Impact of wound management strategies after revascularization for chronic limb-threatening ischemia

OBJECTIVE

There is no established consensus or guidelines for wound management after revascularization for patients with chronic limb-threatening ischemia (CLTI) without severe infection. This study is designed to evaluate the clinical effect of the wound management strategy on toe wounds after revascularization for CLTI.

METHODS

This retrospective cohort study was performed at eight institutions affiliated with Keio University School of Medicine in Japan and included 261 patients who underwent revascularization for CLTI between April 2019 and July 2021. We identified 132 patients with toe wounds from the database who had restored in-line blood flow to the foot. Patients were divided into two groups by the timing of toe resection after revascularization, which dictated the wound management policy. Group A (62 patients) underwent early toe amputation for suspected osteomyelitis, whereas group B (70 patients) underwent watchful waiting. The primary outcome was wound healing after revascularization; the secondary outcome was major amputation. We compared outcomes between groups A and B after propensity score matching.

RESULTS

Using propensity score matching, each patient in group A (33 patients) was matched with a patient in group B (33 patients). Wound healing in matched group A was significantly better than that in matched group B (respectively: 1-year wound healing rate: 90.0% vs 68.2%, P < .001; median wound healing time: 65 days vs 258 days, P < .01). Although five major amputations were necessary in matched group B, none were required in matched group A (P = .05). The high rate of major amputations in group B was attributed to the sudden exacerbation of infection. Limb salvage rate in matched group A exceeded matched group B (100.0% vs 90.5%: 1-year limb salvage rate, P = .02).

CONCLUSIONS

Early toe amputation for highly suspected osteomyelitis in patients with CLTI with toe wounds may expedite wound healing compared with watchful waiting, potentially avoiding unnecessary major amputation. Considering the wound management strategy is crucial when evaluating wound healing outcomes in patients with CLTI with revascularization.

Long-term Outcomes of the Endurant and Excluder Stent Grafts for Endovascular Aneurysm Repair in a Japanese Cohort

PURPOSE

To compare the long-term outcomes of the most widely used third-generation stent grafts, the Endurant and Excluder stent grafts, in Japanese patients using a multicenter registry.

MATERIALS AND METHODS

A retrospective analysis of endovascular aneurysm repairs for abdominal aortic and iliac artery aneurysms using either the Endurant or the Excluder stent grafts from January 2012 to July 2019 at 10 Japanese hospitals was performed.

RESULTS

A total of 332 and 378 repairs using the Endurant and Excluder stent grafts, respectively, were analyzed. Although the patients' characteristics were generally similar in the two groups, the Endurant group exhibited significantly shorter (Endurant: 31.5±18.6 mm, Excluder: 37.4±21.0 mm; p<0.001), larger (Endurant: 22.4±4.2 mm, Excluder: 21.7±3.8 mm; p=0.029), and more reversed tapered (Endurant: 12.1%, Excluder: 5.8%; p=0.003) proximal necks. The incidence of instructions for use (IFU) violations was similar between the two groups (Endurant: 59.0%, Excluder: 54.5%; p=0.223). However, the Endurant group had significantly more proximal neck-related IFU violations (54.1% and 46.3%, respectively; p=0.039), more access-related IFU violations (8.1% and 4.0%, respectively; p=0.019), and fewer bilateral hypogastric artery embolizations (5.1% and 9.3%, respectively; p=0.035) compared with the Excluder group. The incidence of intraoperative (Endurant: 3.6%, Excluder: 3.7%; p=0.950) and perioperative complications (Endurant: 3.6%, Excluder: 3.4%, p=0.899) was equivalent in the two groups. However, there was a significantly higher incidence of postoperative type II endoleaks in the Excluder group (Endurant: 28%, Excluder: 46.0%, p<0.001). Aneurysm sac regression was more frequent in the Endurant group (Endurant: 40.7%, Excluder: 31.7%, p=0.013). The Endurant group also had significantly higher rates of sac increase (Endurant: 13.0%, Excluder: 7.7%, p=0.020). Kaplan-Meier curve and log-rank analyses revealed no statistical differences in late complications (p=0.868) and overall survival (p=0.926).

CONCLUSIONS

There were no statistically significant differences between the Endurant and the Excluder stent grafts in terms of intraoperative, perioperative, and late complication rates; however, the anatomical characteristics of the patients were significantly different.

Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan

Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.

[A Case of Colorectal Cancer with Asymptomatic Idiopathic Pneumatosis Intestinalis during Bevacizumab Administration]

We present the case of a 75-year-old woman who received CapeOX plus Bmab therapy(capecitabine, oxaliplatin, and bevacizumab)after primary excision for an unresectable advanced sigmoid colon cancer with remote metastasis. Pneumatosis intestinalis(i.e., the presence of isolated gas in the abdominal cavity)was revealed accidentally during a periodical imaging examination in the small intestine and transverse colon, albeit no subjective symptoms were reported. Owing to the absence of definitive evidence of pneumatosis intestinalis and gastrointestinal perforation, the patient was diagnosed with idiopathic pneumatosis intestinalis. Bmab was discontinued, and CapeOX therapy alone was continued after follow-up. Approximately 4 months later, pneumatosis intestinalis had completely disappeared. Bmab is a vascular endothelial growth factor antibody with well-known side effect of gastrointestinal-perforation. However, there have been few reports on pneumatosis intestinalis; to our knowledge, there have been no reports on pneumatosis intestinalis associated with colorectal cancer in Japan. Further, the report suggests the need for appropriate and immediate management of pneumatosis intestinalis following diagnosis.

Midterm Results of a Japanese Prospective Multicenter Registry of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Above-the-Knee Femoropopliteal Bypass

BACKGROUND

This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1-36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency.

CONCLUSIONS

AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.

Impact of Stent Graft Design on External Iliac Artery Limb Occlusion Rates After Endovascular Aneurysm Repair: Post-hoc Analysis of a Japanese Multicentre Database

OBJECTIVE/BACKGROUND

It was hypothesised that a helical stent with expanded polytetrafluoroethylene (ePTFE) grafts could provide a preventive effect for external iliac artery (EIA) limb occlusion following endovascular aortic aneurysm repair (EVAR). Therefore, a post-hoc analysis of a Japanese multicentre database was conducted to assess the impact of the stent graft design on EIA limb occlusion rates.

METHODS

Patients who underwent EVAR with EIA limb deployment between 2008 and 2016 were evaluated. The stent graft limbs were divided into two groups: group A comprised stent graft limbs made of a helical stent with ePTFE grafts (Excluder; n = 255), and group B comprised stent graft limbs made of a Z stent with polyester grafts (Zenith, Flex and Endurant; n = 173). The main outcome was the incidence of limb occlusion and severe limb stenosis (EIA related limb complications). The risk factors for EIA related limb complications were analysed and the midterm results between groups A and B compared. Fine-Gray generalisation of the proportional hazards model was used after propensity score matching to calculate the hazard ratio (HR).

RESULTS

One complication occurred in group A and 10 complications occurred in group B. The risk factors for EIA related limb complications for the entire group were a stent graft limb size ≤10 mm (HR 5.41; p = .01) and inclusion in group B (HR 14.9; p = .009). After propensity matching, group A (n = 159) was matched with group B (n = 159). The cumulative incidence function of EIA related limb complications at five years was 0.66% in group A and 7.8% in group B (HR 8.67; p = .039).

CONCLUSION

Stent graft design can affect limb patency in EIA limb deployment. When EIA limb deployment is necessary for patients with a small EIA, such as Japanese patients, stent graft limbs made of a helical stent with ePTFE should be used to reduce the risk of limb occlusion.

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

Single injection digital block: is a transthecal injection necessary?

Three different methods of injection to obtain digital block anaesthesia were performed on 15 healthy volunteers to evaluate the success and extent of anaesthesia. We found that the traditional transthecal injection technique was inaccurate and the injected agent mainly flowed into the subcutaneous space, and did not remain within the sheath. The deep transthecal single injection kept the anaesthetic agent within the flexor tendon sheath, as intended. The duration of anaesthesia and the area anaesthetised by the subcutaneous injection and the traditional transthecal injection was similar and satisfactory. However, the anaesthetic area after the deep transthecal injection was significantly smaller than that of the other two techniques (P<0.01). A transthecal digital block offers no advantage over a simple subcutaneous digital block.

[A case of advanced rectal cancer responding to neoadjuvant chemotherapy with CPT-11, 5-FU and l-LV after coronary artery bypass graft]

A 75-year-old man was referred to our hospital with a diagnosis of lower rectal cancer. Unstable angina attack occurred after admission and cardiac angiography revealed stenosis of three coronary arteries which were treated by percutaneous transluminal coronary angioplasty unsuccessfully. Coronary artery bypass graft was performed after colostomy. It is possible for operative stress, extracorporeal circulation and blood transfusion to diminish immunocompetence and increase the risk of recurrence. Therefore, CPT-11/5-FU/l-LV combination therapy (CPT-11 80 mg/m(2), 5-FU 500 mg/m(2), l-LV 250 mg/m(2) day 1, 8, 15 every 5 weeks) was carried out as neoadjuvant chemotherapy. The tumor decreased in size, and the level of tumor marker was normalized after two courses of the combination therapy. The patient is alive without recurrence three years after abdominoperineal resection.

[A long-term survival case after resection for umbilical metastasis from gastric cancer treated with weekly paclitaxel]

We report a patient with umbilical metastasis of gastric cancer (Sister Mary Joseph' s nodule) who has been treated by weekly paclitaxel for 16 months after resection of an umbilical tumor. A 61-year-old man who underwent total gastrectomy for cytology-positive advanced gastric cancer in March 2002 and received TS-1 after surgery for 2 years, complained of abdominal pain in May 2004. Physical examination and computed tomography showed an umbilical nodule about 20 mm in diameter. An excisional biopsy of umbilical tumor was performed, and the umbilical metastasis and peritoneal dissemination were diagnosed histopathologically. Weekly paclitaxel was administered after resection of umbilical metastasis. The patient has been alive with good performance status and normal level of serum tumor markers after 48 administrations of paclitaxel.

Hepatic resection for colorectal metastases in the caudate lobe of the liver

Although hepatic resections for colorectal metastases have become established procedures, there is still only a small number of reports of hepatic resections for such metastases in the caudate lobe. From 1993 to 2001, seven patients underwent eight hepatic resections for colorectal metastases in the caudate lobe at our department. The patients were five men and two women, and their ages were from 53 to 73 years. The ratio of synchronous to metachronous liver metastases was 2 : 5. Solitary metastasis was observed in one patient. One patient with a metastasis in the Spiegel lobe and three patients with metastasis in the caudate process underwent partial resection of the site. The other patients underwent resection of the Spiegel lobe (two times), resection of the right-sided caudate lobe, and total caudate lobe resection. The mean (+/-SE) operative time was 315.9 +/- 30.6 min. Mean intraoperative blood loss was 1325.9 +/- 421.1 ml, and mean postoperative hospital stay was 21 +/- 3.7 days. One patient, who underwent sigmoidectomy and hepatectomy as an emergency operation due to ileus, experienced wound infection. No patient died within 12 months after the surgery. Five patients were alive at 24 months, and three at 36 months. The outcome of these patients encourages us to continue performing hepatic resection for colorectal metastases in the caudate lobe, as it is assumed to be a safe and effective procedure.

Hepatectomy following transarterial chemotherapy for a metastasis in the caudate lobe

We describe a solitary liver metastasis in the caudate lobe from a colon cancer treated with a hepatic resection following transarterial chemotherapy. A 73-year-old male was admitted with a complaint of melena. The findings from endoscopic examination of the colon showed a type 3 cancer at the hepatic flexure. Computed tomography revealed a metastatic lesion in the caudate lobe of the liver, which was three centimeters in diameter and located between the roots of the middle and the left hepatic vein. A right hemicolectomy was performed and the surgical findings revealed extended lymph node metastasis and the serosal exposure of the primary lesion. A transarterial catheterization to the liver for chemotherapy was placed instead of performing a hepatic resection. After six months of the transarterial chemotherapy, the metastatic tumor was decreased to less than one centimeter and no other new lesion was developed in and out of the liver. The patient underwent a resection of the Spiegel lobe 8 months after the first operation. There were small lesions of viable metastatic cells in the tumor histologically. The patient is currently well without any signs of recurrence 28 months after the first operation.

Direct retroperitoneal open drainage via a long posterior oblique incision for infected necrotizing pancreatitis: report of three cases

Although several surgical approaches have been advocated for patients with infected necrotizing pancreatitis, there is still a high incidence of morbidity and mortality. We used a new approach of direct retroperitoneal open drainage after various other treatments, for three patients with necrotizing pancreatitis and extended infection with multiple-organ failure. Long oblique incisions were made from the root of the 12th rib to the anterior superior spina iliaca on the left or right side of the back, or both, to approach the retroperitoneal area of infected necrosis. The necrotic tissue was removed bluntly and the wound was laid open. Lavage and debridement were done repeatedly after the operation. The patients recovered from multiple-organ failure within 2 weeks, and control of local infection was achieved within 3-4 weeks. All three patients were discharged and are now well. Therefore, we propose that this method is appropriate for patients with spreading infected necroses, who are in poor general condition.

A giant retention cyst of the pancreas (cystic dilatation of dorsal pancreatic duct) associated with pancreas divisum

We describe a rare case of pancreas divisum associated with a giant retention cyst (cystic dilatation of the dorsal pancreatic duct), presumably formed following obstruction of the minor papilla. The patient was treated by pancreatico(cysto)jejunostomy. A 50-year-old man was admitted with complaints of increasing upper abdominal distension and body weight loss. There was no previous history of pancreatitis, gallstones, drinking, or abdominal injury. An elastic-hard tumor-like resistance was palpable in the upper abdomen. Computed tomography and ultrasound (US) examinations revealed a giant cystic lesion expanding from the pancreas head to the tail. Endoscopic retrograde cholangiopancreatography findings showed a looping pancreatic duct which drained only the head and uncinate process of the pancreas to the main papilla. A US-guided puncture to the cystic lesion revealed that the lesion continued to the main pancreatic duct in the tail of pancreas. The lesion was connected to a small cystic lesion, which was located inside the minor papilla, and ended there. The amylase level in liquid aspirated from the cyst was 37 869 IU/l, and the result of cytological examination of the liquid showed class II. A pancreatico(cysto)jejunostomy was performed, with the diagnosis being pancreas divisum associated with a retention cyst following obstruction of the minor papilla. The histological findings of a specimen from the cyst wall revealed that the wall was a pancreatic duct covered with mildly inflammatory duct epithelium; there was no evidence of neoplasm. The patient is currently well, and a CT examination 2 years after the operation showed disappearance of the cyst and normal appearance of the whole pancreas.

The evaluation of pre- and post-operative classification system for cubital tunnel syndrome

Pre- and post-operative classification systems for cubital tunnel syndrome are discussed in this study. Although there are several pre-operative evaluations, a suitable system should be easy to categorise, simple, reliable and reproducible. McGowan's grading system has been widely used for these reasons; however, grade II included complicated cases. Accordingly, McGowan's grade II is divided into two groups, such as grade II-A (relatively good prognostic group) and group II-B (relatively poor prognostic group). As far as the post-operative classification system is concerned, 4 grade (excellent, good, fair, and poor) classification is the most useful and easy to understand.

Successful treatment of recurrent liver metastases from gastric cancer by repeated hepatic resections: report of a case

We describe herein the case of a patient in whom recurrent liver metastases from gastric cancer were successfully treated by performing repeated hepatic resections. A 63-year-old man underwent a total gastrectomy with regional lymph node dissection for an advanced gastric cancer on November 17, 1992, the pathological findings of which confirmed a diagnosis of well-differentiated tubular adenocarcinoma, ss, INFalpha, ly1, v0, n1(+). Follow-up computer tomography (CT) and ultrasonography scans done 7 months after the gastrectomy revealed a metastasis in the liver S5, and a partial resection of S5 was performed on July 5, 1993. Subsequently, on November 17, 1994, an anterior segmentectomy of the liver was performed for a liver metastasis in the liver S8, then on August 11, 1998, a partial resection of the liver S6 was performed for a metastasis in the liver S6. The pathological findings of each liver specimen resected were compatible with metastatic adenocarcinoma from the primary gastric cancer. The liver tumors were expansive-growing tumors with capsules and massive necrosis. The patient is currently well with no evidence of recurrence on repeat CT scans, 6 years 6 months since-the initial gastrectomy, and 5 years 10 months since the first hepatic resection.

Pronator Teres Syndrome Associated with Mononeuritis Multiplex in Polyarteritis Nodosa

A case of pronator teres syndrome associated with mononeuritis multiplex in polyarteritis nodosa is reported. External neurolysis of the median nerve at the proximal forearm and prednisolone were effective for treatment of the disease.

Functional outcome of anterior transposition of the vascularized ulnar nerve for cubital tunnel syndrome

Anterior transposition of the ulnar nerve is a widely used treatment for cubital tunnel syndrome, but neurolysis performed at the time of surgery may impair the blood supply to the ulnar nerve. This study compared the results of intramuscular anterior transposition of the ulnar nerve with or without preserving the extrinsic vessels of the ulnar nerve in 35 patients. The postoperative nerve conduction velocity and the clinical results were better in the group in which the extrinsic vessels were presented.

The effect of allopurinol on interstitial purine metabolism and tissue damage in skeletal muscle I-R injury

OBJECTIVE

Many studies show that allopurinol can reduce skeletal muscle I-R (ischemia-reperfusion) injury, but the mechanism of the effect is still unclear and some studies suspect the effect. In this study, we determined whether allopurinol really reaches to reperfused muscle and reduces tissue injury by inhibiting xanthine oxidase or not.

EXPERIMENTAL DESIGN

In this study, microdialysis method combined with HPLC (high performance liquid chromatography) were employed and purines, MDA (malondialdehyde), allopurinol in gracilis muscle were measured continuously in I-R injury model of canine gracilis muscle. The effect was compared between Group N (no treatment: n=8), Group P (pre-ischemic treatment: n=8) and Group R (pre-reperfusion treatment: n=8).

RESULTS

Allopurinol reduced the increase of xanthine, uric acid, MDA in the muscle and CPK in blood effluent from gracilis muscle after reperfusion. Tissue protecting effect of allopurinol was more effective in group R than in group P.

CONCLUSIONS

By continuous measurement of purines, allopurinol and MDA in canine gracilis muscle during 5 hr ischemia and 2 hr reperfusion, it was proved that allopurinol was delivered to reperfused skeletal muscle and reduced I-R injury by inhibiting xanthine oxidase.

Antinociceptive mechanism of the aconitine alkaloids mesaconitine and benzoylmesaconine

We explored the possible role of the specific regions in the brain stem on the antinociceptive actions of mesaconitine (MA) and benzoylmesaconine (BM) by the microinjection of MA and BM into nucleus reticularis paragigantocellularis (NRPG), nucleus raphe magnus (NRM), and periaqueductal gray (PAG). MA microinjected into NRPG, NRM, or PAG elicited a dose-dependent antinociceptive action, whereas BM injected into NRM or PAG elicited a dose-dependent antinociceptive action but not in NRPG. The NRM appeared to be the most sensitive region among the three tested locations.

The analgesic mechanism of processed Aconiti tuber: the involvement of descending inhibitory system

Tsumura-shuchi-bushi-matsu (TJ-3021) is a processed Aconiti tuber which has a potent antinociceptive action. The present study was undertaken to study the analgesic mechanism produced by TJ-3021. RCS (repeated cold stress) rats in hyperalgesia were markedly suppressed by oral administration of TJ-3021. Intrathecal and intraperitoneal administration of a selective alpha 2-adrenoreceptor antagonist, idazoxan (IDA), reduced significantly the analgesic effect of TJ-3021 in RCS rats. Methysergide (METH), a 5-HT receptor antagonist, demonstrated a similar effect, while intraperitoneal administration of opioid receptor antagonist, naloxone, did not produce the effect. Both oral and intracisternal administration of mesaconitine (MA) which is one of the main potent alkaloids contained in TJ-3021 produced analgesic effect in non-RCS rats.

[Analgesic effect of benzoylmesaconine]

"Tsumura Shuchi-Bushi Powder for Ethical Dispensing" (TJ-3021) is an herbal drug of processed Aconiti tuber that attenuates its toxicity. A greater part of mesaconitine which is regarded as a main analgesic component in processed Aconiti tuber is hydrolyzed into benzoylmesconine (BM) by its processing. In this study, the analgesic effect of BM was examined in comparison with that of TJ-3021 in mice and rats. BM (10 mg/kg, p.o.) depressed the acetic acid-induced writhing significantly. Its analgesic activity was almost similar in magnitude to that of TJ-3021 (300 mg/kg, p.o.). BM (30 mg/kg, p.o.) significantly increased the pain threshold ratio of paw pressure in repeated cold stress (RCS) rats, and its analgesic potency appeared to be equivalent to that of TJ-3021 (1000 mg/kg, p.o.). These results suggest that the analgesic activity of BM is strong enough for explanation of the analgesic effect of TJ-3021, and it might contribute to that of TJ-3021.

[A case of Henoch-Schoenlein purpura with extremely low OKT4 positive T lymphocytes]

We present a patient with Henoch-Schoenlein purpura who had extremely low number of OKT4 positive T lymphocytes. However his lymphocytes responded normally to Leu3a and Coulter T4, which are also monoclonal antibodies that react with CD4 epitope. In vitro lymphocyte function tests revealed that helper-inducer T cell functions were normal. From these findings, we concluded that this patient had an abnormality in the epitope of CD4 positive cells. Since expression of OKT4 antigens in his mother was also low, we considered the possibility of hereditary factors although no relationship with HLA was found.

Thermally-induced activities of the mesencephalic reticulospinal and rubrospinal neurons in the rat

Unit activities of 226 midbrain reticulospinal (mRfS) and non-mRfS neurons and 238 rubrospinal (RbS) and non-RbS neurons were investigated during changes in temperatures of midbrain (Tmb), preoptic and anterior hypothalamus (Thyp) and skin (Ts) in the urethane-anesthetized rat. Responsiveness to Tmb, Thyp and Ts were found in 43.5%, 41.6% and 51.5% of neurons of midbrain reticular formation (mRf), and in 35.2%, 32.7% and 17.6% of neurons of red nucleus (Rb). Higher incidence of responsiveness to remote temperatures was found among Tmb responsive neurons than Tmb unresponsive neurons in both mRf and Rb. The mRf contains significantly greater numbers of neurons having such multiple thermal responsiveness and also of neurons which were activated by falls in temperatures (cold-responsive neurons) than the Rb. These characteristics were more conspicuously seen among mRfS neurons, showing a high degree of convergence of cold signals from different sites of body. On the other hand, RbS neurons did not differ from non-RbS neurons regarding thermal characteristics and showed no particular combinations of responsiveness to temperatures of different sites. Microinjection of procaine and glutamate into the mRf just dorsolateral to the Rb, but not into the Rb, decreased and increased cold-induced increase in EMG activity and shivering without changes in cardiovascular and respiratory parameters and pilomotor activity. The results suggest that mRfS neurons are involved in the control of thermoregulatory muscle tone and shivering.

Responses of anterior hypothalamic-preoptic thermosensitive neurons to locally applied capsaicin

The effects of local application of capsaicin on the activity of single thermosensitive neurons in the anterior hypothalamic-preoptic area were studied in the urethane-anesthetized rat. Local injection of capsaicin through a cannula to the vicinity of the neurons increased the activity in 15 of 28 warm-units, decreased the activity in 2 of 4 cold-units and had no effect on 5 of 10 thermally-insensitive units. Electrophoretic application of capsaicin with the use of multibarrelled microelectrodes excited 16 of 27 warm-units, inhibited 12 of 17 cold-units and had no effect on 35 of 60 thermally-insensitive units. Progressive decreases in the responsiveness of the neurons to both capsaicin and the hypothalamic temperature were observed with repeated applications of capsaicin. Many neurons ceased firing after showing excitatory or inhibitory responses to single or repeated applications of capsaicin either by local injection or electrophoretic application. The results may explain the acute thermolytic response, as well as the subsequent decrease in responsiveness to the injection of capsaicin into the anterior hypothalamic-preoptic area, on the basis of changes in the activity of thermosensitive neurons in the anterior hypothalamic-preoptic area.

Effects of interleukin-1 and arachidonate on the preoptic and anterior hypothalamic neurons

Effects of microelectrophoretic application of ultrapure human interleukin-1 (IL-1), an endogenous pyrogen, on the activity of 80 neurons in the preoptic and anterior hypothalamus (PO/AH) were investigated in the urethane anesthetized rat. IL-1 predominantly decreased the activity of warm-sensitive neurons (15 of 19) and increased the activity of cold-sensitive neurons (10 of 12), but had no effect on 37 of 49 thermally insensitive neurons. The neuronal responses to IL-1 were blocked or attenuated by concurrent application of mepacrine (a phospholipase inhibitor) or sodium salicylate (a cyclooxygenase inhibitor). Local application of sodium arachidonate decreased the activity in 17 of 28 warm-units and excited 12 of 16 cold-units, and the effects of arachidonate were blocked by sodium salicylate. The results are compatible with the view that one or more cyclooxygenase metabolites of arachidonic acid are involved in the IL-1 induced fever.