Absence of exercise capacity improvement after in-hospital short-term cardiac rehabilitation is associated with long-term clinical outcome in heart failure patients

Background

Previous studies suggest Cardiac rehabilitation (CR) improve exercise capacity and decline mortality in heart failure (HF) patients. However, some studies show there are HF patients who do not improve exercise capacity by CR and these patients have a higher risk of adverse events in long-term clinical outcome. We investigated whether absence of exercise capacity improvement after in-hospital short-term CR also has adverse effect in long-term clinical outcome.

Methods

In this retrospective study, 130 HF patients who underwent two weeks in-hospital CR after received standardized HF treatment between July 2014 and August 2020 were included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (delta-Peak VO2) measured at 1st and 14th day of CR by cardiopulmonary test. The median delta-PeakVO2 was 1.3 ml·kg-1·min-1. Patients were classified as responder if they demonstrated delta-PeakVO2 ≥1.3 ml·kg-1·min-1 and as non-responder if they demonstrated delta-PeakVO2 <1.3ml·kg-1·min-1. MeanΩ follow-up was 1236 days. The primary outcome was all-cause death.

Result

63 patients (48.4%) were classified as non-responder. Non-responders were older (75.5±10.6 vs 70.8±11.0, P=0.01) and lower estimated glomerular filtration rate (eGFR) (49.7±19.4 vs 57.9±19.2) and lower albumin (3.5±0.5 vs 3.7±0.3 g/dL, P=0.04) than responders. Transtricuspid pressure gradient (TRPG) measured by transthoracic echocardiography was also higher in non-responders (28.5±10.9 vs 22.7±6.3). Predictor of non-responders were TRPG (OR = 1.1, 95% CI 1.02–1.26) and albumin (OR =0.04, 95% CI: 0.003–0.40). In multivariate analysis including delta-PeakVO2 <1.3 ml·kg-1·min-1 (non-responder), age >75, male gender, PeakVO2 at 1st day of CR, body mass index (BMI), left ventricular ejection fraction measured by transthoracic echocardiography, medication of β-blockers showed that delta-PeakVO2 <1.3 ml·kg-1·min-1 (HR =2.8, 95% CI 1.0–7.5), age>75 (HR11.2, 95% CI 2.1–60.1), BMI (HR =0.8, 95% CI 0.6–0.96) were associated with all-cause death.

Conclusion

The absence of exercise capacity improvement after in-hospital short-term CR was the risk of all-cause death. Especially, the HF patients with higher TRPG and lower albumin have a higher probability of becoming a non-responder.

Funding Acknowledgement

Type of funding sources: None.

Prevention of graft-versus-host disease by intrabone marrow injection of donor T cells: involvement of bone marrow stromal cells

We have developed a new and effective method for bone marrow transplantation (BMT): bone marrow cells (BMCs) are injected directly into the bone marrow (BM) cavity of recipient mice. The intrabone marrow injection of BMCs (IBM-BMT) greatly facilitates the engraftment of donor-derived cells, and IBM-BMT can attenuate graft-versus-host reaction (GVHR), in contrast to conventional intravenous BMT (i.v.-BMT). Here, we examine the mechanisms underlying the inhibitory effects of IBM-BMT on GVHR using animal models where GVHR is elicited. Recipient mice (C57BL/6) were irradiated and splenic T cells (as donor lymphocyte infusion: DLI) from major histocompatibility complex-disparate donors (BALB/c) were injected directly into the BM cavity (IBM-DLI) or injected intravenously (i.v.-DLI) along with IBM-BMT. The BM stromal cells (BMSCs) from these recipients were collected and related cytokines were examined. The recipient mice that had been treated with IBM-BMT + i.v.-DLI showed severe graft-versus-host disease (GVHD), in contrast to those treated with IBM-BMT + IBM-DLI. The suppressive activity of BMSCs in this GVHD model was determined. The cultured BMSCs from the recipients treated with IBM-BMT + IBM-DLI suppressed the proliferation of responder T cells remarkably when compared with those from the recipients of IBM-BMT + i.v.-DLI in mixed leucocyte reaction. Furthermore, the level of transforming growth factor-beta and hepatocyte growth factor in cultured BMSCs from IBM-BMT + IBM-DLI increased significantly when compared with those from the recipients of IBM-BMT + i.v.-DLI. Thus, the prevention of GVHD observed in the recipients of IBM-BMT + IBM-DLI was attributable to the increased production of immunosuppressive cytokines from BMSCs after interaction with host reactive T cells (in DLI).

Activation of granulocytes by direct interaction with dendritic cells

Granulocytes from human peripheral blood were co-cultured with conventional dendritic cells (cDC) or plasmacytoid DCs (pDC) to examine the effects of DCs on the activation or function of granulocytes. After co-culture of granulocytes with DCs, expression of the activation markers of granulocytes (CD63 and CD64) was up-regulated, and increased expression of CD50, the activation marker and ligand for CD209 (DC-SIGN) was also observed. The interaction of granulocytes with DCs was visualized as the cluster where DCs, especially cDCs, were surrounded by granulocytes to form a 'rosette'. After co-culture of granulocytes with cDCs, the secretion of elastase from granulocytes was enhanced significantly when examined cytohistochemically and by enzyme-linked immunosorbent assay. An increase in myeloperoxidase (another activation index of granulocytes) was also observed after co-culture with DCs. These findings suggest the functional and phenotypical activation of granulocytes by interaction with DCs. Furthermore, we examined the involvement of adhesion molecules in the granulocyte-DC interaction, and found that CD209 participates to some extent in this interaction.

[A case of left renal cell carcinoma in a young male adult with left varicocele]

A 25-year-old man presented to our hospital with the chief complaint of left-sided painless scrotal swelling. Varicocele was diagnosed and high ligation was performed. Two months later, he noticed asymptomatic gross hematuria. Transabdominal ultrasonography and abdominal computed tomographic scanning showed a left renal tumor measuring more than 10 cm in diameter. Radical nephrectomy (thoraco-abdominal approach) was performed and pathological diagnosis was granular cell carcinoma (G2, pT2, INF alpha, pNX, pMX). He then received intramuscular injections of interferon-alpha 3 million units on three days per week. The frequency of renal cell carcinoma was reported to be about 1-3% for individuals in the 20s in the recent Japanese literature, and renal cell carcinoma in a young man with left varicocele is very rare.

Use of [123I]-BMIPP myocardial scintigraphy for the clinical evaluation of a fatty-acid metabolism disorder of the right ventricle in chronic respiratory and pulmonary vascular disease

The objective of this study was to evaluate whether or not right ventricle (RV) uptake of iodine-123-labelled-beta-methyliodophenylpentadecanoic acid ([123I]-BMIPP) correlated with the degree of right ventricular pressure overload (RVPO). Myocardial scintigraphy of [123I]-BMIPP and thallium-201 (201Tl) was performed on 46 patients with RVPO. We determined the right ventricle (RV)/left ventricle (LV) ratio = (radioactivities of RV)/(radioactivities of LV), and the RV metabolic index (RVMI) = (RV/LV ratio of [123I]-BMIPP)/(RV/LV ratio of 201Tl). We also evaluated the correlation between RVMI and mean pulmonary arterial pressure (mPAP), and between RVMI and total pulmonary resistance (TPR). Significant correlations were found between the RV/LV ratio of [123I]-BMIPP and mPAP and between the RV/LV ratio of [123I]-BMIPP and TPR. In addition, a significant negative correlation was observed between RVMI and mPAP and between RVMI and TPR. RVMI declined as RVPO increased, suggesting the presence of a fatty-acid metabolism disorder of the RV. Moreover, [123I]-BMIPP myocardial scintigraphy could be useful for evaluating a disorder of the fatty-acid metabolism of the RV with RVPO.

[Psychogenic lower urinary tract dysfunction in women: patho-physiological investigation for psychogenic frequency-urgency syndrome and psychogenic urinary retention]

PURPOSE

Psychogenic lower urinary tract dysfunction (PLUTD) is composed of two syndromes; psychogenic frequency-urgency syndrome (PFUS) and psychogenic urinary retention (PUR). We evaluated the patho-physiology of PFUS and PUR, and explored the different pathogenesis in these syndromes.

MATERIAL AND METHODS

Forty five patients with PLUTD, consisting of 23 patients with PFUS and 22 patients with PUR were investigated by using the psychological tests: CMI (Cornell Medical Index) and TEG (Todai's Egogram), a quantitative perspiration test in 45 females (23 patients with PFUS and 22 patients with PUR), and simultaneous measurements of voiding cysto-urethrography and urodynamic studies using the Life-Tech 6 channel polygraph in 35 patients (17 patients with PFUS and 18 patients with PUR).

RESULTS

The prevalence in ages revealed two peaks, 20 years and 50 to 60 years. Over 25% of them had pyuria more than 10/hpf of WBC. Peak flow rate measured by uroflowmetry showed normal range in PFUS group and decreased in PUR group. The functional vesical volume was less than 100 ml in most patients with PFUS. Residual urine in PUR group was significantly greater. Capacity of the PFUS group were able to hold over 400 ml of contrast instilled through the urethral catheter, despite increased desire to void. Over 15% of the study group with PFUS showed uninhibited systolic contraction of detrusor (> 15 cm H2O) during filling phase. The measurement value of urodynamic parameters demonstrated that a periodic follow-up survey of the upper urinary tract should be performed because of the low compliance bladder in the patients with PLUTD. During voiding phase, the women with PFUS had a tendency to be divided into two groups, hypercontractile or acontractile detrusor. The voiding cysto-urethrography (VCUG) showed a tendency of bladder neck opening on patients with PFUS during filling phase. Most of PLUTD cases demonstrated a round to triangle shape on vesical configuration, which led to a spastic condition of detrusor muscle. We attempted to measure the quantitative perspiration using 3 kinds of loading tests; respiratory, arithmetic and psychological load. In the psychological loading test, we asked 98 questions about their daily lives including occupation, living condition, family relationship and sexual activities. Arithmetic loading test consisted of counting in reverse, subtraction and multiplication. The quantitative perspiration rate resulted in a "positive" in many patients with PFUS. Respiration loading test was performed to measure the respiration volume during 3 large inhales. Most patients with PUR tested within the normal range for respiration except for those patients with decreased or no perspiration during the psychiatric loading test. These results may reflect the psychological elements including suppression and subconscious defense mechanism. Neurosis which was diagnosed as having type III to type IV of the Cornell Medical Index was demonstrated in less than under 40% of patients with PFUS and more than 55% patients with PUR. There was no significant trend or difference between PFUS and PUR detected from Todai's Egogram.

CONCLUSIONS

Due to the reflection of many psychological responses, it is necessary to investigate from various examinations including psychological, autonomical and classical urological studies for accurate diagnosis of PLUTD.

[A case of renal oncocytoma associated with acquired cystic disease of the kidney]

We report a case of renal oncocytoma associated with acquired cystic disease of kidney (ACDK). A right renal mass was incidentally found on an annual ultrasonography of the kidneys in a 56-year-old female patient who had been on maintenance hemodialysis for 6 years. Computerized tomography (CT) showed a right hypervascular renal mass, suggesting a renal cell carcinoma associated with ACDK. Right radical nephrectomy was performed. The post-operative pathological diagnosis was renal oncocytoma. Renal oncocytoma in ACDK is very rare, and the pathological characteristics of oncocytoma are discussed.

[A case of endometrioid carcinoma of the prostate]

A case of endometrioid carcinoma of the prostate is reported. A 64-year-old man was admitted to our department with initial macrohematuria and dysuria. The transrectal ultrasonogram showed remarkable prostatic hypertrophy and the serum level of both prostatic specific antigen (PSA) and prostatic acid phosphatase (PAP) ranged within normal limits. Urethrocystographical and cystoscopical findings indicated prostatic hypertrophy with elongation of prostatic urethra and mild trabeculation of bladder wall. During transurethral resection of the prostate, papillary tumor was accidentally found in the left lobe near the vermontanum. Histopathological examination revealed adenocarcinoma of the prostatic urethra and the tumor displayed no immunoreactivity for PSA or PAP. Under diagnosis of prostatic urethral cancer total cystoprostatectomy and urethrectomy were performed and ileal conduit was constructed for urinary diversion. As intraductal papillae and complex ramifying glands were histopathologically confirmed in the specimen and the immunohistochemical staining showed positivity of PSA and PAP, the tumor was diagnosed as endometrioid carcinoma of the prostate.

[A case of retroperitoneal fibrosarcoma: usefulness of magnetic resonance imaging]

A 62-year-old man with dyspnea was admitted to our hospital. Computed tomography showed a large right renal mass. Results of T1- and T2- weighted magnetic resonance imaging showed a very low-intensity region suggestive of retroperitoneal fibrosarcoma. On March 13, 1996, complete tumor resection and lymphadenectomy were done. The histopathological diagnosis was of fibrosarcoma. After the operation, the patient was treated twice with a combination chemotherapy regimen consisting of cyclophosphamide, vincristine, adriamycin and dacarbazine. At the most recent follow-up, 1-year postoperatively, the patient was well with no local recurrence or distant metastases.

[Suppressive effect of glycopeptidolipid from Mycobacterium avium-intracellulare complex serovar 4 and 16 on blastogenesis of human peripheral blood mononuclear cells]

Mycobacterium avium-intracellulare complex (MAC) consists of 28 serotypes. Co-infection of several specific serotype strains with the advent of acquired immunodeficiency syndrome (AIDS) has been dramatically increasing in the past fifteen years, although the reason for this fact is not clearly understood. Since the cell surface lipid components of MAC impaired the capacity of human peripheral blood mononuclear cells (PBMC) to proliferate, some particular glycopeptidolipid (GPL) with serologically specific carbohydrate chains are supposed to inhibit blastogenesis and to affect the immune response in MAC infection. In this study, we have investigated the effect of serovar 4 and 16 GPLs on the human PBMC function and cell mediated immunity. As the result, it was demonstrated that the percentage of viable cells was decreased prominently after the incubation of PBMC with the serovar 4 GPL. Blastogenic responses of PBMC to stimulation with the purified protein derivatives (PPD) were inhibited by the presence of GPL dose-dependently. In the case of stimulation with anti-CD3 antibody (a-CD3 Ab), blastogenic response of PBMC was suppressed markedly by GPL at the concentration of 175 micrograms/ml. Flow-cytometric analysis demonstrated that the expression of interleukin-2 receptor alpha on a-CD3 Ab-stimulated T lymphocyte was markedly inhibited in the presence of GPL. Enzyme-linked immunosorbent assay showed that the production of interleukin-2 by a-CD3 Ab-stimulated PBMC was reduced dose-dependently after the incubation of PBMC with GPL. In these results, there was no remarkable difference between serovar 4 and serovar 16 GPLs. These results indicate that serovar 4 and 16 GPLs inhibit the cell mediated immunity and serovar 4 GPL can affect the viability of PBMC.

[Clinical features of Sjögren syndrome]

Between 1985 and 1995, 134 patients presented to our clinic with complaints of either dry mouth, decreased salivary flow or salivary gland swelling of unknown origin. These patients were diagnosed retrospectively based on the criteria established by the Sjögren's disease research committee (1977), and 30 patients were definitively diagnosed with Sjögren's disease while 23 were considered suspect. The gender distribution of these 30 patients was 25 female (83%) and 5 male (17%). The average patient age was 55.8 years for females and 42.6 years for males. Of 30 patients, 10 (33.3%) had only sicca syndrome and the other 20 (66.7%) had various complications such as collagen diseases, autoimmune diseases, and malignant lymphoid infiltration. Subjects included 14 cases of rheumatoid arthritis (RA), 1 case of systemic lupus erythematosus (SLE), 1 case of RA with periarteritis nodosa (PN), 1 case of progressive systemic sclerosis (PSS) with SLE, 1 case of PSS with Hashimoto disease, 1 case of malignant lymphoma and 1 case of RA with Waldenström's macroglobulinemia. Positive blood tests showed a relatively high incidence of elevated erythrocyte sedimentation ratios (ESR) (75%), elevated IgG levels (69.2%), positive anti-nuclear antibody (52.3%), positive anti SS A antibody (75%) and positive anti-SS B antibody (50%).

Bladder neck support prosthesis: a nonoperative treatment for stress or mixed urinary incontinence

PURPOSE

We evaluated the usefulness and safety of a bladder neck support prosthesis in patients with stress or mixed incontinence.

MATERIALS AND METHODS

A total of 57 women with stress and 20 with mixed incontinence completed a 12-week prospective clinical trial of a bladder neck support prosthesis. While indexes of incontinence episodes, leakage amounts and urgency along with a bothersome index were subjectively evaluated, a 60-minute pad test and urinary flow parameters were objectively evaluated. Three patients scheduled to undergo surgery for stress incontinence voluntarily used the device, and provided urodynamic data and cystourethrograms. Two prongs at 1 end of the ring, a type of elastic vaginal pessary, elevate the bladder neck against the pubic bone and facilitate pressure transmission around the bladder neck, resulting in urinary continence.

RESULTS

Four subjective indexes significantly improved. There was no urinary flow obstruction. Urine loss decreased from 20.6 to 4.8 gm. per hour (p < 0.001) on the 60-minute pad test. Of the patients 22 (29%) reported complete continence and 39 (51%) had decreased severity of incontinence by more than 50%. Minor adverse effects occurred in 26% of the patients. Taking subjective evaluation, changes in objective parameters and adverse effects into consideration, 62 patients (81%) had some or maximum benefit according to the global usefulness rating.

CONCLUSIONS

The bladder neck support prosthesis is safe, well tolerated and clinically effective for the treatment of stress or mixed incontinence.

Complications and reimplantation of penile implants

BACKGROUND

Complications of penile prosthesis implants can be divided into surgical and mechanical failure. We investigated penile prosthesis implants to clarify the surgical and mechanical complications that have arisen in our clinical experience.

METHODS

In the 11 years between 1984 and 1995, 83 penile prostheses were implanted in 74 patients ranging from 37 to 82 years of age.

RESULTS

Of the 64 malleable and mechanical prostheses, 11 were extracted, including 4 removed because of surgical complications and 2 due to mechanical failure. Of the 19 inflatable prostheses, 6 were removed, including 1 extracted due to surgical complication and 5 extracted due to mechanical failure. Nine reimplantations for 8 patients were performed and all these cases had good results. As a result, 66 out of 74 patients could have coitus after prosthetic surgery.

CONCLUSIONS

Penile prosthetic surgery is an established method of treating organic impotence, however, it should only be considered for selected and well-informed patients to avoid complications and revision surgery.

A cysteine-containing truncated apo A-I variant associated with HDL deficiency

We identified a 50-year-old Japanese woman with a novel mutation in the apolipoprotein (apo) A-I gene causing high-density lipoprotein (HDL) deficiency. The patient had extremely low HDL cholesterol and apo A-I levels (0.14 mmol/L and 0.8 mg/dL, respectively) but no evidence of coronary heart disease. However, she had bilateral xanthomas of the Achilles tendon, elbow, and knee joint as well as corneal opacities. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of serum followed by immunoblotting revealed that the patient's apo A-I had a lower molecular weight (24,000) than normal apo A-I. A partial gene duplication encompassing 23 nucleotides was found by DNA sequence analysis, resulting in a tandem repeat of bases 333 to 355 from the 5' end of exon 4. This tandem repeat caused a frameshift mutation with premature termination after amino acid 207. The frameshift gives rise to a predicted protein sequence that contains two cysteines. We designated this mutant as apo A-ISasebo. Apo A-ISasebo formed heterodimers with apo A-II and apo E in the patient's plasma and was associated with both the low-density lipoprotein and HDL fractions. The patient's cholesterol esterification rate and lecithin-cholesterol acyltransferase activity were reduced to about 30% of normal, although specific enzyme activity was unaffected, suggesting that it remained functionally normal. In addition, cholesteryl ester transfer activity was reduced to about half of normal. Thus, apo A-ISasebo was associated with complex derangements of lipoprotein metabolism.

Spontaneous rupture of non-aneurysmal ascending aorta

Two autopsy cases with pericardial tamponade and spontaneous rupture of non-aneurysmal ascending aorta are described. In case 1, no apparent predisposing factor was clinically noticed in a 74 year old male patient, but postmortem examination revealed laceration of the ascending aorta associated with aortic valvular deformity and slight dilatation of the ascending aorta. In case 2, a 61 year old man, a mild to moderate grade of aortic regurgitation was noticed clinically 5 months before death. Postmortem examination revealed a slight dilatation of the aortic annulus and post-valvular portion of the ascending aorta. These two cases emphasize the clinical significance of aortic valvular disease with subsequent disordered blood flow, even when asymptomatic, as a potential causative factor for spontaneous rupture of the ascending aorta.

[Classification of patterns of nocturnal penile tumescence with continuous monitoring of penile rigidity: analysis of various factors affecting erection]

In 43 men who required further examination of erectile function, we analyzed the relationship between the various factors including hormone levels, penile blood pressure index (PBPI), shape of the arterial wave, erection period after prostaglandin E1 injection and dynamic cavernosography/metry, as well as the patterns of nocturnal penile tumescence (NPT) with rigidity. Normal, dissociation, short episode, low amplitude and flat trace patterns, which were classified by Kaneko, were observed in 11, 8, 11, 2 and 11 men, respectively. Uncoupling was not observed in any men. There were no differences in the levels of prolactin and LH among the 6 patterns. A high FSH level was seen in men with a flat trace pattern; a low level of free testosterone ( < 12.2 pg/ml) was seen in men with dissociation, low amplitude and flat trace patterns, and low PBPI ( < 0.75) in men with flat trace pattern; and an arteriosclerotic shape of the arterial wave was seen in men with short episode and flat trace patterns. Each erection period immediately after prostaglandin E1 injection in men with dissociation, short episode, low amplitude and flat trace was shorter compared with cases with a normal pattern. Venoocclusive dysfunction was observed in 5 men with a dissociation pattern and 6 men with a flat trace pattern. In conclusion, an integral analysis of pattern of NPT with rigidity and other examinations are useful for differentiating organic impotence from psychogenic impotence and for accurately diagnosing pathophysiological disorders of organic impotence and underlying diseases.

[Immunohistochemical study of fibrosis and S-100 protein-positive cells in idiopathic pulmonary fibrosis and in interstitial pneumonia associated with rheumatoid arthritis]

Immunohistochemical methods were used to distinguish idiopathic pulmonary fibrosis (IPF) from interstitial pneumonia associated with rheumatoid arthritis (RA lung). The subjects were six patients with IPF and seven with RA lung, in whom the pathological findings were consistent with usual interstitial pneumonia. Antibodies to vimentin (Vim), alpha-smooth muscle actin (alpha-SMA), and S-100 protein were used for immunohistochemical studies done by the streptavidin-biotin-peroxidase complex method. In fibrosis associated with RA lung, proliferation of both Vim and alpha-SMA-positive myofibroblasts was widely observed, despite pathological findings of honeycombing, usual interstitial pneumonia, and BOOP. Fibrosis in cases of IPF was found to be characterized mainly by Vim-positive fibroblasts, and on occasion was associated with hyperplasia of smooth muscle. Lung tissues from patients with acute exacerbations of RA lung, especially when associated with a BOOP pattern, had many cells positive for S-100 protein. However, such cells were generally hard to find in cases of IPE. Similar results were obtained with regard to the honeycomb pattern in both IPF and RA lung. These findings suggest that IPF and RA lung can be fairly clearly differentiated based on the proliferation of myofibroblasts and on the presence or absence of cells positive for S-100 protein.

[Clinical experience with the artificial urinary sphincter AMS 800 for male incontinence]

BACKGROUND

The aim of this study is to evaluate the therapeutic efficacy of artificial urinary sphincter AMS 800 implants for male patients with urinary incontinence.

METHODS

Eleven male patients with urinary incontinence were treated by implantation of the artificial urinary sphincter AMS 800 between 1988 and 1992. Patient age at the surgery ranged from 14 to 79 years, with a mean age of 58 years. At presentation, 9 patients (82%) had true incontinence and 2 had overflow incontinence, and medical treatments and/or surgical procedures (Teflon injections in 2 and Sling procedure in 1) had been attempted previously elsewhere in all patients. The etiologies of incontinence were post-prostatectomy (transurethral resection in 4 and radical retropubic prostatectomy in 4) in 8 patients (73%) and myelomeningocele, spinal cord injury, pelvic trauma in one each. There were 5 patients with abnormal cystometrogram, and 2 of them were performing intermittent self catheterization. Vesicoureteral reflux was determined in 2 patients preoperatively, which were surgically corrected one year before AMS800 implant in a patient and simultaneously in another patient. The cuff was placed around the bulbous urethra (9), pendulous urethra (1) or bladder neck (1). The device was activated 6 weeks post implantation, and the assessment of therapeutic effects was started 2 weeks after activation.

RESULTS

Follow up ranged from 3 weeks to 75 months, with a mean of 56 months, if 3 cases done explantation due to periprosthetic infections were excluded. After AMS 800 implantation 5 patients (45%) were completely continent, 4(36%) required the use of not more than 1 pad per day, while a patient was not satisfied with the results and another patient was not definitive because of early explantation before device activation. Hence complete or near complete continence was achieved in 9 patients (81%). A patient is performing intermittent self catheterization in conjunction with the AMS 800 without any complications up until now. There were 3 periprosthetic infections (27%) associated with 2 cuff erosions, that consequently required explantation. Besides periprosthetic infection, neither complications nor mechanical device failures was experienced.

CONCLUSION

In conclusion, the AMS 800 artificial urinary sphincter was safe with reasonable mechanical reliability and offered acceptable and satisfactory urinary control to the selected patients with incontinence.

Cine-magnetic resonance imaging of cor triatriatum

Two adult patients with cor triatriatum, which was shown by echocardiography and magnetic resonance imaging (MRI) using both spin-echo and cine-MR techniques, are presented. Spin-echo MRI clearly demonstrated an anatomical relationship between the membrane and pulmonary veins or left atrial appendage, which was not clear on transthoracic echocardiography. In addition, cine-MRI depicted abnormal flow through the fenestration of the anomalous membrane (case 1 and 2) and shunted flow through the associated atrial septal defect (case 2).

[Study on free enzymes and proteins in the urine. Report IV: The effects of Iohexol on elderly patients with renal function disorder]

We assessed the nephrotoxicity of a non-ionic contrast medium, Iohexol, in 18 elderly patients. They were divided into two groups. Group 1 consisted of 12 patients with glomerular flow rate (GFR) above 60 ml/min/1.73 m2 (range 69-136; average 96) and group 2 consisted of 6 patients with GFR below 60 ml/min/1.73 m2 (range 38-59; average 49). Urine samples, collected before, immediately after, and on the third and sixth days after drip infused pyeloureterography (DIP) were analyzed for gamma-glutamyl transpeptidase (gamma-GTP), N-acetyl-beta-D-glucosaminidase (NAG), beta 2-microglobulin (beta 2-MG) and albumin. In group 1, immediately after DIP, the urinary excretion of albumin, gamma-GTP and NAG were significantly increased (p < 0.01, p < 0.01, p < 0.01). In group 2, immediately after DIP, the urinary excretion of gamma-GTP and beta 2-MG were significantly increased (p < 0.01, p < 0.1). The gamma-GTP and NAG values in both groups suggest that the damage of proximal tubules cells will not continue for more than 4 days. However, as for the reabsorption of beta 2-MG on proximal tubules, in group 2 the value did not return to the pre DIP level until 6 days after DIP. We believe it is important to postpone injection of non-ionic contrast medium within 6 days of its last usage.

Long-acting nicardipine for elderly hypertensive patients: effect on diurnal variation of blood pressure

The effect of long-acting nicardipine tablets on diurnal variation of blood pressure was compared with that of standard nicardipine tablets and long-acting nifedipine tablets by 24-hour ambulatory blood pressure monitoring in 35 patients with hypertension. Long-acting nicardipine decreased systolic blood pressure in each age group, and there was no difference in its anti-hypertensive effect when compared with the other two drugs. All three drugs had no effect on the amplitude of daily blood pressure variation, and all three drugs decreased the baseline blood pressure in each age group when compared with untreated patients. In addition, no change was observed in the decrement of baseline blood pressure after switching from the other two drugs to long-acting nicardipine. Long-acting nicardipine had less effect on diurnal blood pressure variation than standard nicardipine tablets, which are administered three times daily. In each age group, long-acting nicardipine also more effectively inhibited the increase in cardiac work resulting from the morning rise phenomenon when compared with standard nicardipine tablets. These findings suggest that long-acting nicardipine may be a more useful preparation for the treatment of essential hypertension, particularly in elderly patients.

Improvement of upper limb function with respect to urination techniques in quadriplegia

A follow up study of urological management was carried out on 38 cervical spinal cord injury patients who were admitted to the Nagano Rehabilitation Centre Hospital and whose surgical reconstructions of their paralytic hands were performed since 1977. Self catheterisation was possible after reconstructive hand surgery in patients whose lowest functioning cord segment was C5-6. All of them had been unable to perform self catheterisation before surgery. Handling of instruments related to the act of urination was possible in two patients where the lowest functioning cord segment was C6-7 and where ileal conduit formation and reconstructive hand surgery had been performed.

[A case of muellerian duct cyst treated with minocycline hydrochloride sclerotherapy under ultrasound control]

We present a case of a muellerian duct cyst in a 55 year-old man. A cystic lesion was incidentally found between the prostate and the bladder on transabdominal ultrasound examination. Computerized tomography revealed a low density area homogeneous and round with a clear margin. Both urethrocystgram and vesiculogram demonstrated no cystic lesion. On diagnosis of muellerian duct cyst percutaneous needle aspiration was performed under ultrasound control. The aspirated fluid was yellow, clear and negative for cytology. Microscopically no spermatozoa were found in it. Minocycline (100 mg) was injected into the cyst. No recurrence has occurred since the operation. The literature of the cyst was briefly reviewed.

[The role of urodynamic study in female patients with urinary incontinence]

To determine the type of urinary incontinence in 96 female incontinent patients, we performed a comparative study between the clinical evaluation and the results of urodynamic studies. Their complaints, physical examination, laboratory examinations including routine urological X-ray and ultrasonic studies, revealed that 15 to 30% of the patients had another type of incontinence than those with stress incontinence, urge incontinence and those in whom diagnosis was made from urodynamic studies. Urodynamic studies disclosed that another urinary incontinence type was observed in 7 to 18% of the patients, who were not improved in spite of treatment which was required because of their complaints and physical examination. Our findings showed that urinary incontinence could not be classified according to the frequency of urination or vesical volume. Urodynamic studies may be essential in female patients with urinary incontinence scheduled to have an operation or for whom initial treatment was unsuccessful.

[The use of a metallic stent in 32 patients with benign prostatic hypertrophy. Preliminary results and 3 months of follow-up]

A prospective noncontrolled study of the safety and potential efficacy of the metallic stent was performed on 32 patients with benign prostatic hypertrophy. Mean age was 76.6 years (range, 56-98 years), and mean prostatic volume was 24.2 cm3. The patients were selected on the basis of a quantitative symptom score (QSS), uroflowmetry measurements, and residual urine volume (RU). Nineteen patients had urinary retention and remaining 13 patients had moderate symptoms and signs of prostatism. Placing the stent was successfully done in 31 patients (97%). It took 15 minutes to place the stent using transabdominal and/or endorectal sonography. After 3 months, 27 patients (87%) showed improved QSS. In patients with dysuria, maximum flow rate (MFR) and RU before treatment were 6.9 +/- 1.7 ml/sec and 112.3 +/- 61.8 ml, respectively. After treatment, they improved to 12.3 +/- 2.7 ml/sec and 12.7 +/- 6.7 ml, respectively. On the other hand, all patients who had urinary retention were able to urinate just after treatment, and MFR and RU were 12.9 +/- 3.6 ml/sec and 24.4 +/- 43.3 ml, respectively. Evaluation on the basis of improvement in MFR and reduction in RU showed that the stent was effective in 71% of total patients (22 out of 31 patients), 94% of the patients with urinary retention (17 out of 18 patients). The overall clinical efficacy of this stent was 68% (21 patients). There were no major complications such as urge incontinence and urinary tract infection during follow-up. Although proximal migration of the stent was observed in 6 patients, the stent could be taken out and replaced in 4 patients. From the above results, we conclude that the metallic stent is useful for the treatment of prostatism and urinary retention.

[Inhibitory effects of IFN on N-butyl-N-(hydroxybutyl) nitrosamine induced rats bladder tumors]

Bladder tumors were induced in rats by the oral administration of 0.025% N-butyl-N-(hydroxybutyl) nitrosamine (BBN). In order to study the suppressive effects of rat interferon-alpha (IFN-alpha) on induction of carcinogenesis in vivo, rats were treated with IFN-alpha i.m. twice a week. The treatment began at 5th week of BBN administration. The bladder mucosa was observed macroscopically and microscopically, and NK activity was examined. The results were as follows. 1) There was no significant difference in the bladder to body weight ratio between the BBN + IFN-alpha and BBN groups in during stage A (10th-14th week when changes in the mucous membrane such as hypertrophy in the bladder wall or vascular formation are observed). This ratio in the BBN + IFN-alpha group was less than that in the BBN group in during stages B and C (15th-19th week and 20th-30th week respectively when tumors are visually recognizable). 2) The rate of carcinogenesis in the BBN + IFN-alpha group was less than that in the BBN group in stages A and C. 3) The pathological grade and stage of the bladder cancer in the BBN + IFN-alpha group were lower than those in the BBN group in stages B and C. 4) There was no significant difference in NK activity between the two groups in stage A, but NK activity of the BBN + IFN-alpha group was higher than that of the BBN group in stage B. 5) These findings substantiated the hypothesis that IFN-alpha can suppress tumor-growth in BBN induced bladder carcinoma.

Temporal minor slow and sharp activity in psychiatric patients

TMSSA was found in 51 (4.7%) of 1091 psychiatric patients, with a higher incidence found in the older group (40 years of age or over). Although TMSSA was found in various disorders, a close association with cerebrovascular dementia was suggested. It was uncommon in patients with primary degenerative dementia. No increase of TMSSA was noted in cerebrovascular disorders without dementia. TMSSA was found fairly often in patients with affective disorders, neurosis, and other functional disorders, suggesting underlying mild cerebral dysfunction in some. TMSA, a variant of TMSSA, was very similar to TMSSA except for its greater frequency in cerebrovascular disorders without dementia.

[Mitral valve prolapse syndrome as an etiologic factor of anxiety disorder]

To assess whether a certain somatic disease is involved in the etiology of anxiety disorder, we examined the relationship between anxiety disorder and mitral valve prolapse syndrome (MVP). Patients with anxiety disorder were diagnosed according to the criteria of the American Psychiatric Association (Quick Reference to the Diagnostic Criteria from DSM-III). Two-dimensional echocardiography was carried out on 36 normal controls (15 males and 21 females) and 39 patients with anxiety disorder (19 males and 20 females); including 21 patients with panic disorder, 12 with generalized anxiety disorder, and 6 with atypical anxiety disorder. The echocardiograms were evaluated by a cardiologist unaware of clinical background about these patients. The presence of MVP was diagnosed according to the criteria by Yoshikawa, et al. or Nagata, et al. Findings of MVP were seen in 18 (46.1%) of the patients and 5 (13.9%) of the controls indicating a significantly higher incidence (chi 2 = 7.711, p less than 0.01) in the patients. In the patient subgroups, 14 patients with panic disorder (66.6%) and 4 with generalized anxiety disorder (33.3%) had MVP, showing a significantly higher incidence in the former (chi 2 = 14.335, p less than 0.01) than in the normal controls, but no statistical significance in the latter. No MVP was found in the patients with atypical anxiety disorder. These results suggest that some somatic diseases such as MVP may play a role in the etiology of anxiety disorder, especially panic disorder.

A newly designed deodorant pad for urinary incontinence

The authors designed a new pad for urinary incontinence. It is composed of a cloth of acrylonitrile copper sulfide and another cloth of iron-phthalocyanine. In vitro experiments showed that acrylonitrile copper sulfide cloth inhibited the growth of most bacteria causing urinary tract infection, and that iron-phthalocyanine cloth effectively eliminated bad-smelling gases. The use of this pad relieved diaper-dermatitis and diminished offensive smells from feces and urine. This pad was well received by nurses and helpers taking care of incontinent elderly people.

[Reappearance and recovery of alpha rhythm after eye opening]

To obtain more informations from routine EEG recording, we studied changes in alpha rhythm after eye opening that had been almost disregarded hitherto. The study was carried out on 26 normal controls and 137 patients with four categories of diseases including 52 patients with psychiatric diseases, 8 with trifling neurological symptoms, 68 with defined organic brain diseases, and 9 with headache without defined organic cause. Following routine EEG recording, each subject was asked to keep their eyes opened for three minutes. The major changes in alpha rhythm after eye opening were composed of two patterns; "reappearance" and "recovery". The reappearance was defined as appearance of 5 or more alpha waves in series; and the recovery, as the amount and amplitude of the alpha rhythm became equal to those of the back ground alpha-rhythm which was seen while their eyes were kept closed. The reappearance was noticed in 84.6% of normal controls and in 89.1% of all patients. In patients with organic brain diseases, the reappearance was seen in 88.2%, while it was in 68.6% of the patients without organic brain disease. The recovery was noticed in 34.3% of all patients (p less than 0.01), while it was only in 15.4% of normal controls. The incidence of the recovery in the patients with organic brain diseases was 41.2%, the value of which was significantly higher than that of the rest of patients (28.8%, 15 out of 52 patients, p less than 0.05). These patients with the recovery tended to show slower frequency and higher amplitude in the back ground alpha-rhythm than the patients without recovery.

[Design and application of laser-disk for clinical pulmonary data base system using the personal computer]

A database system is described for managing the information on pulmonary function test (PFT) measured by three different PFT devices. The data is transmitted into a personal computer, FM-11AD2+ (FUJITSU CO., LTD.) with a 20 MB hard disk and a 800 MB laser disk. Multitasking OS, OS-9/6809, is used to operate the software. PFT data of about 15,000 cases may be stored, which can be easily retrieved for research and discussions on a case study. Despite the present limitation of the processing speed and the capacity of the hard disk, this system is useful because it allows to provide reports readily.

Estimation of personal exposure to ambient nicotine in daily environment

To evaluate the actual exposure level of nonsmokers to environmental tobacco smoke (ETS) in their daily life, the exposure level of ambient nicotine was measured with a nicotine personal monitor carried by a nonsmoker. Average exposure levels of nicotine, even in such smoky places as cars, coffee shops and pubs, were less than 45 micrograms/m3. As a result of all-day monitoring, the highest amount of nicotine inhaled in a day was estimated, in this study, to be up to 310 micrograms, equivalent to actively smoking 0.31 ordinary cigarettes.

[Usefulness of nerve block therapy in patients with herpetic pain]

A retrospective study was performed on 230 patients with Herpes zoster. Among these patients, 156 patients (67.8%) were over 50 years old. Ninety-four percent of the patients who received the nerve block therapy within a month from the onset became ultimately free from pain while only seventy-nine percent of the patients upon whom this therapy was started after 2 months or more were relieved of pain. It was suggested that the earlier the therapy and the younger the patients, the more easily herpetic pain could be controlled. In conclusion, it became apparent that early treatment of Herpes zoster with nerve block therapy, is extremely important for prevention of post-herpetic neuralgia.

[Clinical effect of terodiline hydrochloride on nervous pollakisuria or irritative bladder]

The clinical effect of terodiline hydrochloride (TD-758) was studied in 95 patients with nervous pollakisuria or irritative bladder. TD-758 was given per os randomly at a dose of 24 mg or 12 mg once a day for 4 weeks. The symptoms such as urinary frequency, urinary incontinence and sense of residual urine were improved in 74% of the patients taking 24 mg, and in 51% of the patients taking 12 mg. The difference was statistically significant. Side effects such as dry mouth, constipation and heart burn were observed in 15% of the patients in each group and were not serious. The results of this study indicate that TD-758 is useful for these patients and its optimal dosage is 24 mg once a day.

Urinary tract dysfunctions in tethered spinal cord syndrome: improvement after surgical untethering

We reviewed 55 patients with urinary tract dysfunction owing to the tethered spinal cord syndrome, a form of spina bifida occulta with or without mild myelodysplasia, to evaluate the effects of neurosurgical treatment. Of the patients 24 underwent laminectomy with release of a tethered spinal cord and 31 were followed without the operation. Median followup was approximately 5 years. Urological findings at the most recent examination were compared between the 2 groups. In the operated group 5 patients, including 2 with myelodysplasia, apparently were cured of urinary tract dysfunction and 6, including 2 with myelodysplasia, had somewhat satisfactory results, whereas in the unoperated group only 4 patients had satisfactory results and the remainder were unaffected. Urinary tract dysfunction in some patients with spina bifida occulta may be relieved by surgical release of a tethered spinal cord.

Coexistence of aldosteronoma and pheochromocytoma in an adrenal gland

An extremely rare case is reported in which aldosteronoma and pheochromocytoma coexisted in an adrenal gland. Although the patients presented with clinical features of primary aldosteronism, preoperative examination showed an elevation of both plasma aldosterone and urinary catecholamines. Histology of the removed adrenal gland revealed that, concurrently with a round mass of adrenocortical adenoma, the adrenal medulla was totally occupied by the typical structure of pheochromocytoma.

Bladder function following spinal cord injury: a urodynamic analysis of the outcome

Repeated urodynamic testing was undertaken on a group of 58 consecutive patients admitted with acute spinal cord injury. Thirty-seven (64%) were able to void satisfactorily spontaneously, whereas 10 required bladder outlet surgery and 11 achieved emptying by either abdominal straining, intermittent self-catheterisation or an indwelling suprapubic catheter. The pattern of the initial cystometry soon after injury provided some idea of what possibilities could be expected of subsequent bladder function. Very high detrusor pressures exceeding 80 to 100 cm of water developed in a third of patients with supranuclear lesions. Six patients developed vesicoureteric reflux between 4 and 24 months after injury.

Mobilization of arachidonic acid between diacyl and ether phospholipids in rabbit alveolar macrophages

The metabolism of 20:4 (arachidonic acid) in alkenylacyl, alkylacyl and diacyl lipid classes in choline glycerophospholipids (CGP) and ethanolamine glycerophospholipids (EGP) in rabbit alveolar macrophages was examined. [3H]20:4 was very rapidly incorporated into diacyl glycerophosphocholine (GPC). After the removal of free 20:4, the radioactivity was gradually lost from diacyl GPC. Concomitantly, the radioactivities in alkylacyl GPC and alkenylacyl glycerophosphoethanolamine (GPE) were increased, indicating that 20:4 was mobilized from diacyl GPC to alkylacyl GPC and alkenylacyl GPE. The mobilization was considered to be a 20:4-specific event. The gradual accumulation of 20:4 in ether phospholipids leads to a high abundance of 20:4 in these lipids. These results suggest metabolic relationships between 20:4 and ether phospholipids, including platelet-activating factor (PAF).