solution (CCS) was evaluated in a three group study. The patients having coronary bypass operation or valvular operation were divided into three groups, each consisting of 15 patients, and differing only in the type of CCS employed. Group I was protected by nonoxygenated CCS (PO2 190 mmHg, PCO2, 32 mmHg, pH 7.78, K 30 mmEq/L), Group II by adding DBcAMP to nonoxygenated CCS and Group III by adding DBcAMP to oxygenated CCS (PO2 790 mmHg, PCO2 26 mmHg, pH 7.87). Group III had significantly improved CI and double product (p less than 0.05) compared with Group II. However, CPK, CPK-MB, and myoglobin in the serum were similar in each group. Lactate and pyruvate ratio (L/P) in the coronary sinus bloods were improved to lower value after the pump than before the pump only in Group III. Base excess in the coronary sinus held on alkalosis after aortic declamp only in Group III. The refunction time was significantly shortest with Group III than with other groups (p less than 0.01, 0.05) and Group II was significantly shorter than Group I (p less than 0.05). It is concluded that oxygenation and adding DBcAMP to CCS are effectual for the myocardial metabolism and protect the myocardial damage during cardiac arrest.

[A clinical study on panipenem/betamipron in chronic respiratory tract infections]

Panipenem/betamipron (CS-976, PAPM/BP), a new carbapenem antibiotic, was administered a single dose of 500 mg or 750 mg via intravenous drip infusion twice a day for treatment of chronic respiratory infection to study its clinical efficacy, bacteriological efficacy and safety. Twenty nine cases were studied for the efficacy evaluation. Only the safety evaluation was made in 6 cases which were judged to be unsuitable, because in some of them pneumonia and other diseases were not specified as the subject diseases, of serious illness in some the conditions were too serious, and in the other cases the duration of administration was insufficient since administration had to be discontinued due to side-effects. The duration of administration was 6 to 18 days with 1 g divided into 2 doses daily or 4 to 15 days with 1.5 g in 2 divided doses daily. When clinical efficacies were classified according to different diseases, this preparation was effective in 11 cases and slightly effective in 1 case of 12 cases of chronic bronchitis with an efficacy rate of 91.7%. It was effective in 10 cases, slightly effective in 1 case and ineffective in 1 case of 12 cases of bronchiectasis with an efficacy rate of 83.3%. It was slightly effective in 2 and ineffective in 1 out of 3 cases of diffuse panbronchiolitis, and was effective in 2 cases of pulmonary emphysema with infections. PAPM/BP was given at a dose level of 1 g in 2 divided doses daily to 17 cases and that of 1.5 g in 2 divided doses daily to 10 cases. For the remaining 2 cases, changes in the dose level were made in middle course of treatment. The efficacy rate in the 1 g regimen was 76.5% and that with the 1.5 g regimen was 90%. The overall results in the 29 cases included 23 effective, 4 slightly effective and 2 ineffective cases, thus the overall efficacy rate was 79.3%. As pathogens, 11 species including 24 strains were isolated and identified from 19 cases. They were Gram-positive cocci including 2 strains each of Staphylococcus aureus and Streptococcus pneumoniae, 1 strain each of Staphylococcus epidermidis, Streptococcus sanguis, and Streptococcus viridans and a strain of Streptococcus spp., and Gram-negative rods including 9 strains of Pseudomonas aeruginosa, 4 strains of Haemophilus influenzae and 1 strain each of Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas spp.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical management of the coronary artery to pulmonary artery fistulas; a case of a large ruptured aneurysm

Three patients were treated for coronary artery-pulmonary artery fistula. Each was asymptomatic due to a coronary artery fistula. There was one instance each of myocardial infarction, mitral stenosis and a large closed ruptured aneurysm including a thrombus. All the fistulas were comprised of several small plexiform arranged vessels. The left to right shunt ratio was approximately 8 percent or less. A surgical operation was performed to close the drainage orifice of the fistulas through pulmonary arteriotomy under cardiopulmonary bypass in two patients while one patient underwent a ligation of a large abnormal vessel to the aneurysm followed by a resection of the aneurysm without cardiopulmonary bypass. A large saccular aneurysm of such fistulas is rare and a rupture of such an aneurysm is even more rare. The surgical management of coronary artery fistulas is also discussed herein.

[A case report of type II dissecting aneurysm after aortic valve replacement, successful repair by the modified Cabrol's method]

A case of type II dissecting aneurysm after aortic valve replacement was reported. The patient was a 66-year-old man, who was diagnosed as III degree aortic valve regurgitation without aortic dilatation, and performed aortic valve replacement with a 27A Omniscience prosthesis. Postoperative course was very smooth for 7 years, however he was admitted to our hospital of the sudden anterior chest pain. Computed tomography and aortography revealed marked dilatation and dissection of ascending aorta and occlusion of the right coronary artery. The operation of the modified Cabrol's method was performed, and he is well alive one and half a year after operation. Dissecting aneurysm in the late term after aortic valve replacement is rare, and its prognosis and re-operative results are very poor.