Molecular epidemiologic analysis of a Pneumocystis pneumonia outbreak among renal transplant patients

Between 18 November and 3 December 2011, five renal transplant patients at the Department of Nephrology, Toho University Omori Medical Centre, Tokyo, were diagnosed with Pneumocystis pneumonia (PCP). We used molecular epidemiologic methods to determine whether the patients were infected with the same strain of Pneumocystis jirovecii. DNA extracted from the residual bronchoalveolar lavage fluid from the five outbreak cases and from another 20 cases of PCP between 2007 and 2014 were used for multilocus sequence typing to compare the genetic similarity of the P. jirovecii. DNA base sequencing by the Sanger method showed some regions where two bases overlapped and could not be defined. A next-generation sequencer was used to analyse the types and ratios of these overlapping bases. DNA base sequences of P. jirovecii in the bronchoalveolar lavage fluid from four of the five PCP patients in the 2011 outbreak and from another two renal transplant patients who developed PCP in 2013 were highly homologous. The Sanger method revealed 14 genomic regions where two differing DNA bases overlapped and could not be identified. Analyses of the overlapping bases by a next-generation sequencer revealed that the differing types of base were present in almost identical ratios. There is a strong possibility that the PCP outbreak at the Toho University Omori Medical Centre was caused by the same strain of P. jirovecii. Two different types of base present in some regions may be due to P. jirovecii's being a diploid species.

Chronic atherosclerotic mesenteric ischemia that started to develop symptoms just after anaphylaxis

An 83-year-old woman was referred to our emergency department with acute urticaria and sudden shortness of breath approximately 30 min after taking rectal diclofenac potassium for lumbago. After treatment with adrenaline and corticosteroids, the patient became hemodynamically stable and left the hospital on the next day. She attended our hospital 1 week after the onset of anaphylaxis because of repeated postprandial epigastric pain. No abnormal lesions were found in endoscopy. Radiographic selective catheter angiography revealed chronic mesenteric ischemia caused by atherosclerosis and abundant collateral arteries between the celiac trunk, the superior mesenteric artery and the inferior mesenteric artery. Patients with chronic mesenteric ischemia usually present with a clinical syndrome characterized by painful abdominal cramps and colic occurring typically during the postprandial phase. Fear of eating resulted in malnutrition. She was prescribed proton pump inhibitor, digestants, anticholinergic agents, serine protease inhibitors, prokinetics, antiplatelet agents and transdermal nitroglycerin intermittently, but these had no beneficial effects. It was most probable that this patient with chronic atherosclerotic mesenteric ischemia was suffering from functional abdominal pain syndrome induced by anaphylaxis. Since psychiatric disorders were associated with alterations in the processing of visceral sensation, we facilitated the patient's understanding of functional abdominal pain syndrome with the psychologist. Postprandial abdominal pain gradually faded after administration of these drugs and the patient left the hospital. Developing a satisfactory patient-physician relationship was considered more effective for the management of persistent abdominal pain caused by complicated mechanisms.

[The relation between the frequency of exercise oxygen desaturation following major lung resection and the predictions of postoperative pulmonary function]

The predictors of oxygen desaturation during exercise in patients submitted to major pulmonary resection for lung cancer are to be determined. We analyzed retrospectively the relation between the oxygen saturation by pulse oxymetry (Spo2) during exercise and the predictions of postoperative pulmonary function. A hundred twenty-two patients with lung cancer who underwent lung resection from January 1999 to May 2004 were included (79 men, 43 women, average age 66.9 +/- 9.2). A fall over 5% in Spo2 during exercise was termed 'desaturation'. Twenty-eight patients developed desaturation [group D(+)] and 94 patients did not [group D(-)]. We compared the predictions of postoperative pulmonary function (%ppoVC, %ppoFEV1.0, %ppoDLco) between these 2 groups. As a result, only %ppoDLco was significantly different between 2 groups [D(+) 68.7 +/- 19.1%, D(-) 83.8 +/- 24.9%]. Patients with poor %ppoDLco are at increased risk to develop a postoperative exercise oxygen desaturation.

[The last period of surgical site infection after pulmonary resection for lung cancer with hemodialysis; report of a case]

An 80-year-old man had been on maintenance hemodialysis for nondiabetic chronic renal failure from June 1996. He underwent investigation of an abnormal chest X-ray and was referred to our hospital with a diagnosis of squamous cell carcinoma in the upper lobe of the right lung. On February 20, 2003, right upper lobectomy was performed. The postoperative course was uneventful and he was discharged on postoperative day 13. Two weeks later he was readmitted with a wound infection. Although he received antibiotics, drainage, and wound lavage, his fever persisted and chest X-ray showed inflammatory changes in the right lower lung field. He was placed on mechanical ventilation for dyspnea. After this, his respiratory function became stable and he could be weaned from the ventilator within 2 weeks. The subsequent course was uneventful and he was discharged 1 month after re-admission. This patient needed ventilation due to weakness caused by wound infection. Such infection is uncommon but can be fatal for a compromised host, so we administered antibiotics for 3 days until the wound closed.

[Tension hemopneumothorax complicated by severe hepatic and renal disorder; report of a case]

A 46-year-old man was admitted to our hospital because of dyspnea and chest pain. We diagnosed tension hemopneumothorax and chest tube drainage was performed. A large volume of bloody pleural fluid (1,200 ml) was removed, but severe liver and renal dysfunction were then recognized. He was treated conservatively because there was no more bleeding. Despite administration of methylprednisolone, re-expansion pulmonary edema occurred after 6 hours of drainage, but this was also treated conservatively. After 3 days, his pneumothorax recurrenced. It was successfully managed by video-assisted thoracoscopic surgery (VATS).

The effect of postoperative ataralgesia by manual therapy after pulmonary resection

Muscle therapy, a form of manual therapy, was applied to control pain persisting for more than 1 week following posterolateral thoracotomy, and its efficacy for the alleviation of pain was investigated. Eight patients who underwent posterolateral thoracotomy and lung resection for cancer (n=7) or emphysema (n=1) received manual therapy to incised muscles and the muscles inserting into the ribs in the affected area for an average of 17 days postoperatively. Pressure-friction and stretching techniques were used. Treatment was continued until the intensity of the pressure-friction technique reached a level at which the patient complained of pain and a decrease in muscle tone was detected. Treatment was performed once a week for 3 weeks. Pain severity was measured using a visual analog scale (VAS) (0-10). Before the first treatment, the VAS was set at 10, and changes of the score were observed before and after the treatment as well as over time. After three sessions, all patients showed a decrease in pain from 10 to an average of 1.9 (range 1.3-2.6).

Utilization of the walking oximetry test to allow safe ambulation after pulmonary resection

Supplemental oxygen therapy after pulmonary resection can generally be tapered according to arterial blood gases at rest or pulse oximetry (SpO2). However, detecting exercise-induced oxygen desaturation can be difficult. We developed the walking oximetry test (WOT) so that thoracotomy patients could be rehabilitated without the risk of undetected ambulatory hypoxemia. The subjects were 58 patients who had undergone pulmonary resection and could walk at the bedside, with oxygen at 3 l/min via a nasal cannula. Patients with a value of more than 100 torr were allowed to walk with assistance for 6 min in the corridor. The oxygen flow rate was kept at 3 l/min and the walking pace was less than 50 m/min. SpO2 was determined using a wristwatch pulse oximeter. The test was stopped if the SpO2 fell below 90% or there was a score of 5 or more on the Borg scale (range 1-10). Oxygen desaturation occurred in six patients (10%) during the WOT. These patients underwent ambulatory training with sufficient oxygen supplementation and were then tested again. Patients whose SpO2 values remained higher than 90% and who showed no more than 5% desaturation were permitted to walk in the corridor with oxygen at 3 l/min via a nasal cannula. All these patients had a Borg score of 4 or lower. The WOT is a reliable, nonvasive method for detecting exercise-induced oxygen desaturation during ambulation after pulmonary resection.

Proliferating cell nuclear antigen positive cells in the hippocampal subgranular zone decline after irradiation in a rodent model

Four-week-old ICR mice were systemically exposed to 18Gy X-rays. Afterwards, the expression of proliferating cell nuclear antigen (PCNA) in the cerebrum was observed with time using Western blot analysis and immunohistochemical staining. As a result, PCNA-positive cells were observed in the subgranular zone (SGZ) of the hippocampus and subventricular zone (SVZ) of the lateral ventricles in unirradiated mice. The number of PCNA-positive cells decreased with time in all zones after irradiation, but the decrease was more marked in the hippocampal SGZ. We think that PCNA-positive cells are stem cells. The selective vulnerability to radiation in the hippocampus is considered to be attributed to the fact that stem cells in the SGZ selectively undergo radiation-induced apoptosis.

[Two surgical cases of pulmonary dirofilariasis]

Two surgical cases of pulmonary dilofilariasis (women aged 80 and 54 years old) were reported. They, who had no history of keeping dogs, were admitted to our hospital with complaining of cough and coin lesion on chest X-ray. On investigation, it was difficult to distinguish between pulmonary dilofilariasis and lung cancer. Wedge resection was performed by video-assisted thoracic surgery (VATS), and a definite diagnosis of pulmonary dilofilariasis was made. Nodes 2-3 cm in diameter are formed beneath the pleura in many cases of pulmonary dilofilariasis. Therefore, VATS is useful owing to its minimal invasiveness.

Thiopental enhances human platelet aggregation by increasing arachidonic acid release

Conflicting results have been reported regarding the effect of thiopental on aggregation and cytosolic calcium levels in platelets. The present study attempted to clarify these phenomena. Using platelet-rich plasma or washed suspensions, platelet aggregation, thromboxane (TX) B2 formation, arachidonic acid (AA) release, and cytosolic free calcium concentrations ([Ca2+]i) were measured in the presence or absence of thiopental (30-300 microM). Platelet activation was induced by adenosine diphosphate (ADP, 0.5-15 microM), epinephrine (0.1-20 microM) arachidonic acid (0.5-1.5 mM), or (+)-9,11-epithia-11,12-methano-TXA2 (STA2, 30-500 nM). Measurements of primary aggregation were performed in the presence of indomethacin (10 microM). Low concentrations of ADP and epinephrine, which did not induce secondary aggregation in a control study, induced strong secondary aggregation in the presence of thiopental (> or = 100 microM). Thiopental (> or = 100 microM) also increased the TXB2 formation induced by ADP and epinephrine. Thiopental (300 microM) increased ADP- and epinephrine-induced 3H-AA release. Thiopental (300 microM) also augmented the ADP- and epinephrine-induced increases in [Ca2+]i in the presence of indomethacin. Thiopental appears to enhance ADP- and epinephrine-induced secondary platelet aggregation by increasing AA release during primary aggregation, possibly by the activation of phospholipase A2.

[Two cases of patch closure of pericardial defects using fascia lata after pulmonary resection with pericardiectomy]

We reported two cases of patch closure of pericardial defects using fascia lata after pulmonary resection with pericardiectomy. We confirm many advantages of this method-cheap, low risk of infection, tight tissue and easy technique in a short time with no skilled hand.

[Bronchopleural fistula after pneumonectomy following induction therapy for cT4N0M0 squamous cell lung cancer]

A 69-year-old man developed after thoracotomy for lung cancer. He had centrally located cT4N0M0 squamous cell lung cancer that was downstaged to cTxN0M0 by induction chemoradiotherapy with grade 3 hematologic toxicity. Two months after the finish of chemotherapy, right pneumonectomy with concomitant resection of the superior vena cava was performed. Three weeks later, he developed with a bronchopleural fistula and died of ARDS. This demonstrates increased risk of surgery following induction chemoradiotherapy.

[Experience with induction chemoradiotherapy for cT4N2M0 lung cancer]

The 42-year-old man with cT4N2M0 adenocarcinoma is reported. The primary tumor showed no change in size on chest X-ray film after chemoradiotherapy, but chest computed tomography revealed necrosis of the lesion and was supposed to be down staging to cT3N0M0. Right upper lobectomy and lymph node dissection (R 2) was performed. Pathological examination revealed histological CR, and he is still alive 34 months after the start of induction therapy.

Propofol has both enhancing and suppressing effects on human platelet aggregation in vitro

BACKGROUND

Volatile anesthetics are known to suppress platelet aggregation. In contrast, there is conflicting information regarding the effect of propofol on platelet function. The present study was designed to clarify the effects of propofol on platelet function and the mechanisms underlying these effects.

METHODS

Propofol or an equivalent volume of 10% Intralipos (as a control) was added to test tubes 5 min before the induction of each reaction. Platelet aggregation induced by epinephrine, arachidonic acid (AA), prostaglandin G2 (PGG2), or STA2 (a thromboxane A2 [TXA2] analog) was measured using an eight-channel aggregometer. To determine type 1 cyclooxygenase activity, AA (0.5 mM) was added to an assay mixture containing type 1 cyclooxygenase, and the concentration of the final product, malonaldehyde, was measured by spectrophotometry. Epinephrine-, adenosine diphosphate-, AA-, and PGG2-induced TXA2 formation was measured using a commercially available radioimmunoassay kit. To estimate TXA2 receptor-binding affinity, 3H-S145, a specific TXA2 receptor antagonist, was added, and the radioactivity of receptor-bound 3H-S145 was determined using a liquid scintillation analyzer. Inositol 1,4,5-triphosphate formation was measured in STA2-stimulated platelets using a commercially available inositol 1,4,5-triphosphate assay kit.

RESULTS

Propofol (40 microM) enhanced, whereas 100 microM suppressed, adenosine diphosphate- and epinephrine-induced secondary aggregation without affecting primary aggregation. Propofol (40 microM) also enhanced, but 100 microM suppressed, AA-induced aggregation. Propofol (100 microM) enhanced PGG2- and STA2-induced aggregation. Propofol (100 microM) suppressed AA-induced TXA2 formation but did not alter that induced by PGG2. Propofol (30-100 microM) suppressed AA-induced malonaldehyde formation, indicating inhibition of type 1 cyclooxygenase activity. Propofol did not alter TXA2 receptor-binding affinity. Propofol (30 and 100 microM) augmented inositol 1,4,5-triphosphate formation in STA2-stimulated platelets.

CONCLUSIONS

The present findings clearly indicate that high concentrations of propofol suppress the activity of type 1 cyclooxygenase, the enzyme that converts AA to PGG2. Furthermore, propofol also enhanced STA2-induced inositol 1,4,5-triphosphate formation. These results may explain the inconsistent findings of previous investigators.

Anesthesia with sevoflurane, but not isoflurane, prolongs bleeding time in humans

PURPOSE

Halothane has been shown to suppress platelet aggregation in vitro and ex vivo and to prolong bleeding time. In a previous in vitro study, we demonstrated that sevoflurane had a stronger suppressive effect on platelet aggregation than halothane. The present study investigated whether clinical use of sevoflurane affects bleeding time in vivo.

METHODS

Thirty-four patients undergoing minor elective surgery were randomly assigned to sevoflurane or isoflurane. Anesthesia was induced with intravenous thiopental and maintained with sevoflurane or isoflurane with nitrous oxide. Bleeding time was measured by the Duke method. An initial (control) measurement was obtained in the operating room before the induction of anesthesia, and a second was obtained 5-10 min after endotracheal intubation but before starting the operation, when the end-expiratory concentration of sevoflurane or isoflurane had been stabilized at 1-1.5 times the minimum alveolar concentration (MAC), and the mean arterial pressures were between 80% and 120% of the preanesthetic values.

RESULTS

Bleeding time was increased from the preanesthetic value of 2.07 +/- 0.82 min to 2.83 +/- 0.93 min (n = 15) in the sevoflurane group (P < 0.01) but was not significantly altered in the isoflurane group.

CONCLUSION

Sevoflurane alters bleeding time in the clinical situation.

Platelet aggregation is impaired during anaesthesia with sevoflurane but not with isoflurane

PURPOSE

Halothane suppresses platelet aggregation in vitro and ex vivo, and prolongs bleeding time. In a previous in vitro study we demonstrated that sevoflurane had a more suppressive effect on platelet aggregation than did halothane. The present study investigated whether the clinical use of sevoflurane affected platelet aggregation ex vivo.

METHODS

Thirty-eight patients undergoing minor elective surgery were divided randomly into sevoflurane and isoflurane groups. Anaesthesia was induced with thiopentone i.v., and was maintained with sevoflurane or isoflurane with nitrous oxide. Blood was collected to measure platelet aggregation induced by adenosine diphosphate (ADP) and epinephrine. The first (control) blood collection was performed in the operating room before induction of anaesthesia, and the second 5-10 min after tracheal intubation but before the start of surgery, when the end-expiratory sevoflurane or isoflurane concentrations had stabilised at 1-1.5 times the minimum alveolar concentration (MAC) and mean arterial pressures were between 80-120% of preanaesthetic values.

RESULTS

In all samples obtained during sevoflurane anaesthesia (n = 15), ADP and epinephrine could not induce secondary aggregation, although they did induce primary aggregation. In contrast, in the isoflurane group, both primary and secondary aggregation were observed in 14 out of 15 patients, and secondary aggregation was abolished in only one of the samples obtained during anaesthesia.

CONCLUSIONS

Sevoflurane, but not isoflurane, alters platelet aggregation in the clinical situation, possibly by suppression of thromboxane A2 formation.

[An adult case of Williams-Campbell syndrome associated with pulmonary hypertension and a severe decrease in ventilatory response]

Williams-Campbell syndrome is a unique form of bronchiectasis caused by a congenital defect in bronchial cartilage, and is rare in Japan. A 34-year-old man was admitted to our hospital with a fever, and a productive cough. Arterial blood gas analysis revealed severe type II-respiratory failure. Many thin-walled cystic shadows (5-60 mm in diameter) were present in the entire lung field. Pulmonary function tests revealed obstructive impairment. Bronchograms demonstrated cystic bronchiectasis, with ballooning on inspiration and collapse on expiration, characteristic of Williams-Campbell syndrome. Despite severe hypoxia, he did not suffer from dyspnea. We examined ventilatory response to hypercapnea (HCVR) and hypoxia (HVR), and both HCVR and HVR were abnormal. In addition, the mean pulmonary artery pressure was 26 mmHg, indicating pulmonary hypertension.

Donor-specific cytotoxic lymphocyte activity from bronchoalveolar lavage during acute canine lung allograft rejection

OBJECTIVE

We investigated the relationship between acute lung rejection and donor-specific cytotoxic activity (DSCA) in recipient's lymphocytes obtained from bronchoalveolar lavage (BAL).

METHODS

A total of 26 mongrel dogs underwent left lung allotransplantation. Dogs received either no immunosuppressive treatment (group I), cyclosporine (group II), or cyclosporine and methylprednisolone for evidence of acute rejection (group III). DSCA was measured by a 51Cr release assay, using lymphocytes from BAL samples as effector cells and 51Cr-labeled donor skin fibroblasts as target cells. The pathologic findings of the transplanted lungs were classified according to the working formulation for classification and grading of pulmonary rejection. In addition, the degree of cellular infiltration in the perivascular, peribronchial, interstitial, and intraalveolar areas was determined based on an infiltration score.

RESULTS

DSCA in BAL samples was elevated during mild, moderate and severe acute rejection. The accuracy of the diagnosis of mild or moderate rejection was 92.3% at effector:target (E:T) ratios of 100:1 and 50:1. The DSCA in the BAL fluid and the total infiltration score were correlated closely with correlation coefficients of 0.859 and 0.828 at E:T ratios of 100:1 in group I and group II dogs, respectively. Lung aeration improved and DSCA decreased with methylprednisolone therapy in three of four dogs with grade 2 rejection.

CONCLUSION

There is a direct relationship between the DSCA in BAL fluid and the degree of tissue damage caused by acute rejection. The DSCA can be detected by a 51Cr release assay which may hold promise for future clinical applications.

[Are we legally allowed to administer blood for lifesaving to a patient who refuses it?]

We surveyed the literatures and discussed the legal issues whether we should administer blood for lifesaving to a patient who refuses it. The valid refusal of the transfusion requires the distinct intention of a competent patient. Minors below fifteen years of age are incompetent and their parents make a substituted judgement. Anyone must not give priority to the parents' belief and blood ought to be transfused if necessary for the children's benefits. We could evade liability for withholding blood only when we manage an operation arranged to succeed without blood transfusion, undergoing the sufficient treatments to avoid the risks, as well as on the basis of the valid refusal of a patient. The release deed and the intervention of hospital directors, ethics committees and courts are invalid for the immunity from liability. Anesthesiologists have to take the responsibility on themselves of administering blood or not. A statute law should be established to define what is a patient's valid intention and who is responsible.

Sevoflurane inhibits human platelet aggregation and thromboxane A2 formation, possibly by suppression of cyclooxygenase activity

BACKGROUND

Halothane increases bleeding time and suppresses platelet aggregation in vivo and in vitro. A previous study by the authors suggests that halothane inhibits platelet aggregation by reducing thromboxane (TX) A2 receptor-binding affinity. However, no studies of the effects of sevoflurane on platelet aggregation have been published.

METHODS

The effects of sevoflurane, halothane, and isoflurane were examined at doses of 0.13-1.4 mM. Human platelet aggregation was induced by adenosine diphosphate, epinephrine, arachidonic acid, prostaglandin G2, and a TXA2 agonist ([+]-9, 11-epithia-11, 12-methano-TXA2, STA2) and measured by aggregometry. Platelet TXB2 levels were measured by radioimmunoassay, and the ligand-binding characteristics of the TXA2 receptors were examined by Scatchard analysis using a [3H]-labeled TXA2 receptor antagonist (5Z-7-(3-endo-([ring-4-[3H] phenyl) sulphonylamino-[2.2.1.] bicyclohept-2-exo-yl) heptenoic acid, [3H]S145).

RESULTS

Isoflurane (0.28-0.84 mM) did not significantly affect platelet aggregation induced by adenosine diphosphate and epinephrine. Sevoflurane (0.13-0.91 mM) and halothane (0.49-1.25 mM) inhibited secondary platelet aggregation induced by adenosine diphosphate (1-10 microM) and epinephrine (1-10 microM) without altering primary aggregation. Sevoflurane (0.13 mM) also inhibited arachidonic acid-induced aggregation, but not that induced by prostaglandin G2 or STA2, although halothane (0.49 mM) inhibited the latter. Sevoflurane (3 mM) did not affect the binding of [3H]S145 to platelets, whereas halothane (3.3 mM) suppressed it strongly. Sevoflurane (0.26 mM) and halothane (0.98 mM) strongly suppressed TXB2 formation by arachidonic acid-stimulated platelets.

CONCLUSIONS

The findings that sevoflurane suppressed the effects of arachidonic acid, but not those of prostaglandin G2 and STA2, suggest strongly that sevoflurane inhibited TXA2 formation by suppressing cyclooxygenase activity. Halothane appeared to suppress both TXA2 formation and binding to its receptors. Sevoflurane has strong antiaggregatory effects at subanesthetic concentrations (greater than 0.13 mM; i.e., approximately 0.5 vol/%), whereas halothane has similar effects at somewhat greater anesthetic concentrations (0.49 mM; i.e., approximately 0.54 vol/%). Isoflurane at clinical concentration (0.84 mM; i.e., approximately 1.82 vol/%) does not affect platelet aggregation significantly.

[Effect of superoxide production on nitric oxide release from the pulmonary vascular endothelium during reperfusion after warm ischemia]

It has been reported that reperfusion injury results in the diminished nitric oxide (NO) release from the pulmonary vascular endothelium. However, this mechanism is completely unknown. We examined the effect of superoxide dismutase (SOD) on NO release at reperfusion. A rabbit lung was perfused with Krebs-Henselit buffer in a recirculation system. Cyclic GMP (cGMP) content in the lung effluent from the left ventricle was assayed in a time-dependent manner. In the control group, the lung was immediately perfused without interventing ischemia. In the warm ischemia and reperfusion group, the lung was reperfused after 30 min of warm ischemia. In the SOD group, SOD (60,000 U and 120,000 U) was administered at reperfusion after warm ischemia. The cGMP release in the warm ischemia and reperfusion group significantly decreased compared with the control group. In the SOD group, cGMP release was reversed with increasing doses of SOD, and the cGMP content was significantly reversed at all time points with SOD administration of 120,000 U. The impairement of cGMP release by reperfusion injury was restored by SOD administration. This data suggests that NO release from the endothelium may be quenched by superoxide anion generated at reperfusion. In lung transplantation, efforts must be pursued to preserve the endothelial function such as NO pathway.

[Surgical treatment to the lung cancer in a patient receiving hemodialysis]

We performed right lower lobectomy for lung cancer in a 62-year-old man who had been under hemodialysis for 4 years. During the operation, hyperkalemia occurred and was treated by GI therapy (continuous intravenous infusion of glucose + insulin). On the 3rd postoperative day, CVP was increased and hypotension occurred during hemodialysis. It was considered that heart failure had developed. Attention to the possibility of heart failure is important in the postoperative management of patient on chronic hemodialysis who require lung resection. He was discharged without bleeding of infection. There have been few reports on operations for lung cancer in such patients, so our experience is significant.

[Influence of warm ischemia and reperfusion on no-derived cyclic GMP release in the perfused rabbit lung]

To elucidate the vascular endothelial function at pulmonary ischemia and reperfusion, cyclic GMP (cGMP) release in lung perfusate at reperfusion after ischemia was examined as a marker of nitric oxide (NO) release from the endothelium in an in situ perfused rabbit lung. The lung was perfused from the pulmonary artery with Krebs-Henselite buffer and cGMP in the lung effluent from the left ventricle was assayed in a time-dependent manner. The inhibition of cGMP release by NG-nitro-L-arginine methyl ester and the reversal of the effect by L-arginine indicated that cGMP released into the perfusate was elicited by NO from the endothelium. There was a significant decrease in cGMP release during reperfusion after warm ischemia (30 min and 60 min) compared with the immediately perfusion without intervening ischemia. These data suggest that NO release is impaired by the endothelial dysfunction at reperfusion after warm ischemia in the perfused rabbit lung and the biochemical studies of the perfusate is useful in assessing the vascular endothelial function.

[A case of surgical treatment of triple cancers in the stomach, rectum and lung]

A case of triple cancers involving the stomach, rectum and lung is reported. A 75-year-old male was admitted to our clinic for the treatment of lung cancer. Right upper lobectomy was performed. Histological diagnosis was small cell lung carcinoma intermediate cell type (pT2N1M0, stage II). At the age of 70-year-old (sixty-two months before the pulmonary resection), he had undergone the resection of gastric cancer. At the age of 74-year-old (fourteen months before the pulmonary resection), rectal cancer was resected. Twenty four resected cases of triple cancers including lung cancer have been reported in the Japanese literature.

[Correlation between acute rejection and the role of donor specific cytotoxic T lymphocyte in canine lung allotransplantation]

We investigated the correlation between the donor specific CTL activities and pathological findings of the grafted lungs by using mononuclear cells obtained from BAL fluids (BAL), peripheral blood (PBL), spleen (SpL) and grafted lungs (GIL) in canine lung allotransplantation. Twenty eight mongrel dogs underwent left lung allotransplantation. Fifteen dogs were not given immunosuppressive drugs. Thirteen dogs were given cyclosporine a 20 mg/kg/day per os for ten days postoperatively. Dogs were monitored by chest roentgenograms and cytotoxic activity tests of which targets were donor's fibroblasts. Pathological findings were classified by Prop's classification. The results were as follows. In latent and vascular phases no elevations of cytotoxic activities were demonstrated in PBL, BAL and GIL. But in early alveolar phase the cytotoxic activity was elevated to 19.83 +/- 14.54% in BAL. In late alveolar phase the highest cytotoxicities of 30.83 +/- 15.28% in PBL, 72.63 +/- 7.36% in BAL and 70.07 +/- 6.34% in GIL at E:T = 100:1 were demonstrated. In pneumonia cytotoxicity did not elevate at all in any effectors. As a result of them, it clearly shows that BAL is a good tool for the diagnosis of lung rejection.

[A case of foreign body granuloma]

A 45-year-old man referred to our hospital complaining of dry cough. Chest X-ray and CT scan film indicated tumor shadow in the right anterior mediastinum. Although preoperative diagnosis was teratoma, the specimen extirpated by thoracotomy revealed macroscopically and microscopically foreign body granuloma originated from gauzes. He had undergone segmentectomy of right upper lobe for tuberculosis 28 years ago, so the gauzes were thought to be left in right thoracic cavity at the operation. The foreign body granuloma originated from gauzes are iatrogenic and few cases were reported previously, however, whirl like pattern demonstrated by MRI is retrospectively considered to be an important diagnostic finding in this case.

The capacity of dog lung to release prostaglandin I2 as a biochemical parameter for evaluating lung damage during preservation

The release of prostaglandin I2 (PGI2) from the vasculature is thought to reflect damage to the vessels. Basal and bradykinin (BK)-stimulated release of PGI2 from isolated dog lungs after 6-hr preservation were investigated to evaluate lung damage after preservation. Maximal PGI2 release induced by BK decreased significantly after preservation at 24 degrees C (room temperature), but not after hypothermic preservation at 4 degrees C, although basal PGI2 release without BK stimulation did not change in either group of lungs after preservation. The function of allotransplanted lungs assessed by arterial oxygen tension was impaired by preservation at room temperature but not by hypothermic preservation. No differences were observed by light microscopy in either group in the pulmonary tissues, including the pulmonary artery, after preservation. In summary, damage to the lung after preservation may be reflected by the maximal PGI2 release from the lung after BK infusion. Therefore the maximal PGI2 releasing capacity induced by BK may be a useful biochemical parameter for estimating the viability of preserved lungs.

Auto-antibody against adenine nucleotide translocator in dilated cardiomyopathy and myocarditis--incidence and relation to cardiac function and morphology

Using an enzyme-linked immunosorbent assay, we measured anti-adenine nucleotide translocater (ANT) antibody in control subjects and in patients with dilated cardiomyopathy (DCM), myocarditis, and other heart disease. Analysis with sodium dodecyl sulfate-polyacrylamide gel electrophoresis, Western blotting, and immunoabsorption tests confirmed accurate purification of the ANT protein and correct measurement of anti-ANT auto-antibody. Anti-ANT antibody was detected in 6 of 37 cases (16%) of DCM and in 5 of 12 cases (42%) of myocarditis. This antibody was not positive in other heart diseases or in apparently healthy controls. There were no differences between anti-ANT autoantibody-positive and -negative DCM or myocarditis patients in any of the cardiac parameters examined (left ventricular ejection fraction, LVEF; left ventricular end-diastolic dimension, LVDd; and cardiothoracic ratio, CTR). Moreover, in patients who were positive for anti-ANT auto-antibody, no positive correlations were found between the parameters and anti-ANT antibody titers in either DCM or myocarditis. Although these results indicate that the detection of anti-ANT antibody was achieved at a high specificity and could have certain diagnostic value in DCM and myocarditis, there was no statistically significant relationship between the cardiac parameters (LVEF, LVDd, and CTR) and anti-ANT antibody titers in either DCM or myocarditis. Some compensatory mechanism of ventricular function may mask the effects of the anti-ANT auto-antibody or alternatively, this auto-antibody may have mimic effects on the pathogenesis and/or progression of DCM and myocarditis.

[Influence of thoracotomy and partial lung resection on pulmonary function: comparison with median sternotomy]

The influence of thoracotomy on respiratory function was examined in 49 patients: 22 with intercostal thoracotomy without lung resection (ICT), 11 with partial lung resection (PLR) and 16 with median sternotomy (MST). Respiratory function (FVC, FEV1.0 and FEV1.0%) was measured preoperatively, in the early stage (14 days) and in the stable stage (after 3 months) postoperatively. In each group, the FVC and FEV1.0 were decreased to 70-80% of preoperative respiratory function in the early stage and rose to 90-95% in the stable stage. There were no significant differences among the groups. FEV1.0% did not vary in the different stages in any of the three groups. The ICT group was classified according to the type of skin incision (axillary incision (AI), anterolateral incision (ALI) and posterolateral incision (PLI)). FVC and FEV1.0 in the ALI subgroup were higher (p < 0.05) than in the PLI subgroup in the early stage. These results suggest that the selection of the skin incision is important for preserving respiratory function.

Dose study of the immunosuppression of FK 506 in canine lung allo-transplantation

The immunosuppressive effect of FK506 (FK) in comparison to cyclosporine A (CsA) on lung graft rejection was demonstrated using 24 mongrel dogs with left lung allotransplantation. The cytotoxic activity of peripheral blood mononuclear cells was evaluated using donor skin fibroblasts. In eight dogs not given immunosuppression, the grafted lungs lost aeration 5-10 days postoperatively, and histologic findings revealed grade II rejection and cytotoxic activity elevated to between 10.7 and 60.5%, being an average of 31.2% at an effector/target (E/T) ratio of 50. Of 12 dogs treated with FK, none demonstrated a cytotoxic activity of 10% or more at an E/T ratio of 50. Moreover, histologic examinations of the specimens obtained by open chest biopsy revealed no signs of rejection during the first 10 postoperative days of FK administration, except in one dog showing grade I rejection from the FK 0.05 mg/kg group. A dose study of the duration until the onset of graft rejection and the elevation of cytotoxic activity after the termination of FK administration revealed approximately 1-2 weeks in the FK 0.05 mg/kg group, 3-4 weeks in the 0.1 mg/kg group, and later in the 0.4 mg/kg and 2.0 mg/kg groups. However, severe body weight loss was seen in the 0.4 mg/kg and 2.0 mg/kg groups postoperatively, without recovery even after the termination of FK. In fact, two dogs died of pneumonia possibly derived from general emaciation. These results suggest the optimal concentration of FK in canine lung allo-transplantation to be 0.1 mg/kg intramuscularly.

Factors influencing survival after endoscopic Nd:YAG laser surgery for unresectable advanced malignancies of the trachea

The effects of endoscopic Nd:YAG laser surgery were studied in 36 patients with unresectable advanced primary and metastatic malignancies in the trachea with special reference to the factors influencing long-term survival. Overall effectiveness of YAG laser treatment was demonstrated in 34 of the 36 patients (94 per cent), while the overall 1, 3 and 5 year survival rates after the first laser treatment were 25 per cent, 13 per cent and 13 per cent, respectively. Neither histologic type nor the severity of clinical symptoms before laser treatment showed any significant influence on the survival curves, however, endoscopic findings of stenosis, the effect of laser treatment and irradiated longitudinal length were all significantly correlated with the survival curves. In other words, endoscopically protruding type tumors with a longitudinal length of irradiation of 3.0 cm or less, and good responses not only to laser treatment but also to other combined modalities are favorable factors for achieving long-term survival in patients with tracheobronchial malignancies undergoing endoscopic Nd:YAG laser treatment. Endoscopic Nd:YAG laser surgery is considered to be a promising part of the multi-modality treatment for unresectable advanced primary and metastatic malignancies of the trachea.

[A comparative study of weight of regional lymph nodes in association with the presence of metastasis in primary lung cancer patients]

The weight of regional lymph nodes was measured in 173 patients who underwent surgical resection of the primary lung cancer and lymph nodes from January, 1986 to January, 1989 in our hospital. Histological examination was also performed and correlation of metastasis and the weight of lymph nodes were studied. The average weight of metastatic lymph nodes was 2.34 g while that of non-metastatic ones was 0.83 g indicating a significant (p less than 0.05) increase of weight in metastatic lymph nodes. Although the percentage of metastasis increased as the weight of lymph nodes increased, 7.6% of lymph nodes weighing less than 0.5 g was positive for metastasis. On the other hand, 66.7% of the lymph nodes weighing more than 3.0 g in adenocarcinoma and 34.5% in squamous cell carcinoma were positive for metastasis indicating the difference of the metastatic tendency to the lymph nodes between the two histological types. The comparative study of the weight of each lymph node station according to the JJC criteria demonstrated the difference of average weight of non-metastatic lymph nodes among each lymph node station. The average weight of pretracheal (#3), subcarinal (#7), interlobar (#11), and segmental (#12) lymph nodes without tumor metastasis were more than 1.0 g, however those of anterior mediastinal (#3a), paraesophageal (#8), and pulmonary ligament (#9) were less than 0.5 g. The average weight of metastatic lymph nodes in each lymph node station was in proportion to those of non-metastatic ones.

Association between high grade ventricular arrhythmia and extent of left ventricular hypertrophy in hypertrophic cardiomyopathy

The association between the extent of left ventricular (LV) hypertrophy and severity of ventricular or atrial arrhythmias are examined. Two-dimensional echocardiography and 24-h Holter electrocardiography monitoring were performed in 60 patients with hypertrophic cardiomyopathy (HCM). According to the distribution of the LV hypertrophy, the patients were divided into three groups: 1. Apical hypertrophy (APH), 2. Septal hypertrophy, and 3. Extensive hypertrophy. Ventricular arrhythmias were found in 82% of the patients and supraventricular arrhythmias were detected in 70% of the patients. Lown grade III and IV arrhythmias occurred significantly more frequently in patients with extensive than with septal hypertrophy. Lown grade III to IV arrhythmias did not occur in patients with APH. Present results show a significant association between the extent of LV hypertrophy and the severity of ventricular arrhythmias in HCM.

[A case of effective chemotherapy with CDDP and VDS for metastatic lesions of the lung and spleen and simultaneous resection]

A case of 51-year-old woman, she was suffered from primary parotic cancer and the right parotic gland was resected in 1980, and pulmonary metastatic nodule was also operated in 1982. She was admitted in our institute with complaint of bloody sputum and cough in 1989, and diagnosed as pulmonary and splenic metastasis of parotic cancer. Two courses of combined chemotherapy, with CDDP by administration through bronchial artery, with CDDP and VDS by a systematic intravenous injection, was done. With these therapies, partial responses were obtained in the metastatic lesions, so spleen and left lower lobe of lung were resected. In the histological examination of the resected tumors, tumor cells were nearly disappeared, and we obtained Ef-2 effect according to the general rule for clinical and pathological record of lung cancer. She was discharged after one more chemotherapy and with no sign of recurrence now. We reported this case because of the possibility of the effective adjuvant therapy of the case with multiple lesions of cancer metastasis, and the rare case of splenic metastasis.

[Antagonism of diazepam-induced sedative effects by flumazenil in patients after surgery under lumbar spinal or epidural anesthesia]

The efficacy and general safety of flumazenil (YM684), a specific benzodiazepine antagonist, have been evaluated. Forty-seven patients scheduled for surgery under lumbar spinal or epidural anesthesia with diazepam sedation received flumazenil at the end of the procedure. Criteria of efficacy were the degree of sedation and antegrade amnesia. Before injection all patients were heavily sedated with the mean dose of 27 mg of diazepam (range 10-50 mg). After the mean dose of 0.21 mg of flumazenil (range 0.2-0.4 mg), all patients were awake or drowsy within 1-6 min but sedation recurred in one patient 1 hour later. The amnesia was eliminated by flumazenil in 34 patients (72%). No serious side-effects or hemodynamic changes were observed after flumazenil. It is concluded that flumazenil is an effective antagonist of sedation induced by diazepam.

Morphological rejection phases and cytotoxic activity in peripheral blood lymphocytes in canine lung allo-transplantation

The relationship between the morphological changes in allografted lungs and the cytotoxicity of recipient peripheral blood lymphocytes was studied. Left lung allotransplantations were performed in 14 adult mongrel dogs. Four dogs were treated with cyclosporin A (20 mg/kg/day po.) and four were treated with FK-506 (0.1 mg/kg/day im.) for 10 days. Six dogs were not given any immunosuppressive drugs. Cytotoxicity was measured with the 51Cr release assay in which the donor skin fibroblasts were used as target cells. The histological changes of the grafted lungs were classified into three grades: grade 0; no abnormal findings, grade I; perivascular and peribronchial mononuclear cell infiltration, and grade II; edema, hemorrhage and a fibrin-like substance in the alveolar space in addition to the findings of grade I. The grafted lungs of the dogs with elevated cytotoxicity showed the histological findings of grade II (8 of the 14 dogs) and significantly higher cytotoxicity (44.1 +/- 25.7 per cent) were seen in these dogs than in those with grade 0 (2.0 +/- 3.9 per cent) or grade I (2.6 +/- 1.9 per cent). It is therefore considered that the cytotoxicity against donor skin fibroblasts in recipient peripheral blood lymphocytes is associated with morphological rejection phases in allografted lungs.

[Ewing sarcoma originated from rib in 3-year-old child--a case report]

A 3-year-old girl was admitted to our hospital with a 3-month history of moderate fever, cough and dyspnea. Chest X-ray and C-T scan showed huge mass with high density, occupying right anterior thoracic cavity. Tumor marker including CEA, AFP, NSE in serum and VMA in urine revealed within normal data. Cytological finding obtained by percutaneous fine needle aspiration demonstrated neuroblastoma. 4 days after admission, urgent operation was performed, because of reinforced dyspnea. Huge tumor was successfully dissected, with combined resection of 2nd and 3rd ribs. Pathological diagnosis showed Ewing sarcoma originated from rib. This case is the youngest case of Ewing sarcoma of bone in Japan, and the patient is alive with disease free at the postoperative period of 21 months.

[Detection of donor specific cytotoxic T lymphocyte activity in lung grafted mongrel dogs]

Cytotoxic activity against donor skin fibroblasts in peripheral blood mononuclear cells was evaluated by using 10 mongrel dogs with left lung allografts and the results obtained herein were as follows. 1) Culture of skin fibroblasts primarily separated with collagenase and disperse was feasible to grow monolayers within several days to 1 weeks. Four hour responding time of mononuclear cells to targets was superior to 18 hour responding time, with the reproducibility of this assay under the 4 hour cocultivation between effectors and targets. 2) The effectors in this assay established in our laboratory were the cells nonadherent on plastics and nylon wool, suggesting T lymphocytes and donor specificity was confirmed by cold competition. 3) This donor specific cytotoxic activity derived from T lymphocytes was steeply elevated 4 to 8 days postoperatively with the average of 6 days in rejecting lung allografts and histologic examination revealed edema and fibrin-like substance in alveolar space. Cyclosporin A, however, could remarkably suppress its activity and grafted lung maintained function. In conclusion, the effectors in cytotoxic activity against donor skin fibroblasts in lung allografted mongrel dogs developed in our laboratory revealed as donor specific cytotoxic T lymphocytes and this assay is very useful to demonstrate rejection, the effect of immunosuppressive drugs and the differentiation between rejection and infection.

[Application of transbronchial brushing for histological diagnosis of lung cancer]

In order to improve the preoperative diagnostic rate of lung cancer, histological examination was performed by transbronchial brushing in 35 cases, and diagnostic contribution of brushing specimen was compared with that of transbronchial forceps biopsy (TBFB). Histological structures were well preserved in the histology section of brushing specimens, especially in cases of small cell lung cancer. The positive rate of brushing histology was 46%, which was the same as that of TBFB. The total histological diagnostic rate was 66% with simultaneous examination of bronchial brushing and TBFB specimens. Consequently, the use of brushing specimens for histologic evaluation made an additional contribution to the correct positive histology diagnostic rate. Brushing histology is indicated for all types of lung cancer, because in most TBFB-negative cases, biopsies were performed from inappropriate sites of tumors or their materials wer crushed by forceps. It was suggested that concomitant application of brushing specimen for histology examination, contributed to more accurate preoperative histology diagnosis for lung cancer.

[Postoperative sequential testing of cytotoxic activity against the autologous and allogeneic tumor cells in patients with primary lung resected cancer]

The objective of this study of 27 primary lung resected cancer patients was to evaluate sequentially the cytotoxic activity against autologous and allogeneic tumor cells during the postoperative period. In patients given a complete resection, the cytotoxic activity against the autologous tumor cells during the postoperative 1-2 weeks was significantly higher than during the postoperative 4-5 weeks (P less than 0.05, Student t test). In patients given an incomplete resection, however, no significant difference was demonstrated between the postoperative 1-2 weeks and during the postoperative 4-5 weeks. In contrast, the cytotoxic activity against the PC-3 cells or K562 cells during the postoperative 4-5 weeks tended to rise in comparison to those at the postoperative 1-2 weeks all patients in any cancer stage and whatever the amount of their lung resection. The phenotype of the effector cells which mediated the cytotoxic activity to the autologous tumor cells was the monoclonal antibody OKT 3(+), 8(+), 4(-) OKM 1(-) and the cells which were cytotoxic to the K562 cells had an OKT 3(-), 4(-), 8(-), OKM 1(+) phenotype. These results suggest that the effectors which mediate cytotoxic activity to the autologous tumor cells and to the K562 cells seems to be different and a concomitant immunity may exist in primary lung resected cancer patients.

[A sensitivity test of UFT and FT-207 against human pulmonary cancer using nude mice]

Transplanted tumors of human pulmonary adenocarcinoma subcutaneously into nude mice were used, to investigate the effect UFT and FT-207. Concentration of 5-FU and uracil in tumors, measured by the gas chromatographic-mass fragment graphic method, was followed. 5-FU concentration in UFT group were higher than other group, and uracil concentration show no significant difference. In one of the lines, tumor growth was stopped in UFT group and regression rate was 68% in comparison with control group, pathologically revealed grade II b in classification of Simosato-Oohoshi. It was also indicated in this experiment, anticancer effect is related with specific anticancer drug sensitivity.

[A resected case of adenosquamous-carcinoma of the lung]

A resected case of an adenosquamous carcinoma of lung diagnosed from sputum and trans-bronchial-aspiration cytology is reported. The patient, a 39-year-old woman, was identified by mass screening testing for pulmonary cancer. Sputum cytology and trans-bronchial-aspiration cytology conducted by means of a bronchofiberscope revealed the presence of both an adenocarcinoma and squamous carcinoma cells. A histologic examination of the resected lung revealed the adenosquamous carcinoma. This case is very rare in having been diagnosed before surgery, and by sputum cytology which was very available.

Hepatocellular carcinoma metastatic to the oral cavity including the maxilla and the mandible: report of two cases and review of the literature

Two cases of hepatocellular carcinoma metastatic to the oral cavity are presented. One patient had metastases to the maxilla and finally, to the mandible, and the other patient, to the mandible. Both cases histologically showed highly-differentiated trabecular hepatocellular carcinoma which had vascularized stroma, explaining the frequently observed oral hemorrhage. The clinical signs and symptoms described here suggested the existence of a tumor metastatic to the oral cavity, and might indicate an unusual manifestation of hepatocellular carcinoma. Reports of metastatic lesions of hepatocellular carcinoma to the oral cavity, including the mandible, maxilla and gingiva proper, are reviewed.