Arterial blood ketone body ratio as a possible indicator for predicting fulminant hepatitis in patients with acute hepatitis.

Encephalopathy and severe coagulopathy in patients with acute hepatitis (AH) are good markers for the diagnosis of fulminant hepatitis (FH), which occurs in only about 1% of AH patients. However, even if patients show severe coagulopathy, it is quite difficult to predict FH before the onset of encephalopathy. The ratio of acetoacetate/beta-hydroxybutyrate in arterial blood (KBR) has been reported to reflect the cellular energy charge level in hepatocytes. In our previous report, KBR was quite low in FH patients and was an excellent marker for predicting the prognosis. KBR of normal subjects is distributed in a range of 1.0-2.1 (1.54 +/- 0.26, mean +/- SD). In this study, we assessed KBR serially in 15 AH patients with severe coagulopathy (hepaplastin test (HPT) < 40%), including seven patients who developed FH, to see if we could predict FH by using KBR as a marker. Seven patients with KBR < 0.6 of long duration (4 days or more) were complicated with hepatic encephalopathy (HE) and it took 3 or more days of KBR below 0.6 before HE appeared. The other eight patients with KBR < 0.6 of short duration (less than 4 days) were not complicated with HE. These data suggest that AH patients with HPT < 40% and a 3-day duration of KBR < 0.6 are at serious risk of FH.


Delayed treatment of a malreduced distal femoral epiphyseal plate fracture.

Fractures of the epiphyseal plate are considered rare when compared with the more prevalent injuries found in competitive sports, but the complications associated with this type of trauma are a major concern. The factors affecting the success or failure of healing include the severity of injury, patient age, and the type and expedience of treatment. This case study examines the clinical presentation and treatment of a 15-yr-old high school football player who sustained a displaced, distal femoral epiphyseal Salter II fracture. Primary treatment consisted of nonmanipulative, nonweight bearing knee immobilization. The treatment resulted in malunion, pain, decreased range of motion and physical deformity; therefore, the patient sought a second opinion. On physical exam, the displacement and rotational deformity of the fracture site were unacceptable. The fracture was treated 20 days post-injury via open reduction with internal fixation. On follow-up, the athlete demonstrated radiographic healing, normal physical exam, and no significant leg length discrepancy or deformity. The athlete successfully returned to full competitive sport activity.


Case report: bilateral ankle pain in an aerobic dancer.

A 32-yr-old female presented to Sports Clinic with bilateral ankle pain and swelling following the initiation of an aerobic dance program 3 months earlier. Physical exam revealed bilateral ankle edema and the recent appearance of discrete tender nodules on her anterior tibias, consistent with erythema nodosum (EN). As part of her evaluation, chest radiographs were performed and demonstrated bilateral hilar adenopathy. This case discusses the evaluation of the patient with joint involvement, EN, and hilar adenopathy. The increased accessibility of sports medicine clinics makes it incumbent on the physician to be familiar with a wide range of differential diagnoses.


Hypertrophic cardiomyopathy in a college athlete.

The greatest catastrophy in sports is an athlete's unexpected sudden death. Identifying those athletes at risk remains a great challenge to physicians performing preseason examinations. Hypertrophic cardiomyopathy is the most common cause of nontraumatic sudden death in athletes. Most cases of this diseased heart are diagnosed easily by echocardiography. The case presented exemplifies the attention to detail required to differentiate the borderline diseased heart from the conditioned athletic heart. Once a diagnosis of hypertrophic cardiomyopathy is made, further participation in intense physical exercise is discouraged. This recommendation is necessary despite the unknown relative sudden death risk for the minimal criteria cases.


Effect of different modalities of exercise and recovery on exercise performance in subjects with sickle cell trait.

The sickle cell trait (HbAS) does not seem to affect exercise performance. It remains unclear, however, whether the capability to sustain repeated brief maximal effort and recovery by HbAS subjects, is also preserved. To study this, nine HbAS and nine matched controls underwent on two different occasions, a series of four, approximately 2-min duration, maximal cycle exercise tests separated by 20-min recovery periods of either absolute rest (P) or light pedaling (A) as well as an incremental test to exhaustion. In all tests, work performed, heart rate, blood hematocrit, lactate, and serum creatine kinase (CK), lactate dehydrogenase (LDH), and aspartate aminotransferase (GOT) were measured. Performances were similar in HbAS and HbAA subjects in both the predominantly anaerobic and aerobic exercise series. There were no observable differences in work, power, or heart rate in the two groups both during peak exercise or recovery periods. A significant hemoconcentration was observed during P, with hematocrit increasing in HbAS from 46.4 +/- 0.7% to 48.3 +/- 0.4% at the end of the last recovery period. Similar changes were seen in HbAA. Significantly greater fluid losses were found during A (1.3 +/- 0.2 l in A and 0.6 +/- 0.1 l in P for HbAS; P < 0.001), but fluid losses were similar in each type of recovery in the two groups. Despite similar performance, significantly lower blood lactate concentrations were consistently found in HbAS in each of the three exercise series (P < 0.001). Lower lactate levels in HbAS were observed only at exercise loads above the lactate threshold during the incremental test (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


Anaerobic exercise causes transient changes in leukocyte subsets and IL-2R expression.

There is evidence that the stress of intense athletic competition and training depresses cellular immunity and predisposes athletes to increased infection. This paper reports changes in circulating leukocyte subsets of trained (group I: VO2max = 67.2 +/- 5.4 ml.kg-1min-1; age = 22.0 +/- 6.2 yr) and untrained (group II: VO2max = 55.0 +/- 4.9 ml.kg-1min-1; age = 21.4 +/- 2.0 yr) males following 1 min of bicycle ergometry at maximum effort. Significant post-exercise increases in concentrations of total leukocytes, monocytes, lymphocytes, CD3+, CD4+, CD8+ lymphocytes were observed in both groups (all P < 0.01). The CD4/CD8 ratio decreased significantly (P < 0.01) but the granulocyte concentration was not altered (P > 0.05). Despite groups I and II not differing in either peak power or total work performed during the exercise test (P > 0.05), group II had a significantly greater concentration and percentage of CD8+ lymphocytes immediately after exercise (P < 0.01). All of the early changes were transient, with normalization occurring within 1 h. Only trained subjects showed a significant decrease in the percentage of CD25+ lymphocytes following PHA stimulation of whole blood obtained 6 h post-exercise. Alterations in leukocyte subpopulations found in response to predominantly anaerobic exercise appear to be associated with a significant, but possibly transient, alteration in the mitogenic responsiveness of lymphocytes that is restricted to aerobically trained subjects.


Effects of brief, heavy exertion on circulating lymphocyte subpopulations and proliferative response.

Ten healthy males (mean age 22.3 +/- 0.8 yr) pedaled with maximal effort for 30 s against a workload adjusted prior to the start of the test to 0.98 N.kg body mass-1. Blood samples were collected before, and 3 min and 1 h following exercise. Peak and average power mean values were 1020 +/- 51 and 738 +/- 34 W, respectively. Total leukocytes increased 40% in response to the exercise bout, but were 16% below pretest levels after 1 h of recovery (F = 123, P < 0.001). Neutrophils and lymphocytes represented approximately 60% and 30% of the leukocytosis, respectively. Lymphocytes increased 30% following exercise, but were 36% below pretest levels after 1 h recovery (F = 56.4, P < 0.001). The post-test lymphocytosis can be explained primarily from the 176% increase in natural killer cells (NK) and 28% increase in cytotoxic/suppressor T cells, while the 1-h recovery lymphopenia occurred because of a sharp decrease in total T cells and a moderate decrease in NK cells. No significant changes in lymphocyte proliferative response or serum immunoglobulin levels were found when appropriate adjustments for changes in plasma volume or lymphocyte subset changes were made. Plasma epinephrine increased 300% in response to the exercise bout, and best explains the measured changes in circulating levels of lymphocyte subsets. These results demonstrate that changes in circulating levels of leukocyte and lymphocyte subsets, especially NK cells, occur rapidly in response to 30 s of brief, heavy exertion.


Growth hormone, IGF-I, and testosterone responses to resistive exercise.

It has been suggested that growth hormone (GH), testosterone (T), and insulin-like growth factor I (IGF-I) play large roles in muscle tissue growth; however, in only two investigations IGF-I responses to resistive exercise have been examined. Eight young males who had not weight trained for a minimum of 5 months participated in the study. Three sets of bench press (BP), lat-pull (LP), leg extension (LE), and leg curl (LC) exercises were performed at a 10-RM load for 10 repetitions or until failure. Blood samples were collected from an IV catheter before exercise (-30 min and -10 min), after each individual exercise (BP, LP, LE, LC), and after the exercise session (+5, +15, +25, +35, +95 min; +5:35, +22:30, and +23:30 h). GH, IGF-I, and T determinations were corrected for plasma volume change. GH significantly increased (P < 0.05), but IGF-I did not change. Correction for plasma volume accounted for significant increases in T, but did not account for GH and IGF-I results. These data suggest that moderate resistive exercise may increase GH concentrations, whereas elevated T levels can be accounted for by exercise-induced alteration of plasma volume.


Plasma amino acid concentrations in the overtraining syndrome: possible effects on the immune system.

Overtraining and long-term exercise are associated with an impairment of immune function. We provide evidence in support of the hypothesis that the supply of glutamine, a key fuel for cells of the immune system, is impaired in these conditions and that this may contribute to immunosuppression. Plasma glutamine concentration was decreased in overtrained athletes and after long-term exercise (marathon race) and was increased after short-term, high intensity exercise (sprinting). Branched chain amino acid supplementation during long-term exercise was shown to prevent this decrease in the plasma glutamine level. Overtraining was without effect on the rate of T-lymphocyte proliferation in vitro or on the plasma levels of interleukin-1 and -6, suggesting that immune function is not impaired in this condition. Given the proposed importance of glutamine for cells of the immune system, it is concluded that the decrease in plasma glutamine concentration in overtraining and following long-term exercise, and not an intrinsic defect in T lymphocyte function, may contribute to the immune deficiency reported in these conditions.


Pulmonary function changes following exercise.

Many studies have documented differing changes in forced vital capacity (FVC) following various intensities and durations of exercise. This investigation used three different intensities and durations of treadmill running, with subjects who were active runners, with the intent of finding an intensity or duration that might elicit changes in FVC and if these changes are related to respiratory muscle fatigue. Intensities and durations included a graded maximal test to exhaustion (7-14 min); a 7-min test at 90% of maximal VO2, and a 30-min test at 60% of maximal VO2 (intensity). Maximal inspiratory pressures (MIP), maximal expiratory pressures (MEP), forced expiratory volume in 1 s (FEV1.0) and FVC were measured pretest, and 5, 10, and 30 min post-test (time). MIP was not different across time or intensities. The decrease in MEP approached significance at 10-min post-exercise compared to pretest values (P = 0.0569), with no differences found between intensities. FVC was different between times (P = 0.0117) but not between intensities. FVC was decreased at 5 and 10 min post-test compared with pre and 30 min. FEV1.0 was significantly reduced at 5 and 10 min post-test compared with pretest. These data suggest that a combination of duration and intensity may be necessary to elicit pulmonary function changes after exercise and that expiratory muscle fatigue may be a factor that results in a reduced FVC.


Dynamic and steady-state ventilatory and gas exchange responses to arm exercise.

Previous studies have suggested that, for the same power output, arm exercise requires higher oxygen uptake (VO2), carbon dioxide output (VCO2), and ventilation (VE) than leg exercise and that response kinetics are slower. To evaluate these differences, four healthy subjects performed a total of 95 arm cranking tests. Each subject performed several tests at each of three or four power outputs spaced evenly below the maximum the subject could sustain (average = 53 W). Breath-by-breath responses to identical stimuli were averaged. End-exercise blood lactate was determined at each power output. Responses were compared to leg exercise responses in these subjects (J. Appl. Physiol. 67:547-555, 1989). For power outputs unassociated with lactic acidosis, differences between steady-state VO2, VCO2, and VE responses for arm and leg exercise were not significant. At higher power outputs, the higher VO2, VCO2, and VE during arm exercise were well correlated with higher lactate. For power outputs not engendering lactic acidosis, the time constants (tau) for VO2, VCO2 and VE were not greatly different for arm than for leg exercise. For each variable, at higher power outputs tau became longer by an amount correlated with higher lactate level. Like leg exercise, the slower kinetics of VO2 and VE (but not VCO2) at higher power outputs were well described as a superimposed slower component. We conclude that both dynamic and steady-state responses of VE and gas exchange to arm exercise do not differ substantially from those to leg exercise so long as the power output does not elevate blood lactate.


Viscoelastic stress relaxation in human skeletal muscle.

Viscoelastic stress relaxation refers to the decrease in tensile stress over time that occurs when a body under tensile stress is held at a fixed length. The purpose of this study was to demonstrate viscoelastic stress relaxation in human skeletal muscle. Resistance to stretch (tensile force), hip flexion range of motion (ROM), and reflex contractile activity (IEMG) of the hamstring muscle group were measured during a passive straight leg raise. The testing protocol involved a first stretch to the maximum tolerated ROM with the lower extremity held at that point for 45 s (test 1). All 15 subjects tested (9 men, 6 women) had a stretch induced EMG response. The onset of a sustained EMG response occurred at a specific hip flexion angle in 10 subjects. These 10 subjects (6 men, 4 women) underwent a second straight leg raise stretch (test 2) to a ROM 5 degrees below the ROM at which the onset of EMG activity occurred in test 1. The stretch was held at this hip flexion angle for 45 s. There was a significant decrease in force at final ROM during the 45 s in test 1 (11.35 +/- 1.75 N, P < 0.0001) and in test 2 (4.2 +/- 1.55 N, P < 0.05). The percent decrease from the force at the respective final ROM was not significantly different between the tests (14.4 +/- 2.2% in test 1 and 13 +/- 2.3% in test 2). In test 1 there was a significant decrease over time in IEMG of 59.71 +/- 16.01 microV.s (P < 0.01) which was not significantly correlated to the decrease in force.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of pelvic position and stretching method on hamstring muscle flexibility.

Hamstring muscle strain represents a significant injury to the athlete participating in sporting activities. Lack of hamstring flexibility has been correlated to hamstring muscle injury. There is, however, conflict concerning the most efficient hamstring stretching technique. The purpose of this study was to compare static stretch (SS) and proprioceptive neuromuscular facilitation (PNF) hamstring stretching techniques while maintaining the pelvis in two testing positions: anterior pelvic tilt (APT) or posterior pelvic tilt (PPT). Two groups of 10 subjects were randomly assigned to either an APT or PPT position. Each subject then performed eight sessions using PNF on one leg and SS on the other leg while maintaining the pelvis in the assigned position. Hamstring flexibility was assessed with the hip positioned at 90 degrees while actively extending the knee, i.e., active knee extension test (AKET). A two-way ANOVA comparing stretching technique and pelvic position revealed that the APT group significantly increased hamstring flexibility (P = 0.0375). There was not a significant difference between SS or PNF stretching technique in the APT position. There was not a significant increase in hamstring flexibility in the PPT group with either stretching technique (P > 0.05). The results suggest that APT position was more important than stretching method for increasing hamstring muscle flexibility.


Heel movement within a court shoe.

Lateral movements of the leg and foot were filmed from behind to evaluate court shoes. Inversion/eversion may be an indicator of potential injuries, but estimates of actual inversion/eversion have typically been measured as the angular displacement of marker pairs on the lower leg and on the shoe. The purpose of this study was to measure the shoe movement versus the heel movement inside the shoe in order to determine the appropriateness of using shoe markers to represent the heel position. Two windows were cut into the heel counter of the shoe to show the heel position in addition to shoe position. The subjects were filmed from behind during a lateral side-stepping movement. The difference between the shoe and heel position was [corrected] statistically significant. The average maximum change in heel inversion inside the shoe was 13.3 +/- 3.8 degrees, compared with 30.7 +/- 6.2 degrees for the shoe. In addition, the maximum change in heel inversion in a barefoot movement was 10.1 +/- 3.1 degrees. The results suggest that for a lateral movement shoe markers do not accurately represent the position of the heel, and heel movement inside a shoe is similar to a barefoot movement. Skin markers on the heel as observed through windows in the shoe give a better indication of the actual position of the calcaneus than do markers placed directly on the shoe.


Estimates of mechanical work and energy transfers: demonstration of a rigid body power model of the recovery leg in gait.

Many studies concerning the mechanical work and efficiency of human motion have used models based on segmental energy. It has been shown theoretically that such work estimates may be in error due to offsetting compensations in power sources underlying the energy profiles. Further, mechanical energy transfers calculated from these energy models have been interpreted as metabolic energy-saving mechanisms. This paper examines the use of mechanical power analysis to calculate work and energy transfer estimates, using the motion of the recovery leg in walking and running for one subject as a demonstrative example. Work and energy transfer estimates from both energy and power models are compared and contrasted. The energy model underestimates the work of the recovery leg in both walking (54% of power model estimate) and running (38%), due to muscle powers at joints opposing each other in energy generation and absorption. Energy transfers calculated with energy models are shown to suffer the same problem of offsetting power sources. In contrast, the power model identifies four energy transfer mechanisms (pendulum, whip, tendon, and joint force transfers), which contribute to energy change within the leg in varying amounts. For the recovery leg, the joint force and whip transfer mechanisms have the greatest magnitude, while the pendulum and tendon transfers are much smaller. These energy transfers can be observed on a time-varying basis throughout a motion sequence and illustrate differences in energy distribution between walking and running. These power-based transfers are discussed in terms of their nature regarding metabolic energy cost and mechanical energy distribution within a multisegmented system. It is suggested that the work and energy transfers calculated from the power analysis are more accurate than those calculated from mechanical energy models and are more useful for understanding performance.


Environmental effects of genotoxins (eco-genotoxicology).

Genotoxic chemicals can damage the genetic material of humans as well as that of organisms living in the environment. With respect to adverse effects, alterations induced in the germ line, leading to alterations in the genetic make-up of populations, are of primary concern in ecosystems, because somatic changes, even if they lead to a loss of individuals, will not be critical in populations with a large reproductive surplus. This is different in human toxicology where genetic alterations in germ cells as well as in somatic cells of any individual are of concern. Increased frequencies of mutations and related genetic alterations in the gene pools of individual species or populations in ecosystems have to be judged against the background of spontaneous mutations that have enabled species to survive and adapt in changing environments since the beginning of life on our planet, and which have played an important role as the substrate for evolutionary developments. Examples of the selection of altered phenotypes (and genotypes) in response to environmental pollution and environmental stress are melanism in moth populations, metal resistance in plants, insecticide resistance in insects and malaria resistance in humans. Pollution, in general, can represent a stress factor selectively leading to a change in genetic make-up. In addition, environmental genotoxins can directly alter gene pools. A change in the genetic constitution may be advantageous for certain populations living in stressful conditions, but may present a disadvantage for others, including man.(ABSTRACT TRUNCATED AT 250 WORDS)


Comparison of 32P-postlabelling and cytogenetic analysis of human blood treated in vitro with melphalan.

Various 32P-postlabelling methods have been evaluated for the detection of melphalan-DNA (mel-DNA) adducts in melphalan treated calf thymus DNA and human blood treated in vitro with melphalan. When the butanol extraction procedure was used for the postlabelling studies, increasing adduct levels were seen between 0.01 and 1.0 micrograms/ml melphalan (maximum adduct value = 3.29/10(8) nucleotides at 1.5 micrograms/ml melphalan). The labelling efficiency, however, was thought to be low. Human blood treated in vitro with a dose range of melphalan from 0.01 to 1.5 micrograms/ml was analysed for micronuclei, sister chromatid exchanges, chromosome aberrations and DNA adducts. A correlation was seen between mel-DNA adducts and cytogenetic damage for each of the endpoints studied.


Relationships between in vitro mutagenicity assays.

This paper analyzes the mutagenicity results reported by the US National Toxicology Program (NTP), relative to 41 chemicals assayed with four in vitro short-term tests [Salmonella typhimurium (STY), Chromosomal aberrations in Chinese hamster ovary (CHO) cells (CHA), Sister chromatid exchange in CHO cells (SCE), mutation in L5178Y mouse lymphoma cells (MLY)] and puts this database in perspective with respect to other databases. It is shown that the test relationships pointed out by the experiments on the 41 chemicals are in substantial agreement with those indicated by a previous NTP report on 73 chemicals, and that the same test relationships were also indicated by the results on the International Program for the Evaluation of Short-Term Tests for Carcinogens (IPESTTC). The NTP and IPESTTC databases consistently indicated that there is a gradual increase in the sensitivity to the genotoxins in the following order: STY < CHA < SCE < MLY. On this scale, SCE and MLY show a great degree of similarity of responses to the chemicals, as does STY with CHA. The overall evidence provided by these results, and by the general pattern of IPESTTC and NTP genotoxicity profiles, does not support the notion that the genotoxic chemicals have genetic end point specificity. Moreover, a mathematical simulation analysis demonstrated that MLY and SCE--the two most sensitive assays of those studied by NTP--are not more subject to erratic results than other assays, and that they form--together with STY and CHA--a consistent family of genotoxicity assays.


Metsovo-tremolite asbestos fibres: in vitro effects on mutation, chromosome aberration, cell transformation and intercellular communication.

Samples of Metsovo-tremolite asbestos, previously found to be the causative agent of endemic pleural calcification and an increased level of malignant pleural mesothelioma in a rural area of north-western Greece (Metsovo area), were tested in various in vitro toxicity test systems. It was found that asbestos fibres of this type were strong inducers of micronuclei and numerical chromosomal abnormalities while they induced low levels of chromosomal aberrations in mammalian cells in culture. Furthermore, this type of asbestos can induce a low level of in vitro transformation of Syrian hamster embryo cells. The fibres had no effect on gap-junctional cell-cell communication (followed by the dye-transfer method) and did not induce any mutations in the Salmonella typhimurium strain TA102 which is known to be sensitive to the action of various oxidative agents. These results support the hypothesis generated from studies on other types of asbestos that such fibres induce tumours by causing chromosomal mutations.


Chlorophyllin is both a positive and negative modifier of mutagenicity.

The mechanism responsible for the modification of mutagenicity by chlorophyllin has been investigated using mutagenic compounds with different mechanisms of action, including the monofunctional alkylating agents, N-methyl-N'-nitrosourea (MNU) and ethylmethanesulphonate (EMS); nitrosamines related to tobacco products, i.e. dimethyl-nitrosamine (DMN), N-nitrosonornicotine (NNN) and 4-(N-methyl-N-nitrosoamino)-1-(3-pyridinyl)-2-butanone (NNK); the polycyclic aromatic hydrocarbon (PAH) benzo[a]pyrene (B[a]P) and two of its metabolites, i.e. (-)-7 beta,8 alpha-dihydroxy-7,8-dihydrobenzo[a]pyrene (7,8-diol) and (+)-7 beta,8 alpha-dihydroxy-9 alpha,10 alpha-oxy-7,8,9,10- tetrahydrobenzo[a]pyrene (BPDE); and a complex mutagenic mixture, an extract and subfractions of Swedish moist oral snuff (SMOS). Mutagenicity was monitored with the Ames Salmonella/microsome assays (STY) and hprt V79 point mutation assay (V79). The effects of chlorophyllin on the mutagenicity of the nitrosamines in the STY assays were found to be complex. In the presence of either NNN or NNK, low concentrations of chlorophyllin actually potentiated the mutagenicity > 2-fold. However, at higher, but still non-toxic concentrations, chlorophyllin decreased the mutagenicity of both compounds. The same type of dose-response relationship for chlorophyllin was indicated in the V79 assay system with DMN, although the effect was much weaker. The results with STY were further confirmed by replacing chlorophyllin with another porphyrin compound, hemin. In contrast, biliverdin, a porphyrin structure without the central metal ion, was unable to potentiate the mutagenicity of NNK in STY.(ABSTRACT TRUNCATED AT 250 WORDS)


Computerized electrocardiogram diagnosis: fuzzy approach.

This paper investigates the computerized analysis of electrocardiographic signals. The biological variability, the lack of standards in the definition of measurements and of diagnostic criteria make the classification problem a complex task. Two basic methods of the diagnostic process are described: the statistical model and the deterministic approach. In particular, a model for ECG classification will be illustrated where the imprecise knowledge of the state of cardiac system and the vague definition of the pathological classes are taken care of by means of the fuzzy set formalism.


On the detection of the number of signals in multi-lead ECGs.

New methods which have been developed in the field of signal processing to detect the number of intrinsic source signals in a set of multiple signals have been studied in their application to the analysis of multilead ECGs (body surface maps). All these methods are based on the analysis of the eigenvalues of the covariance matrix related to the observed data. By using artificial multilead ECGs in which the properties of the signal and noise parts were known, the effect of taking into account these properties was investigated. It was found that the method based on information-theoretic criteria was superior in detecting the number of signal components, in the case that the noise in the data is non-white, as compared to a simple threshold method.


The performance of information-theoretic criteria in detecting the number of independent signals in multi-lead ECGs.

Three different methods to detect the number of independent signals in multilead ECGs were evaluated by using different ECG realizations with known specifications for signal and noise: a threshold method (TM), the minimum description length (MDL) and Akaike's information criterion (AIC). The fundamental assumption in this kind of signal processing is that both the signal and the noise stem from independent stochastic generators. The consequence is that the detection of the number of signals is only possible if the noise is white, or if the noise properties have been specified. The evaluation was performed with respect to the QRS complex of individual multilead ECG simulations and to the entire ensemble. In the simulated ECGs the number of independent signals was fixed (eight). It was found that, out of the three methods studied, the performance of MDL was the best, especially when the number of available observations in the noise (used to estimate the noise specifications) was moderate.


Simple computer-assisted diagnosis of acute myocardial infarction in patients with acute thoracic pain.

In order to minimize the initial diagnostic uncertainty in patients suspected of having acute myocardial infarction, we prospectively extracted predictive variables from previous history, ECG, and clinical chemical parameters of 87 patients, who were admitted for acute thoracic pain. The variables thus extracted were: Thoracic pain in previous history, duration of pain, white blood cell count, blood glucose, creatine-kinase, and S-T elevation in the ECG. These parameters were used for formulating a mathematical model based upon univariate and multivariate statistical methods. The sensitivity of the model in the study population was 95% and the specificity 77%. Correct classification was achieved in 89% of cases. In a second phase, the prognostic index was prospectively evaluated in a second set of 122 consecutive patients. In this test population, the sensitivity was 89% and the specificity 86%. 87% of patients were classified correctly.


Structured reporting of medical findings: evaluation of a system in gastroenterology.

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.


Study and applications of an informational measure of dependence in survival models.

In survival models, when the factor of interest is a continuous variable or is expressed through a group of several variables, the classical measures of risk, i.e. relative risk and odds ratio, are not appropriate and there is no standard measure of dependence between survival and the considered factor. The Information Gain has been proposed by Linfoot (1957) and Kent (1983), giving any parametric model as a generalization of the squared product-moment correlation coefficient of the linear regression model with normal errors. By using simulation methods, we studied the statistical properties of the information gain as a measure of dependence, in the particular case of survival regression models. We suggest several efficient applications of this informational concept to some classical problems of regression analysis and prognostic analysis. Our ideas are illustrated through an example on the prognosis of idiopathic dilated cardiomyopathy.


LIED--liver: information, education and diagnosis.

In this paper we describe LIED (Liver: Information, Education and Diagnosis), a diagnostic expert system devoted to medical education in the field of hepatology. LIED combines the facilities of a traditional expert system for clinical diagnosis with several modules designed for educational purposes. The goal of such modules is to train physicians, in particular as regards the improvement of their problem solving ability (at the end of their curricula students in medicine usually lack experience in organizing an efficient and accurate diagnostic process). Training on real and simulated cases has been widely recognized as a proper approach to clinical experience. The architecture of the diagnostic system is introduced, which forms the core of LIED, and which has been derived from our previous experience, and the various educational functions are discussed that were developed on top of the basic architecture.


Health program effectiveness measurement: a case of degenerative disease.

An administrator of a Health Program aiming at the control of a specified disease has a need for a quantitative evaluation of the consequences of the Program's realization. On the population level, Lifetime Lost (LTL) figures calculated for both target and reference populations might be used for this purpose. The LTL methodology provides a user with a new procedure for medical data processing. It allows to estimate the LTL values from mortality data only, without the laborious procedure of registration of the morbidity episodes in target and reference populations. This approach is valid for a special case of degenerative diseases.


Graphic summaries of expert knowledge for the medical curriculum: an experiment in second-year nephrology.

This study was conducted to test the effects of Concept Graphics on learning in clinical nephrology. Second-year medical students were exposed to summaries of the major renal pathologies presented as text with, or without Concept Graphics for 30 minutes, followed by a quiz. Concept Graphics summarize diagnoses using icons that are metaphors of objects or processes. Of nine quiz questions, five were classified as correlation questions and four as memorization questions. The experimental group (n = 39) performed better than the controls (n = 33) in answering the correlation questions (p = 0.018). The experimental group mentioned more frequently than the controls two pathogonomic criteria of the nephritic syndrome (p = 0.02). Results of an opinion poll of the students, comparing sources used in their studies of nephrology were treated by correspondence analysis; the Concept Graphics ranked closest to the classification "very useful".


The menopause, urinary incontinence and other symptoms of the genito-urinary tract.

In a study on incontinence and other symptoms of the genito-urinary tract in postmenopausal women covering their prevalence, consequences and predisposing factors, the prevalence of incontinence was found to be 26.4%. Daily incontinence was present in postmenopausal women more than twice as often as before the menopause (P < 0.05). The frequency of medical consultation for such incontinence was low; only 26.1% of the postmenopausal women had ever seen their doctor about it. Urgency, nocturia and dyspareunia were more prevalent in postmenopausal women, while vaginal itching and discharge were more frequent in premenopausal women (P < 0.05). The prevalence of incontinence and the other genito-urinary symptoms was higher after surgical than after natural menopause. Multivariate analysis showed the menopause to be the only factor that contributed significantly to the onset of incontinence (P < 0.001).


Low-dose oestradiol in the treatment of urogenital oestrogen deficiency--a pharmacokinetic and pharmacodynamic study.

Twenty-four postmenopausal women with vaginal atrophy due to oestrogen deficiency were treated with 17 beta-oestradiol administered as vaginal tablets containing 10 and 25 micrograms, respectively, in a slow-release system (Vagifem, Novo Nordisk, Denmark). All the women were treated for 2 weeks with each dose in a double-blind, cross-over study. Plasma concentrations of unconjugated oestradiol and unconjugated oestrone were measured at regular intervals for 24 h on days 1 and 14 of each treatment regimen. Cytological and clinical evaluations of the vaginal and urethral epithelium were also carried out. Initially, when the epithelium was still atrophic, dose-dependent absorption of oestradiol was demonstrated. After 14 days of treatment maturation of the vaginal epithelium was seen with both regimens and the absorption of oestradiol then declined significantly on both the 10 and the 25 micrograms dose. Oestrone levels remained unchanged and gonadotrophin levels were unaffected during treatment. Vaginal cytology showed maturation on both the 10 and the 25 micrograms dose, whereas urethral cytology showed a reduction in parabasal cells that was significant only on 25 micrograms. Clinical and subjective improvement was apparent on both doses and acceptance of treatment was good.


Estrogens, progestins and breast cancer risk in post-menopausal women: state of the ongoing controversy in 1992.

During the past 10 years an extensive literature has been generated concerning the risks and benefits of hormonal replacement therapy in post-menopausal women. Although some of the questions have been answered during this period, controversy about the risk of breast cancer continues. This paper attempts to evaluate the risk of breast cancer in the light of epidemiological, experimental and histological findings. An interpretation of the available data and practical therapeutic recommendations are given. It is concluded that no change in the currently recommended schedule of combined sequential estrogen progestin therapy is necessary at this stage.


Reproductive and general lifestyle determinants of age at menopause.

Determinants of age at menopause were evaluated using data of control subjects collected in the framework of a case-control study on breast and female genital tract neoplasms. After exclusion of women with surgical or pharmacological menopause, a total of 863 post-menopausal women aged 55-74 years admitted to a network of general and university hospitals for non-neoplastic, non-gynecological, non-endocrine-related acute conditions were considered for this analysis. No relationship emerged between cohort of birth, marital status and mean age at menopause. No association was observed with education, but women with 12 years of schooling or more reported a slightly later mean age at menopause (50.2 years vs. 49.3 for < 7 years of schooling). There was a strong, statistically significant association with smoking, mean age at menopause being more than 1 year earlier in ever-smokers than in never-smokers. Nulliparous women tended to report an earlier age at menopause (49.0 years) than parous ones (49.5) and mean age at menopause rose with number of births, being 49.8 in women reporting three or more births. This trend was of borderline statistical significance. No association emerged between age at menopause and number of spontaneous abortions, lifelong menstrual pattern and age at menopause. The significant association between smoking, parity and age at menopause observed in the univariate analysis was confirmed after taking into account the potential confounding effects of age and education in multivariate analysis.


Can we improve compliance with long-term HRT?

In order to increase awareness of strategies to prevent osteoporosis and heart disease we designed a clinic offering education and screening to all women aged 40-60 years on our practice list of 8600 patients, starting in January 1988. Screening and supervision of HRT users occurred at a weekly clinic run by the doctor and nurse. Audit in August 1991 showed that there were 260 present users of HRT (20%) of our population of 1322 women aged 40-60 years. Seventy-eight percent had taken HRT for over a year and 15% for more than 5 years. Ex-users totalled 117, of whom 52% had taken HRT for over a year and 14% for over 5 years. Examination of the clinic registers and responses to postal questionnaires showed that 681 (51.5%) of patients attended the health education clinic. Of the clinic attenders, 25% took HRT compared with 10.8% of non-attenders. Compliance with long-term therapy measured by audit of repeat prescriptions varied between 84% and 92% over a period of 5 years. Reasons for stopping treatment were anxiety over possible side-effects, especially breast cancer and dislike of bleeding.


Nutritional and physiological factors affecting germination of heterothallic Saccharomyces cerevisiae ascospores.

Saccharomyces cerevisiae strain AP-3 was examined with respect to those nutritional requirements and physiological conditions which influence its germination rate. It was found that glucose as a carbon source supported the most rapid rate of germination for this heterothallic strain. In contrast, strain AP-3 spore germination was supported the least by the carbon sources potassium acetate and lactose. Of the nitrogen sources tested in culture medium containing glucose, the complex nitrogen sources peptone and casein hydrolysate appeared to be capable of stimulating germination better than a control culture containing ammonium sulphate. None of the amino acids screened were found to stimulate strain AP-3 germination compared with ammonium sulphate. The optimal culture medium pH for ascospore germination was 4.5 although spore germination could still be initiated by glucose between pH 3.0 and pH 7.5. Germination initiation by glucose was observed over a temperature range from 25 degrees C to 50 degrees C, but the optimal temperature appeared to be 40 degrees C.


Extracellular dextranase from Streptococcus oralis.

A human dental plaque organism, Streptococcus oralis (S. mitior), was cultivated in a dextran-free, dialysed medium, and dextranase activity was isolated from the cell-free, culture supernatant. The lyophilized, crude enzyme preparation, optimum pH 6, was subjected sequentially to anion exchange and gel filtration fast protein liquid chromatography (FPLC). The dextranolytic fraction from gel filtration FPLC produced a symmetrical, baseline resolved peak. The dextranolytic enzyme was purified 1,126-fold with a yield of 2.4%. Amino acid analysis revealed a large proportion of alanine and an abundance of acidic amino acids. This extracellular enzyme isolated from S. oralis is constitutive and has a relative molecular mass of 45 kD. Further investigation of the possible structural and biochemical effects of endogenous bacterial glucanases in human dental plaques is necessary.


Sensitivity of Pseudomonas stutzeri to EDTA: effects of growth parameters and test conditions.

EDTA is highly toxic for Pseudomonas stutzeri. The bactericidal effect is not significantly attenuated by treatment of the cells at 0 degrees C rather than 25 degrees C, nor by osmotic stabilisation of the treated cells. The few surviving cells are not genetically resistant, but resistance to EDTA (and to some cationic antibiotics) can be induced by growing organisms in magnesium-limited media. Under these conditions, there is increased production of a protein of molecular mass about 20 kD. Comparable results have been reported for Pseudomonas aeruginosa. The mode of action of EDTA on these pseudomonads is discussed.


[Local infiltration thrombolysis of arterial occlusions with tissue plasminogen activator].

Only few reports deal with local low dose thrombolysis of peripheral arterial occlusions by the infiltration technique with recombinant human tissue plasminogen activator (rTPA). We report the treatment of 45 cases (38 patients, 13 times women and 32 times men, aged 33 to 86 years). The patients suffered from thrombotic occlusions of the femoropopliteal artery (n = 39), a femoro-popliteal PTFE bypass (n = 3), a femorocrural bypass graft (n = 2) or a popliteal embolus (n = 1). The thrombus was infiltrated with 2.5 mg rTPA/hour attenuated to 30 ml normal saline solution. In the mean 7.1 mg rTPA was given. The rate of recanalisation was 76% during the days the patient stayed in hospital. The rate of recanalisation was higher (88%) in 16 cases suffering from acute arterial occlusion (< 24 hours). Even in those cases with undetectable or absent peripheral arterial runoff, therapeutic success was achieved at 92%.


[Correlation studies of the validity of hemodynamic measuring techniques in peripheral arterial occlusive diseases].

With the aim of validating the methodology employed for Fontaine's classification, haemodynamic correlation investigations were carried out on a group of 35 patients suffering from stage I to IV peripheral arterial occlusive disease and in six healthy patients. These investigations showed that the measurement of tcPO2 at +44 degrees C, capillaroscopy in the foot, measurement of the arterial blood pressure in the ankle by Doppler ultrasound, and measurement of peak flow in the lower limb using venous plethysmography are suitable for distinguishing normal from abnormal blood flow states. A comparison of the various methods made it clear that determination of Fontaine's stages is best achieved by a combination of arterial systolic blood pressure measurement at the ankle with Doppler ultrasound and vital capillaroscopy in the foot. Used alone, vital capillaroscopy, tcPO2 measurement and plethysmography all failed to differentiate Fontaine's stages with adequate reliability.


[How are tumor markers used in diagnosis and in after-care of gastrointestinal cancers? Results of a nation-wide German survey].

To obtain appropriate information about the present use of tumor-associated antigens (TAA) in diagnosis and follow-up of gastrointestinal carcinomas, an inquiry into 102 German university and non-university hospitals was performed. 97 answers to ten standardized questions were available for evaluation. TAA are generally used in gastrointestinal carcinomas by 98.5% and 92.6% of internists (i) and surgeons (s), respectively. Preoperatively, serum concentrations of TAA are determined in 63.9% (i) and 84% (s) of gastric carcinomas. The corresponding rates in colorectal carcinomas are 93.8% and 92.6%. TAA are a routine part of postoperative care in 68.8% (i) and 76% (s) of gastric and in 100% (i) and 96.2% (s) of colorectal cancers. Interest is almost exclusively focused on CEA and CA 19-9. Other tumor associated antigens are rarely investigated in these diseases. Increasing serum concentrations of TAA induce intensive diagnostic procedures in 82.4% and 95.7% of internists and surgeons. However, an indication for a second-look operation solely based on increasing TAA concentrations is only seen by 30.6% of internists and 37% of surgeons. In gastric cancer the course of TAA concentrations is used for determining the effects of chemo- or radiotherapy in 36.4% (i) and 71.4% (s). The corresponding rates for colorectal carcinomas vary between 66.6% (i) and 80% (s). The results of this nation-wide inquiry confirm the wide use of CEA and CA 19-9 in gastrointestinal carcinomas. There are obvious differences with respect to diagnostic or therapeutic consequences based on postoperatively increasing serum levels of TAA.(ABSTRACT TRUNCATED AT 250 WORDS)


[Memento intestinal tuberculosis].

We report the history, symptoms and diagnostic procedures of eight patients (four female, four male; mean age 44.5 years) with abdominal tuberculosis. In all cases differential diagnosis was complicated by an inadequate interpretation of chest X-rays. Only two patients were immigrants. Chemotherapy of tuberculosis was successful in seven patients, one 65-year old female with miliary tuberculosis and ileus died.


Measles surveillance--United States, 1991.

A total of 9,643 measles cases was reported from the United States in 1991, a 65.3% decrease from the 27,786 cases reported in 1990. The overall incidence of measles was 3.9 cases per 100,000 population. The highest age-specific incidence was among children < 12 months of age (46.9/100,000) and 1-4 years of age (19.6/100,000). Incidence rates among American Indians, Hispanic, and black children < 5 years of age were 19, 6, and 4 times that for non-Hispanic white children, respectively. More than 61% of all cases were reported from seven large outbreaks, which involved predominantly unvaccinated preschool-age children in large urban areas. Although reported measles cases decreased in 1991 compared with 1989-1990, only a sustained effort to provide age-appropriate vaccination will prevent another resurgence of measles.


Years of potential life lost before age 65, by race, Hispanic origin, and sex--United States, 1986-1988.

A substantial proportion of mortality among young persons is preventable. National vital statistics were used to establish a baseline for the surveillance of rates of years of potential life lost before age 65 (YPLL < 65) in the United States. Rates of YPLL < 65 were calculated for 1986 through 1988 for leading causes of preventable death, by race, Hispanic origin, and sex. U.S. racial and ethnic populations differed widely in YPLL < 65. Among males, the rate (per 1,000 population < 65 years) of YPLL < 65 was highest for non-Hispanic blacks (140.0), followed by American Indians/Alaskan Natives (100.9), Hispanics (74.3), non-Hispanic whites (68.3), and Asians/Pacific Islanders (38.2). Among females, the rate was highest for non-Hispanic blacks (73.7), followed by American Indians/Alaskan Natives (52.0), non-Hispanic whites (35.7), Hispanics (32.9), and Asians/Pacific Islanders (23.2). For non-Hispanic blacks, the high rate of YPLL < 65 was due to increased rates for all causes of death considered, particularly homicide. The high rate for American Indians/Alaskan Natives was due principally to deaths from four causes: unintentional injuries, cirrhosis, suicide, and diabetes. Asians/Pacific Islanders had low rates for most causes of death. In setting health-care priorities and prevention strategies to reduce the large racial-ethnic gap in early deaths, it is essential to recognize the differences in causes of premature mortality among sex, racial, and ethnic populations. Periodic reassessment of YPLL < 65 among these groups provides a simple, timely, and representative means of conducting surveillance to measure the impact of intervention strategies on a national basis.


Group B streptococcal disease in the United States, 1990: report from a multistate active surveillance system.

Group B streptococcal (GBS) disease is the most common cause of neonatal sepsis and meningitis in the United States. It is also an important cause of morbidity among pregnant women and adults with underlying medical conditions. Because most states have not designated GBS disease as a reportable condition, previous estimates of the incidence of GBS disease were based on studies from single hospitals or small geographic areas. This report summarizes the results of population-based active surveillance for invasive GBS disease in counties within four states that had an aggregate population of 10.1 million persons in 1990. A case of GBS disease was defined as isolation of group B streptococcus from a normally sterile anatomic site in a resident of one of the surveillance areas. Age- and race-adjusted projections to the U.S. population suggest that > 15,000 cases and > 1,300 deaths due to GBS disease occur each year. The projected age- and race-adjusted national incidence is 1.8/1,000 live births for neonatal GBS disease and 4.0/100,000 population per year for adult GBS disease. Intrapartum chemoprophylaxis for pregnant women at risk for delivering infants with GBS disease is the most effective strategy available for prevention of neonatal disease. Development of effective GBS vaccines may prevent GBS disease in both infants and adults. Ongoing surveillance for GBS disease is important for targeting preventive measures and determining their effectiveness.


[Early and late results of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty].

The indication of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for coronary artery disease, especially for multivessel disease, remains controversial. We examined the characteristics and outcomes of the CABG group (799 consecutive patients) and the PTCA group (944 patients) from 1984 to 1991. The proportion of 3-vessel and left main disease in the CABG group was 77% and that of single-vessel in the PTCA group was 92%. The characteristics between 2 groups were distinct. But the results were good respectively. The occurrence of hospital death was similar (1.3% vs 0%). The early graft patency rate in the CABG group was 91% and primary success rate in the PTCA group was 90%. And over a 5-year follow-up the cumulative survival rate of 3-vessel disease undergoing CABG and single-vessel disease patients undergoing PTCA was 96% versus 98%, respectively. It is concluded that PTCA is suitable for single-vessel and 2-vessel without totally occluded artery disease patients, whereas CABG for other multivessel disease patients.


[Comparative study of CABG following PTCA and PTCA following CABG].

Forty-five cases of PTCA with prior CABG and 14 cases of CABG with prior PTCA were studied on their pathogenesis and results. Ninety-four PTCA procedures were performed electively after CABG on 45 patients and 145 lesions. Lesion success rates were 95.8% in stenosis and 55.6% in occluded vessel. The mortality was none and no emergent surgery was needed. Causes of PTCA following CABG included the progression of coronary artery disease (13.1%), graft stenosis (15.0%), graft occlusion (31.0%), incomplete revascularization (13.8%), restenosis after the initial procedure (26.2%). Especially percentage of the progression of coronary artery disease was increased with a lapse of time, and it was 31.7% in PTCA group over 3 years after CABG. Fourteen patients with prior PTCA were received CABG because of unsuccessful PTCA (50.0%), progression to LMCD (21.4%), restenosis (21.4%), and PTCA complication (7.1%). Both interventions were appropriate and useful to reduce the recurrent ischemia and cardiac events with each other. Myocardial revascularization should not be considered either PTCA or CABG, but PTCA and CABG. In conclusion the strategy that much more benefits can be obtained from supplementary use of PTCA and CABG makes it possible to reduce the mortality and morbidity associated with intervention.


[Initial and follow-up results of PTCA and PTMC].

On the bases of the initial and follow-up results of patients who underwent percutaneous transluminal coronary angioplasty (PTCA) and percutaneous transvenous mitral commissurotomy (PTMC), the proper applications of these interventional therapies were discussed. The efficacy of PTMC on valvotomy was comparable to open mitral commissurotomy and the procedural safety was noticed. Our results supported the use of PTMC for patients with plicable mitral valve. Despite the good and acceptable results of elective PTCA, low initial success rate and high incidence of major cardiac events including mortality was noted in the group of urgent PTCA for patients with multivessel lesions. The urgent use of PTCA for refractory unstable angina should be restricted to selected patients without high-risk multivessel lesions.


[Comparison of long-term outcome of closed mitral commissurotomy (CMC) versus open mitral commissurotomy (OMC) and mitral valve replacement (MVR)].

To predict the late result of percutaneous mitral balloon valvotomy (PMV), we studied long term outcome of CMC which is similar to PMV in terms of closed heart technic, comparing with those of OMC and MVR. 226 patients with mitral stenosis were studied. 117 patients had CMC, 72 had OMC and 37 had MVR. The cumulative follow up period in these groups were 1892 patient year, 632 patient year and 200 patient year respectively. Postoperative actual survival rate at 5, 10, 15 years in CMC patients were 95 +/- 2%, 91 +/- 3%, 86 +/- 3% respectively. No operative or late death was seen in OMC or MVR patients. Postoperative event free rate at 10 years in OMC or MVR patients (97 +/- 2%, 90 +/- 6%, respectively) were higher than that in CMC patients (79 +/- 4%). Thromboembolism developed in 7 (6%) CMC patients, and 4 of these patients died from cerebral embolism. No patient in OMC or MVR group had thromboembolism. Reoperation was done for mitral restenosis or regurgitation in 40 CMC patients. 15 (38%) of these patients were associated with pulmonary hypertension, and 22 (55%) patients had secondary tricuspid regurgitation. On the other hand, only 1 OMC patient and 1 MVR patient had reoperation due to restenosis or thrombosed artificial valve. These results suggest that PMV should be indicated for restricted cases of mitral stenosis.


[Percutaneous transvenous, mitral commissurotomy versus open mitral commissurotomy].

Effects of PTMC (percutaneous transvenous mitral commissurotomy) were evaluated retrospectively in 34 patients with mitral stenosis and compared with those of OMC (open mitral commissurotomy) in 28 patients. PTMC resulted in a decrease in transmitral pressure gradient from 11 +/- 6 to 6 +/- 4 mmHg (p < 0.001) and an increase in cardiac index from (2.4 +/- 0.4 to 2.7 +/- 0.5 L/min.m2 and mitral valve area from 1.0 +/- 0.3 to 1.7 +/- 0.4 cm2 (p < 0.001). Mitral valve area remained increased (1.6 +/- 0.4 cm2) after a mean follow-up period of 19 +/- 11 months. Death, cerebro-vascular accident, or sever mitral regurgitation (> III degrees) did not occur. NYHA class improved from 2.28 +/- 0.63 to 1.44 +/- 0.50 (p < 0.001). OMC resulted in a greater increase in mitral valve area (from 1.1 +/- 1.4 to 2.0 +/- 0.5 cm2, p < 0.001) and greater improvement of NYHA class (2.25 +/- 0.65 to 1.11 +/- 0.34, p < 0.001). Thus OMC surpasses PTMC in hemodynamic effects and symptomatic improvement. However, PTMC may still be the first choice for the treatment of mitral stenosis because of its excellent safety and efficacy.


[Surgical versus nonsurgical therapy of fatal tachyarrhythmias].

Interventional treatment is necessary for fatal drug-refractory tachyarrhythmias. Thirty-three, 33 and 16 patients (pts) with intractable ventricular tachycardia (VT) and/or fibrillation (VF) were managed with cryosurgery (CS), electrical catheter ablation (EA) and implantable pacer-cardioverter-defibrillator (PCD), respectively. Seventy-six and 43 pts with sudden death risk in the Wolff-Parkinson-White syndrome (WPW) also underwent CS and EA, respectively. CS success rates were 85% in VT/VF and 95% in WPW. Those of EA were 48% and 81%, respectively. EA success rates were 100% (6/6) in idiopathic verapamil-sensitive VT originated from LV, 0% (0/2) in VT following TOF repair and 0% (0/2) in idiopathic VT originated from right ventricular outflow tract. A new VT developed in 5 of 11 pts with arrhythmogenic right ventricular dysplasia (ARVD) following EA. PCD was effective for prevention from sudden death in idiopathic VF and pleomorphic VT. All of pharmacologic, EA and CS therapies were relatively effective in ischemic heart disease without low EF. In conclusion, the decision of VT-VF therapy may be affected by the underlying heart disease and EA may be established as an initial intervention for high risk WPW.


[Current treatment of Wolff-Parkinson-White syndrome and ventricular tachycardia: surgical ablation versus catheter ablation?].

From November 1973, 454 patients with Wolff-Parkinson-White syndrome underwent surgical ablation of accessory pathways. Overall curative rate was 94% in our series including 65 cases of simultaneous surgical repair for combined heart diseases. In recent months, radiofrequency catheter ablation was applied in 7 cases. There has been 2 failures, which have taken more than 2 hours of radiation exposure and have required surgery. There has been 47 patients who underwent surgical ablation for non-ischemic ventricular tachycardia. Forty cases (85%) had a successful outcome of surgical ablation and another 2 cases required DC catheter ablation postoperatively to eliminate ventricular tachycardias. In conclusion, radiofrequency ablation of WPW syndrome in patients without combined heart disease or multiple accessory pathways is feasible. Surgical ablation is effective and safe technique compared with catheter ablation in patients with ventricular tachycardia.


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

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


[The controversy on the treatment of aortic dissection].

It is obvious that there are many controversies regarding to the treatment of aortic dissection. In this report, we discuss following points such as 1) classification, 2) thrombosed type dissection, and 3) simultaneous graft replacement of ascending and aortic arch with the reconstruction of cervical branches. From the patho-morphological status, dissection will be classified into two types, localized and extended types. From the anatomical and surgical points of view, it will be also classified as 1) ascending-arch, 2) descending-thoracoabdominal, and 3) abdominal. With the combination of these two, dissection will be classified more clearly. The thrombosed type will be incorporated into localized type. We have experienced 76 cases of this dissection, and clinical features and outcome by medical treatment only are presented. The simultaneous reconstruction of ascending aorta and aortic arch for the dissection at ascending-arch type was undertaken in total of 35 patients. The surgical results as well as follow up data are presented and the benefit of this extended procedure is presented as well.


[Principle of treatment of intermittent claudication due to arteriosclerosis obliterans--reconstruction or conservative treatment].

Two hundred and one patients of arteriosclerosis obliterans (ASO) with intermittent claudication (IC) were studied. Improvement of IC, score of return to social life, change of life condition and prognosis were compared between the two groups of reconstructive and conservative treatment. Improvement of IC was seen in 88.0% of the patients in the group of reconstruction and only 30.4% in the conservative treatment group. In the reconstructive group, the score of return to social life improved from 2.10 to 1.31 and the score of life condition also improved from 2.71 to 1.66. However in the conservative treatment group these score showed no significant improvement. Moreover the long term mortality rate was lower in the treatment group of reconstruction. The arterial reconstruction for IC is significant for improving the quality of life and exerts a favorable effect on life prognosis.


[The fate of patients with intermittent claudication-comparison of surgical and non-surgical treatment].

The purpose of this study was to determine the operative indication for patients with intermittent claudication because of arteriosclerosis obliterans, and to compare the late result of the surgical treatment group (182 cases, 250 limbs) with that of the non-surgical treatment group (35 cases, 43 limbs). There were 3 operative deaths and 34 late deaths in the surgical group, and 14 late deaths in the non-surgical group. The number one cause of death was heart failure, including ischemic heart disease, in both groups. The 4-year cumulative patency rates were 91% in the aorto-iliac, 71% in the femoro-distal and 79% in the aorto-femoro-distal arterial reconstructions. Long term symptom free rates of the surgical group and the non-surgical group, except fatal case, were 83% and 44% in the aorto-iliac, 79% and 27% in the femoro-distal, 87% and 33% in the aorto-femoro-distal arterial regions, respectively. Late result of intermittent claudication in the surgical group was better than that in the non-surgical group. We concluded that intermittent claudication should be considered to be the indication for surgery, except for the cases with high risk diseases or malignant diseases.


[Indication and results of surgical treatment of intermittent claudication].

In order to clarify the propriety of surgical treatment for intermittent claudication caused by arteriosclerosis obliterans (ASO), indication for vascular reconstruction and efficacy of surgery on patient's quality of life were investigated. Bypass surgery or laser angioplasty (PTLA) was undertaken in 149 of 188 ASO patients. Because of high risk factors (renal failure, ischemic heart disease, cerebro-vascular disturbance or malignant tumor), 39 patients were treated conservatively. Intellectual dysfunction in aged patient was evaluated by Okabe's brief mental scale test. Coronary artery disease was revealed by coronary angiography performed next to routine dipyridamole-loaded ECG in 19 to 78 patients. CABG or PTCA was performed prior to peripheral vascular reconstruction in 3 patients with serious coronary disease. Extra-anatomical bypass or PTLA was indicated mainly in patients with coronary artery disease or intellectual dysfunction. The anatomical bypass and the extra-anatomical bypass were undertaken in 88 and 61 patients respectively. Graft occlusion was observed in 8 cases. Patency rate of the anatomical bypass was 96.6% and that of the extra-anatomical bypass was 91.8%, at 32 months of postoperative mean follow-up period. The operative mortality rate was 2.7%. There was no major amputation due to graft occlusion.


[Comparison of long-term patency rates of transluminal angioplasty and bypass grafting].

We have applied transluminal angioplasty (TAP) and bypass grafting (BG) to the lower-limb ischemia for ten years since 1982. We have treated 176 cases (194 limbs) by TAP and 250 cases (323 limbs) by BG. The TAP treated group was divided into two groups. The first was classified as a stenotic artery group (TAPs) and the other was as an obstructive artery group (TAPs). BG was also divided into two groups, the first belonged to a ringed graft (RPTFE) while the other was a bypass with a saphenous vein (BG sv). The registered patent rates for TAP and TAPs are 61.2%, 75.1% recorded after 5 years and 51.4%, 57.0% after 7 years, respectively. The patent registry rates for BG and RPTFE are evaluated as being 64.2%, 82%, after 5 years and 48.2%, 82% after 7 years, respectively. The results showed that the patent registry rate for BG is significantly better than that of the TAP but the results indicate similarities between TAPs and RPTFE. As a conclusion, we recommend the use of TAP for the stenotic lesion of the artery and RPTFE for obstructive lesion of arteries.


[Conservative treatment of acute deep vein thrombosis of lower extremities].

To evaluate conservative treatment for acute deep vein thrombosis (DVT) of lower extremities, 56 limbs of 53 patients (29 men and 24 women, age ranging 20 to 77 years, mean age of 50.1 years) were reviewed. Only three patients underwent thrombectomy of restricted iliac venous regions by Fogarty catheter within 24 hours of the onset and their symptoms were relieved immediately after operation with good follow-up condition. Forty-five limbs were treated conservatively. Among 45 limbs, 15 limbs were treated within 7 days of symptom's onset using heparin and urokinase for 6-10 days followed by oral anticoagulant. Forty-seven percent of the patients were freed from their symptoms within one year. However 30 limbs received conservative therapy after 7 days of the onset showed 23% recovery from their symptoms within one year and in extensive thrombosis recovery was only 14%. We concluded that conservative treatment for DVT was effective if it was started within 7 days of the onset, and thrombectomy of ilio-femoral regions might be more effective than conservative treatment under the same condition.


[The treatment of choice in deep vein thrombosis of the lower extremity].

Of 67 patients with acute deep vein thrombosis of the lower extremity (DVT), 43 patients were treated by venous thrombectomy and 24 patients were managed by conservative treatment. The clinical effect of thrombectomy was evaluated by analyzing follow-up results in the 2 groups. The cumulative incidences of pigmentation and stasis ulcer at the 5th year were 2.7% and 0% respectively in the thrombectomy group, and 24.3% and 10% respectively in the conservative treatment group. Pigmentation and stasis ulcer were significantly more frequent in the conservative treatment group (p < 0.01). It is concluded that venous thrombectomy is superior to conservative treatment to prevent late postthrombotic sequelae. Protein C, protein S and plasminogen were assayed in 40 DVT patients to determine the incidence of hypercoagulable state in DVT. Congenital deficiency or abnormality were found in 15 patients (37.5%). In such DVT patients with thrombophilia anticoagulant prophylaxis should be continued to decrease a risk of rethrombosis.


[Controversy in the treatment of superficial esophageal carcinoma--indications and problems of the procedures].

In our institution, 152 cases have been treated, which are 24.3% of total 626 cases with esophageal carcinomas. Analysis of these 152 cases revealed that neither intraepithelial cancer (ep), nor mm2 cancer, in which the lesion is limited within the upper two-thirds of the proper mucosal layer, had any vessels invasion and lymph node metastases. In addition, only 25% of the cases with mm3 cancer, limited within the deeper one-third of the proper mucosal layer, had vessels invasion without lymph node metastases. The 5-year survival of the cases less than sm1 was as good as 100%. However, those of sm2 and sm3 patients were 58.9% and 54.2%, respectively. Thus, we made the treatment strategy for superficial esophageal cancer as follows: 1. For ep to mm2 cases, endoscopic mucosal resection could be applied. 2. For the cases whose lesions widely spread in the esophagus, blunt resection would be indicated. 3. For the cases with mm3 to sm3 cancer, thoracotomy and laparotomy with wide lymph node dissection from neck to abdomen should be employed. Since a radical operation for esophageal cancer has high operative risk and poor postoperative quality of life, we should properly pick up and apply more cases with mucosal carcinoma for endoscopic mucosal resection.


[Evaluation of endoscopic mucosal resection (EMR) as a curative therapy against early gastric cancer].

This study investigated the effectiveness of EMR as a curative therapy against early gastric cancer, comparing with that of radical operation. In 256 radical operation cases, five year survival rates were 97.5% in m-cancer and 93.2% in sm-cancer. In these cases, postoperative complications occurred in 7.8%, with operative mortality being 0.78%. In 56 EMR cases, nine encountered slight bleeding, which was controlled by ethanol injection under endoscopy. Regarding prognosis of EMR, cancer recurrences occurred in 45.8% of cases with stump involvement in the resected mucosa (stump (+)). In cases without stump involvement in the resected mucosa (stump (-)), no recurrence were found except one case, in which distance from the cancer edge to the stump was only 0.6 mm, suggesting that enough distance (2mm) to the stump is required for curative EMR. Stump (-) rate was high (81.2%) in cases of small cancer less than 1 cm in diameter, but was low in cases of cancer greater than 2 cm and those located in upper body or lesser curvature. To establish EMR as a curative therapy, it must be performed by single collection to check remaining cancer. In conclusion, although radical operation is still the standard curative therapy, EMR should be considered as an alternative therapy.


[Controversy between endoscopic and surgical treatment against early gastric and colorectal cancer].

Although endoscopic treatment against the patients with early cancer in gastrointestinal tract is an excellent method especially in high aged or poor risk patients, there still exists controversy about the indication for endoscopic treatment because of deeper invasion of the cancer or lymph node metastases. In order to clarify whether the patient has a possibility of nodal involvement or not, we made the clinicopathological analysis concerning 220 cases with early gastric cancers and 118 cases with colorectal cancers. Our retrospective analysis shows that endoscopic resection can be indicated for small polypoid cancer less than 10 mm in size, excluding IIa + IIc type. As to small depressed type, this procedure should be applied for IIc type which is well differentiated adenocarcinoma without ulcer formation (U1 (-)). Regarding early colorectal cancer there has been many discussion how to treat the patients with sm-cancer. Based on our analysis of 39 cases with sm-cancer, we led to the conclusion that the characteristics of sm-cancer with lymph node metastases are i) massive invasion into submucosal layer, ii) positive lymphatic permeation, or iii) "de novo" cancer. As a result, a decision of further surgery should be made even in small lesions less than 10 mm, taking the fact into consideration of the possibility of nodal involvement of sm-cancer.


[Controversy on therapeutic modality to early colorectal carcinomas from the viewpoint of histopathological features].

We have investigated prognostic factors of early colorectal carcinoma mainly based on pathological aspects. We have experienced 175 lesions of early colorectal carcinomas, in which 116 lesions were obtained by operation and 59 lesions were endoscopically resected. Histologically, well differentiated adenocarcinoma was subclassified into two types, pure type and combined type. We expressed extent of submucosal invasion by sm depth and sm width. We represented specific pathological features in the invasive margin as single cell infiltration (SCI) and mucinous component (MUC), which were indicating biological invasiveness of submucosal invasive carcinomas. As a result of this research, we concluded that minimal submucosal invasion of early colorectal carcinoma should be defined as carcinoma having sm depth less than 1 mm and sm width less than 5 mm, on the contrary, sm massive invasion as sm depth above 1 mm or sm width above 5 mm. We guessed that SCI was good parameter of lymphatic invasion because of their correlation to other adverse prognostic factors. We make a policy that subsequent intestinal resection should be performed to early colorectal carcinomas, which having SCI or MUC concomitant with the degree of submucosal invasion more than our standard despite of absence of vascular permeation.


[Controversy--surgical vs. medical management of inflammatory bowel disease].

The controversy in the treatment of inflammatory bowel disease is how to decide surgical vs. medical management in each case. Of 309 patients with ulcerative colitis in our department, 63 (20%) patients had received surgical treatment. The mean age was 33.5 +/- 13.7 years old and the mean duration from onset to operation was 6.72 +/- 5.51 years. The indications for surgical treatment were 47 (75%) resistant cases against medical treatment, 9 (14%) severe cases and 7 (11%) cancer or dysplasia cases. In surgical cases compared with medical ones, the ratio of total duration (months)/number of admission showed below 10, and the total amount of used steroid was over 300 mg per month. These ratios were considered to be the useful markers for surgical indication. Operative procedures were 15 total proctocolectomy+ileostomy, 29 total colectomy+ileorectal anastomosis, 13 total proctocolectomy+ileoanal anastomosis and 6 others. Restorative proctocolectomy using double stapling method with two stage operation was chosen in 8 patients because of easier and safer operative procedure and a few complications. We conclude that early surgical treatment for the patients resistant against medical management is considered to improve the patients' quality of life.


[Surgical and non-surgical treatments of gallstones].

Comparisons were made of therapeutic modalities for gallstones. Four-hundred thirty-five patients with gallstones were operated on with the mortality rate of 0.7%. Extracorporeal shock-wave lithotripsy (ESWL) was performed in 84 patients with gallbladder stones. Complete stone disappearance rate at 1 year was 31% in patients with one to three radio-lucent stones not larger than 3cm in diameter and 57% in solitary stones up to 2cm with the US pattern of Ia or Ib. There was no major complication. Endoscopic sphincterotomy (EST) was performed in 131 patients with common bile duct stones. The success rate was for stone extraction, was 97%. Immediate complications occurred in 8% cases, yielding the mortality rate of 0.8%. Common bile duct stones recurred in 2 of 113 patients (3%). Acute cholecystitis was experienced in 2 of 43 patients with the gallbladder left in situ; 2 of 12 with and none of 31 without gallbladder stones. In conclusion, ESWL is a safe and effective treatment in selected patients. EST can be the first-choice modality in the treatment of not only the post-cholecystectomy cases but also the patients with the gallbladder without stones.


[Clinical significance of endoscopic sphincterotomy compared with surgical common bile duct exploration and surgical sphincterotomy].

Records of 940 patients with endoscopic sphincterotomy (ES) and 100 patients with choledochotomy for stone removal were compared. Those with ES were characterized by older mean age (65.9 vs. 60.6, p < 0.001), similar frequency of operative risks (36% vs. 45%), and a less complication rate (8.2% vs. 53%, p < 0.001) as compared with the surgery group. Complications of ES included cholangitis, pancreatitis, bleeding, and basket impaction. One patient each with cholangitis and pancreatitis died, thus a mortality rate of 0.2%. Complications of choledochotomy occurred in 53 patients with no death. Most of them were associated with anesthesia, laparotomy, wound and immobilization. The complications of ES should decrease due to recent development of lithotripsy instruments and endoscopic stenting to prevent cholangitis. Follow-up of 74 patients 15-21 years after surgical sphincterotomy revealed recurrent stones in 3.5%, which was lower than a recurrence rate of 10.3% in 290 patients 5-14 years after ES. However, that rate may be an underestimate, because the follow-up was obtained in only 79% of those with surgical sphincterotomy as compared with 99% of ES. Ninety percent of those with recurrence after ES underwent endoscopic treatments again, whereas 10% had surgery. Easy repetition at the time of recurrence is one of major advantages of the endoscopic treatment.


[Extracorporeal shock wave lithotripsy for choledocholithiasis].

By the advent of extracorporeal shock wave lithotripsy (ESWL), the plan to manage choledocholithiasis has changed greatly. As a non-operative treatment, endoscopic sphincterotomy (EST) is intensively performed, but ESWL is much safer than EST in invasiveness and complications. Without EST, 5 Fr endoscopic naso-biliary drainage (ENBD) and percutaneous transhepatic biliary drainage (PTBD) aiming at preservation of the function of the papilla Vater were inserted to make drainage first for the patients with choledocholithiasis with obstructive jaundice who visited our hospital. After the cholangitis subsided, ESWL was performed under the direct cholangiography through ENBD and PTBD and excellent results were obtained which are herein reported. ENBD has been performed on 98 cases of choledocholithiasis over the past 4 years. ESWL has been performed on 42 cases (ENBD 36 cases and PTBD 6 cases). Choledocholithiasis completely disappeared in 31 cases (73.8%). For unsuccessful cases, EST, percutaneous transhepatic cholangioscopy (PTCS), or laparotomy was performed.


[Evaluation of urgent treatment for impacted bile duct stones].

One hundred and forty-four urgent treatments for acute obstructive suppurative cholangitis (AOSC), acute obstructive cholangitis (AOC), or/and acute pancreatitis caused by impacted bile duct stones were performed for eight years from 1984 to 1991. The breakdown of these treatments are as follows. [table: see text] It was not easy to diagnose every severe case of AOSC. As a result, however, endoscopy was very effective both in diagnosis and treatment. Concerning patients with thinner bile duct, endoscopic drainage was useful than percutaneous drainage. We prefer ENBD to EST followed by basket extraction of bile duct stones in an emergency state. ENBD is a rather easy technique even for beginners of ERCP, and is less invasive. The life-saving effect of ENBD is not inferior to that of EST.


[Selection of treatment in primary hepatolithiasis (PHL)].

Two hundred and three patients with PHL were encountered for the last 10 years. In order to select treatment of PHL, we classified PHL on the basis of atrophy of hepatic parenchyma (AHP), existence of extrahepatic gallstone and dilatation of extrahepatic bile duct (DEBD). For the case with AHP hepatic resection must be performed, because there is often chronic proliferating cholangitis and improvement in hepatic function can not be expected in view of AHP. For the case with extrahepatic gallstone without AHP hepatic resection. For the case with DEBD and without AHP extrahepatic gallstone must be removed. For the patient with extrahepatic gallstone and DEBD without AHP, indication of the removal of stones, depends on the existence of symptoms. Twenty-two cases treated by biliary drainage procedure often had some complications in postoperative course, that is 5 patients had cholangitis and 7 patients liver abscess. It was suggested, therefore, that biliary drainage procedure was contraindicated in PHL.


[Balloon plasty for biliary strictures associated with choledochal cysts].

Balloon plasty with a Meditec balloon dilatation catheter was performed in thirteen patients who had choledochal cysts with intrahepatic biliary strictures. The age of the patients ranged from one to 28 years. Eleven were female, and two were male. The site of the biliary stricture was both the right and left hepatic duct in eight patients, the left hepatic duct in four, and the right hepatic duct in one. Balloon plasty was performed postoperatively through the fistula of the percutaneous transhepatic drainage tube in seven patients and during the operation in six. Dilatation was adequate in ten patients but insufficient in three. The preoperative imaging character of the biliary strictures in the successful cases was membranous stenosis of less than 2mm in length. In contrast, the strictures of the patients with insufficient dilatation were long stenoses of more than 5mm in length.


[Diagnosis and management of benign biliary strictures with percutaneous transhepatic cholangioscopy (PTCS)].

From January 1981 through March 1991, we encountered twenty four cases of benign biliary strictures. In 10 cases of anastomotic stricture, percutaneous dilatation was carried out in 1 patient under fluoroscopy and in 3 patients under PTCS without recurrence. Endoprosthesis with silicone or polyurethane catheters was carried out under PTCS in 5 patients. One of them died of hepatic failure due to clogging of the catheter, and in other four patients the endoprosthetic catheter was dislodged spontaneously or removed by PTCS because of dislodgement or obstruction of the catheter, and PTCS revealed that the anastomotic stricture had improved. Reoperation of cholangiojejunostomy was carried out in 1 patient, who died of hepatic failure 5 years later due to recurrent of stricture. In 8 cases of the iatrogenic and 1 case of traumatic stricture, percutaneous dilatation was carried out (1 under fluoroscopy and 4 under PTCS) without recurrence. Cholangiojejunostomy was carried out in 3 cases without anastomotic stricture. PTCS was performed for 5 cases of the inflammatory stricture of the hepatic hilus due to cholecystitis to confirm the histological findings by cholangioscopic biopsy. And all cases could be managed by cholecystectomy. Authors recommend that PTCS should be used for the diagnosis and treatment of benign biliary stricture.


[Management of biliary tract malformations in childhood--long-term survival and reoperation].

During the past 32 years, 67 of 145 cases of biliary tract malformations survived for 8-30 years as the result of various types of management from childhood. Controversies regarding management were analyzed. The majority of the patients with biliary tract malformation required radical operation initially. Regarding postoperative complications, however, non-surgical managements; PTCD, endoscopic lithotomy for remaining calculi, endoscopic injection sclerotherapy for esophageal varices or PSE (partial splenic embolization) for portal hypertension, are preferred. The optimal time to treat the patients; biliary atresia--within 2 mo. for Kasai operation, choledochal cyst depends on the patient's symptom-onset, but extrahepatic biliary tract perforations may occasionally occur in infants, then antenatal ultrasonography (US) is necessary. Five infants out of 8 patients with choledochal dilatation due to congenital duodenal obstruction and annular pancreas were successfully treated following duodenal surgery alone, however a 18 yr-old female with this lesion underwent biliary tract reconstruction because of irreversible biliary tract dilatation. The preferred management we recommend; 1) pre-or intraoperative diagnosis using US, cholangiography or intraoperative direct probe survey of the biliary or pancreatic duct, 2) accurate surgery with complete excision of the cyst or biliary stenosis plasty with adequate anastomosis, 3) a sustained long-term follow-up study utilizing US.


[Therapeutic modality for esophago-gastric varices analyzed by endoscopic ultrasonography].

For 64 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and esophagus by endoscopic ultrasonography (EUS). Variously developed intra- or extra-mural vascular structures had a relationship to the endoscopic variceal form, and the communicating (inflow) vessels to varices were found in 35 of 50 primary treated cases (70%). We classified the esophago-gastric varices into three types according to the vascular structure, such as the esophageal type, the esophago-gastric type and the solitary gastric type. From the analyses of these collateral structures, we should select a treatment as follows. In the esophageal type which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophago-gastric type, which has many enlarged inflow vessels, the Hassab operation is effective to devascularize extramural inflow vessels, and the combination of EIS is necessary to sclerous the intramural varices. In the solitary gastric type which is a part of the downward porto-systemic shunt, Hassab operation is recommended to prevent the rupture of varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without intramural running vessel.


[Significance of embolization therapy for esophagogastric varices].

To evaluate the efficacy of the embolization therapy (Emb) for varices, we performed endoscopic injection sclerotherapy (EIS) alone and EIS combined with Emb. Various embolizations such as percutaneous transhepatic obliteration, splenic artery embolization and left gastric artery embolization have been employed. The efficacy rates were 76.5% of the patients in the EIS alone and 87.5% in the EIS with Emb group (EIS+Emb). The cumulative percentages of rebleeding at one year and 3 years were 23.1%, 34.6% in EIS alone, and 10.7%, 25.0% in EIS+Emb respectively. Especially in the patients with the Child C, there was significant difference in the efficacy rates: 60.0% (EIS alone) versus 88.9% (EIS+Emb), and recurrence rates within one year: 41.7% (EIS alone) versus 12.5% (EIS+Emb) (p < 0.05) and length of treatment free periods: 9.7 months versus 17.5 months (p < 0.01). After the treatments, improvement of Child's criteria was seen to be better in EIS+Emb than in EIS alone. The similar results have been obtained in the patients with hepatocellular carcinoma and with gastric varices. These results suggest that EIS should be combined with Emb to increase durability and to improve general condition.


[Clinical evaluation of endoscopic injection sclerotherapy and esophageal transection].

We investigated the effects of EIS and esophageal transection on treatment of esophageal varices and the late result of EIS treatment group with that of surgical treatment group. One hundred and forty-seven patients underwent esophageal transection and 244 patients injection sclerotherapy in our institute. 1. The 5-year cumulative survival rate in patients with EIS was 58%, while 62% in those with transection. 2. Judging from the findings of varices after treatment which showed the negative red color sign, or changes from F2 or F3 to F1, the effect of two methods were 72% in operation group and 73% in EIS group, respectively. 3. There was no significant difference in the rates of rebleeding between EIS (7.8%) and operation (10.2%) groups. 4. Prognosis of esophageal varices treated with EIS or operation was considered to depend on the Child's classification. We conclude that endoscopic sclerotherapy should be considered to be the first choice of treatment for esophageal varices.


[Surgical versus non-surgical treatment in patients with esophageal varices--a prospective randomized study].

In Japan, non-shunting procedures and selective shunt such as esophageal transection (ET), and distal splenorenal shunt (DSRS) have been widely performed. A prospective randomized trial was done to assess the effects of EIS and DSRS for treating patients with esophageal varices. Ninety-six Japanese with good liver function (Child A or B) and large esophageal varices were randomly assigned to one of three groups given different treatments; (EIS, n = 32), (ET, n = 32) and (DSRS, n = 32). Five patients (15.6%) of the DSRS group has to be excluded from this study, because of severe chronic pancreatitis. No patient died within 30 days of the treatments. The 5-year cumulative bleeding rates were 0%, 4.3% and 12.1% in the EIS, ET and DSRS groups, respectively, with no statistical significances. In no case in the three groups did the death occur because of variceal bleeding. Nineteen patients died mainly due to the underlying liver disease; 5 in the EIS, 5 in the ET and 9 in the DSRS group. There was no statistically significant difference in the survival rates among the three groups. We conclude that EIS is a satisfactory alternative to ET or DSRS for the management of patients with large esophageal varices.


[Results of non-decompression surgery for esophago-gastric varices--postoperative disappearance, recurrence, rebleeding rate of varices, and cumulative survival rate].

A total of 508 patients had an non-decompression surgery for esophago-gastric varices in our department, from September 1979 to December 1991. These patients consisted of 387 cases of transthoracic esophageal transection with para-esophagogastric devascularization, 40 cases of transabdominal esophageal transection, and 81 cases of Hassab procedure. The original diseases were cirrhosis in 432 patients, IPH in 35, extrahepatic-portal occlusion in 24, primary biliary cirrhosis in 6, Budd-Chiari syndrome in 4, and others in 7. Operative mortality rate was 5.3%. By thoracic approach, esophageal varices completely disappeared. Postoperative cumulative variceal recurrence and bleeding rates at 10 years were 12% and 7%, although recurrence occurred more often than not in cases with hepatocellular carcinoma (HCC). Cumulative survival rates at 5, 10 years were 69%, 46% in liver cirrhosis without HCC. Present study confirmed that our non-decompression surgery is effective in controlling esophagogastric varices in long term of periods.


[The current role of devascularization and transection procedures in portal hypertension].

It is not clear which theory should be used in patients with bleeding esophageal varices that are not controlled by emergency endoscopic sclerotherapy. Definitive hemostasis is the key to successful therapy of variceal bleeding. Recurrence of haemorrhage in patients with portal hypertension is the most feared life threatening complication. Based on our management of 658 patients with esophageal varices and the availability of treatment options at our institution, the strategy of management of uncontrollable variceal haemorrhage by endoscopic sclerotherapy has evolved. Bleeding was controlled in 64 liver cirrhosis (100%) by devascularization and transection procedures and 50 patients (78%) survived to leave the hospital including 43 of 64 patients (67%) with Child grade C liver cirrhosis. Cumulative rebleeding rate at 10 years following emergency surgery was 3% (2/64). It is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. We suggest that emergency transection and devascularization is an effective salvage treatment for the endoscopic sclerotherapy failed group.


[Long-term results of terminal esophago-proximal gastrectomy for esophageal varices].

Between 1973 and 1991, 193 patients underwent terminal esophagoproximal gastrectomy (TEPG) for esophageal varices. One hundred and sixty patients (84%) were cirrhotics. Ten patients (5.2%) were died within hospital stay. In 116 elective patients who had been free from hepatocellular carcinoma during therapeutic courses, the 5- and 10-year survival rates were 77% and 62% in Child A, and 62% and 38% in Child B, respectively. There was a significant difference between the two groups (p < 0.05). Postoperative rebleeding from esophageal varices was infrequent within 5 years but increased after 5 years especially in Child B and Child C. For patients with these recurrent varices, endoscopic injection sclerotherapy was very effective and improved the prognosis. The survival rate of patients with extremely decreased platelet counts was not different from that of patients without. There were no other severe complications after TEPG. We conclude that TEPG would be indicated firstly for elective or prophylactic cases unless they have severe hepatic damage.


[Choice of left gastric vena caval shunt for esophageal varices--its rationale and clinical results].

We have surgically treated esophageal varices, particularly by left gastric vena caval shunt (LGCS) as the first choice in patients with good liver function (n = 40). The correlation between clinical outcomes and preoperative splanchnic hemodynamics, and therapeutical plans were evaluated: 1) Operative mortality was nil with recurrence rate of 15.0% and rebleeding noted in only one case. 2) The liver function according to Child's classification showed no significant changes before and after operation. Survival rate was more than 70% with good rehabilitation rate (over 90%). 3) The presence of hyperdynamic splanchnic circulation (left gastric venous flow and gastric wall microcirculation) lead to successful clinical results. 4) Combined use of sclerotherapy was efficacious in case of persistent and recurrent varices. We conclude that LGCS is successful in treating esophageal varices in the setting of hyperdynamic portal circulation with acceptable liver function.