[A survey of intestinal parasites of the foreign laborers (Indonesians and Filipinos) in Ishikawa Prefecture]. A survey of intestinal parasites was conducted on 198 foreign workers aged 19-27 from Inodonesia and Philippines. They work for a private company in Ishikawa Prefecture as technical trainee. On the base of stool examination, 94 (71%) out of 133 Indonesians and 48 (74%) of 65 Filipinos had intestinal helminths and/or protozoan infections. The prevalence of Ascaris lumbricoides, Trichuris trichura and Hookworm was 4.5, 64.1, 10.6%, respectively. In addition, the positive rate of the cyst of Entamoeba coli, Endolimax nana, Blastocystis hominis and Giardia lumblia was 11.1, 5.6, 4.5 and 2.0%, respectively. No E. histolytica was found; however, counter current immunoelectrophoresis revealed that one out of 112 sera possessed the antibody against the antigen of HK-9 strain of E. histolytica. Sixty-three cases of trichuriasis were treated with mebendazole at a dose of 200 mg/day x 3 consecutive days. Re-examination revealed that 53 (85.5%) of them were cured.


[Studies on tsutsugamushi diseases in Gifu Prefecture. 5. Characterization of monoclonal antibodies to prototype strains of Rickettsia tsutsugamushi and immunological grouping of newly isolated strains using the antibodies]. We characterized 8 monoclonal antibodies (MAbs) to Karp, Kato, and Gilliam strains of Rickettsia tsutsugamushi, and analysed 17 isolates from patients with Tsutsugamushi disease using these MAbs. These were divided into 3 strain-specific (Kp/D11, Kt/2D9, and Gi/E4) and 5 cross-reactive MAbs (Kp/1F11, Kp/1C10, Kp/C6, Kt/3B2, and Kt/3C2). All MAbs recognized characteristic protein antigens using the indirect fluorescent-antibody test (IFA) and proteinase K treatment. Analysis by polyacrylamide gel electrophoresis and immunoblotting techniques revealed that Kato-specific MAb Kt/2D9 recognized a polypeptide with a molecular mass of 54 kilodalton (kDa) of the homologous strain, and cross-reactive MAbs Kp/1F11, Kp/C6, and Kt/3B2 recognized those of 46-47 kDa, 46-47 KDa, and 60 kDa, respectively to the homologous and heterologous strains. MAbs Kp/1C10 which exhibited a high IFA titer against the Karp strain and only low titers against heterologous strains recognized only the 110 kDa polypeptide of the homologous strain. MAb Kt/3C2 which reacted with both Karp and Kato strains recognized a 54 to 56 kDa polypeptide band of the two prototype strains as well as several other polypeptides, however, each molecular mass was present in only one of two strains. Testing by the plaque reduction technique showed another characteristic of MAb Kt/3C2 to neutralize both Karp and Kato Strains. Fourteen isolated strains from patients in the south and west regions of Gifu Prefecture, the Shimokoshi stain isolated in Niigata Prefecture, and Kawasaki and Kuroki stains isolated in Miyazaki Prefecture were examined for reactivities to 8 MAbs by IFA to classify their antigenicities. No isolated strains reacted with Karp-specific Kp/D11, Kato-specific Kt/2D9, or Gilliam-specific Gi/E4.(ABSTRACT TRUNCATED AT 250 WORDS)


Drug-resistant Staphylococcus aureus contamination in the ward environment. A total of 282 strains of Staphylococcus were isolated from University Hospital ward environment from April 1991 to January 1992 and drug-susceptibility tests were performed. The main isolates were 84 strains of S. epidermidis (30%), 65 strains of S. aureus (23%), and 58 strains of S. haemolyticus (21%). One hundred and thirty-six strains of all staphylococci (48%) and 13 of 65 strains of S. aureus (20%) were methicillin (DMPPC)-resistant. The DMPPC-resistant strains of S. aureus were multiple drug-resistant to three to seven antibiotics; ampicillin. cephaloridine, cephametazole, tetracycline, erythromycin, gentamicin, and methicillin, while the DMPPC-susceptible strains were resistant to less than two drugs. These results indicate that this routine testing, along with testing of the anterior nares of the medical staff, is necessary to prevent nosocomial transmission.


[Etiology of pneumonia and host defense]. To investigate the relationship of efficacy of chemotherapy to host defense, we reviewed the clinical features, treatment and outcome in 648 patients with acute pneumonia (424 males and 224 females; mean age, 65 years) treated between 1984 and 1989. Pneumonia complicated pulmonary disease in 336 patients (52%) and complicated systemic disease in 258 (40%). Pneumonia pathogens were diagnosed in 346 patients (53%); the five major pathogens were S. pneumoniae (19%), H. influenzae (16%), S. aureus (14%), K. pneumoniae (14%) and P. aeruginosa (11%). The incidence of K. pneumoniae infection were decreased from 18% to 3.5% and that of S. aureus increased from 10.9% to 26.3% during the study period. The incidence of S. aureus and of P. aeruginosa infection was much higher in patients with nosocomial pneumonia, systemic disease, or serum protein concentration under 6.5 g/dl. beta-lactamase antibiotics were administered to 70% of all patients, with an efficacy rate of 74.9% of after the first course of antibiotics therapy. The efficacy rate was decreased in patients with nosocomial pneumonia, systemic or pulmonary disease, or malnutrition. The data presented in this study indicate that the risk of pneumonia must be taken into careful consideration in patients with compromising complications.


[Clinical evaluation of SD-8828 (antibody coated bacteria assay kit) in urinary tract infection]. Clinical usefulness of a newly developed assay kit for ACB (SD-8828) which detects urinary bacteria coating IgG was evaluated and compared to the enzyme antibody plate method. A total of 48 patients including 20 patients with acute simple cystitis and 28 patients with acute or chronic pyelonephritis, who were shown to have pyuria of at least 5 cells/HPF, bacteriuria of at least 10(4) CFU/ml were enrolled in this study. By enzyme antibody method. ABC was positive in 92.9% of patients with upper urinary tract infection and negative in 100% of patients with lower UTI, this difference being statistically significant (p < 0.02). By SD-8828, 85% of positive coincidence rate and 100% of negative coincidence rate, compared to the enzyme antibody technique, was obtained. The overall coincidence rate was high (91.7%). This SD-8828, a new simple assay for ACB, which detects IgG alternating the plate method, may be used as a convenient method in clinical practice.


[A case of miliary tuberculosis presenting as fever and jaundice with hepatic failure looking like the course of fulminant hepatitis]. A 79-year-old male was admitted to the Metropolitan Hiroo Hospital with chief complaints of icterus and fever. A few weeks prior to admission, he developed fever and swelling of right side of the neck and was seen at a local hospital where an anti-inflammatory agent was prescribed. The fever subsided in a few days, but recurred together with development of icterus a few weeks later, precipitating this hospitalization. After admission, hepatic failure progressed rapidly, indicating a fulminant hepatitis. Renal failure also developed and he died. Autopsy revealed diffuse caseous necrosis with demonstration of acid-fast bacilli in the liver, as did in the spleen, kidney and bone marrow. This case epitomizes a subset of miliary tuberculosis in which the hepatic failure predominates the clinical presentation while lacking the ante-mortem chest X-ray features suggestive of pulmonary tuberculosis and post-mortem macroscopic changes indicative of tuberculosis.


Ethics in dentistry.

Ethics in dentistry. In this article I would like to do two things: to discuss the foundations of ethical thinking in general, and to link this discussion to the particular concern of dentists. My argument is divided in three sections: Firstly, I shall attempt to define the term 'ethics' and briefly outline the context for the discussion of professional ethics. Secondly, I would like to draw attention to the categories and approaches in ethical thinking and also to the complexity of any adequate ethical reflection. In my third and final section I shall try to make a few suggestions in terms of how dentists could incorporate ethical thinking in their understanding of the dental profession.


The oral care of HIV positive patients at Berlin clinic. Two final year dental students spent an elective period in the HIV clinic of the Dental Hospital of the Freie University of Berlin. The oral manifestations and management of 50 HIV patients were observed.


Three years postgraduate programme in orthodontics: final report Erasmus project. A new curriculum with a common content of 75%, leaving 25% for electives has been developed for a three year programme for specialty education in Orthodontics. The result is a joint effort of the original eight participants and invited professors from Italy and Eire as well as from five non-EC countries (Austria, Finland, Norway, Sweden and Switzerland). Unaminity among the 15 participants was reached on all essential matters and on the contents of the final report. The main objective of the programme has been defined and the different courses have been formulated in terms of goals to be accomplished in three levels of comprehension and by the minimal hours students must devote to each subject. Furthermore, procedures that should be mastered have been specified.


[Mitral valve surgery for patients after undergoing percutaneous transvenous mitral commissurotomy (PTMC)--investigation on indication of PTMC based on the intraoperative findings]. Ten patients underwent open heart surgery for mitral valve after PTMC because of post PTMC MS (n = 4) and MR (n = 6) out of 150 patients undergoing PTMC in our hospital between June 1987 and October 1991. Intraoperative findings of 4 patients with residual mitral stenosis included severe thickening, stiffening and calcification on anterior and posterior leaflets, commissures and subvalvular apparatus. Mitral valve repair was possible in 2 and mitral valve replacement (MVR) was necessary in the other 2. In all 6 cases who massive mitral regurgitation after PTMC, in repairable tears in the mitral leaflets necessitated MVR. Since in these cases changes in the leaflets were less severe than those of the commissures or subvalvular apparatus, surgical repair could have been possible if open mitral commissurotomy (OMC) was done primarily. Patients selection for PTMC versus OMC based on precise morphological evaluation of mitral valve would reduce occurrence of massive MR resulting in surgical replacement.


[Left ventricular performance after patch reconstruction of the left ventricular wall for postinfarction left ventricular aneurysms]. Left ventricular performance in patients with a left ventricular aneurysm (LVA) treated with patch reconstruction is largely unknown. This study consisted of 15 patients, 14 men and 1 woman, with the average age of 59 +/- 8.5 years. The resected area of LVA was 40 +/- 27 cm2. The area of the woven Dacron patch used for reconstruction was 57 +/- 19% of the resected area including the sewing rim. The EF (Ejection Fraction, 1/3FF (Filling Fraction) and PFR (Peak Filling Rate) were calculated by 99mTc equilibrium cardiac pool scintigraphic images. The A/R ratio (peak velocity during atrial kick phase/peak velocity during the rapid filling phase) was measured using Doppler echocardiography, at the mitral orifice level. These parameters were determined before and 1 to 2 months after the operation. The time course was followed for A/R ratios. The preoperative resting global EF was 0.28 +/- 0.14 (0.44 +/- 0.13 for the contractile area) and the EF during exercise was 0.31 +/- 0.14. Resting and exercise EFs improved significantly (p < 0.01) to 0.40 +/- 0.11 and 0.43 +/- 0.10 postoperatively. The 1/3FF (%) and PFR (/sec) were low before operation (1/3FF, 11.3 +/- 8.3; PFR, 1.2 +/- 0.47). Postoperatively, the 1/3FF rose to 14.8 +/- 9.3 and the PFR showed a significant (p < 0.05) increase to 1.6 +/- 0.6. The A/R ratio significantly (p < 0.05) improved from preoperative 1.76 +/- 0.46 to 0.95 +/- 0.11 on the 3rd postoperative day. This improvement was maintained until the late postoperative period, with a value of 1.14 +/- 0.29 at month 16.(ABSTRACT TRUNCATED AT 250 WORDS)


[Effects of open-heart surgery on renal function in patients with chronic renal failure--is hemodialysis during cardiopulmonary bypass really required?]. In 300 consecutive adult patients who underwent open-heart surgery in our department, 16 patients (ischemic heart disease in 8 patients, valvular heart disease in 7 and congenital heart disease in 1) were preoperatively complicated with chronic renal failure (CRF); creatinine clearance (Ccr) < 40 ml/min and serum creatinine (Scr) > 1.6 mg/dl. The effects of open-heart surgery on renal function were studied in these CRF patients who were divided into the following 3 groups according to their preoperative Ccr values: Group 1 (6 patients), 30 < Ccr < 40 ml/min; Group 2 (5 patients), 20 < Ccr < 30 ml/min; and Group 3 (5 patients, 4 of whom were on dialysis preoperatively), Ccr < 10 ml/min. In addition, Group C (38 patients, Ccr > 50 ml/min) was set up as normal controls. Instead of hemodialysis, the extracorporeal ultrafiltration method (ECUM) was employed for all patients during the cardiopulmonary bypass (CPB). The Ccr in Group 1 showed the lowest value of 24.2 +/- 12.0 ml/min on postoperative day (POD) 0 which then recovered to the preoperative level on POD 1. This quick recovery of the Ccr in Group 1 was similar to that in Group C. In contrast, the Ccr in Group 2 showed the lowest value of 13.0 +/- 6.0 ml/min on POD 1, followed by a delayed recovery that did not reach the preoperative level until POD 5. The Ccr in Group 3 was quite low (< 5 ml/min) throughout the test period.(ABSTRACT TRUNCATED AT 250 WORDS)


[Surgical treatment of primary cardiac tumors]. Twenty patients with primary cardiac tumors were operated on during the past ten years. The age of 15 female and 5 male patients ranged from 17 to 73 years. Eighteen patients had myxomas, 16 of which located in the left atrium and 2 in the right atrium. Systemic embolism occurred in 8 patients, subsequently caused cerebral infarction in 4, ischemia of extremities in 2, myocardial infarction in 1 and pulmonary infarction in 1. Emergency operation was performed in 5 patients because of severe congestive heart failure. In all cases, removal of myxoma was performed together with the excision of the wall to which the pedicle attached with the use of cardiopulmonary bypass. One patient with pulmonary infarction underwent resection of the infarcted lung simultaneously. Only one patient with severe heart failure died of pulmonary insufficiency one month after the operation. Another patient with cerebral infarction underwent clipping of cerebral aneurysm which appeared later in the infarcted area. The 17 patients including the latter patient showed a good recovery and no local recurrence during the follow-up period of 1 to 120 months. Two patients had malignant tumors, which were malignant fibrous histiocytoma of the left atrium and leiomyosarcoma of the pulmonary artery, respectively. Both of these rare tumors were resected noncuratively and led to the death because of their local recurrence with distant metastasis, though they received adjuvant chemotherapy. The symptoms, complications, diagnoses, surgical treatment and outcome of the primary cardiac tumors are reviewed in this study.


[The effects of protease inhibitor upon the ischemia-reperfusion injury]. The purpose of the study is to investigate the effects of protease inhibitor (Nafamostat mesilate: NM) upon myocardial protection. Hearts were subjected to 20 min working control perfusion followed by 3 min cardioplegic infusion with the St. Thomas Cardioplegic Solution (ST) contained various concentrations of NM, and global ischemia for 33 min at 37 degrees C (Exp. 1) or 150 min at 20 degrees C (Exp. 2). Hearts were then converted to Langendorff reperfusion (the leakage of Creatine Kinase (CK) and Cathepsin B (Cat-B) ware measured) and 20 min working reperfusion. Various concentrations of NM added during Langendorff reperfusion (Exp. 3). During working perfusion cardiac functions (aortic flow (AoF), coronary flow (CoF), heart rate (HR), aortic pressure (AoP)) were measured, and expressed as the percent recovery of pre-ischemic control value. Post-ischemic recovery of AoF (%AoF) showed the bell-shaped dose-response curve, and the optimal dose was 3 microM (Exp. 1) and 10 microM (Exp. 2) respectively. There was a significant (p < 0.05) increase of %AoF in optimal dose compared with that in controls (64.2 +/- 1.2% vs 52.3 +/- 2.5% in Exp. 1, 68.9 +/- 3.1% vs 54.1 +/- 1.4% in Exp. 2). These increase of functional recovery reflected in the values for CK and Cat-B leakage. The addition of NM in ST reduced CK and Cat-B leakage significantly in the concentration of 5 microM (in Exp. 1) and 10 microM (in Exp. 2) respectively. But the addition of NM in reperfusate did not reduced CK leakage significantly.(ABSTRACT TRUNCATED AT 250 WORDS)


[Late postoperative outcome of plastic operation versus valve replacement for mitral regurgitation]. Between January 1980 and August 1991, 99 patients underwent operation for mitral valve regurgitation (MR). The ages of the patients ranged from 12 to 67 years, (49.4 +/- 11.9 years), and there were 39 males and 60 females. Pathological cause of regurgitation, which was determined by intraoperative inspection and histological findings of excised leaflets, was rheumatic in 46, degenerative in 38, infective endocarditis in 9, ischemic in 4 and unknown in 2 patients. Cardiac rhythm was atrial fibrillation in 73, normal sinus rhythm in 24 and junctional rhythm in 2 patients. Our principles for valve repair were (1) excision of responsible segment and repair for prolapsed leaflet due to torn chordae, (2) shortening of elongated chordae, (3) annuloplasty, and (4) repair of perforated leaflet. Finally, 19 patients endured plastic operation, and 80 patients underwent prosthetic valve replacement. The rate of plastic procedure was 62.5% (10/16) in degenerative MR with mural chordal lesions, 42.9% (3/7) in rheumatic MR without stenosis, 22.2% (2/9) in infective endocarditis and 100% (2/2) in MR with unknown etiology. Mitral valve repair was failed both in rheumatic MR associated with stenosis (39 patients) and in ischemic MR (4 patients). A ten-year survival rate after operation was 92.2 +/- 3.1% in patients with valve replacement and 83.6 +/- 10.0% with valve repair (N.S.), and a proportion of event-free survival in patients with valve replacement was similar to valve. Late postoperative cardiac catheterization revealed decreased left ventricular volume indices and increased left ventricular end-systolic stress/volume ratio in both groups compared to preoperative values, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)


[The evaluation of pre and intraoperative factors influencing the false lumen after graft replacement surgery to the extended dissecting aneurysm]. We evaluated the residual false lumen of type I and IIIb dissecting aneurysm by CT, MRI and angiography postoperatively. The 19 patients with type I dissecting aneurysm were included eleven men and eight women, the average age was 55.8 +/- 10.2 years old. The 20 patients with type IIIb dissecting aneurysm were included sixteen men and four women, the average age was 56.2 +/- 8.5 years old. The rate of distal patent false lumen was 52.6% of type I and 35% of type IIIb dissecting aneurysm after graft replacement surgery. In type I dissecting aneurysm, the rate of distal patent false lumen was 40% of acute stage vs 66.7% of chronic stage, 66.7% of ascending and partial arch replacement vs 46.2% of ascending and total arch replacement, and 90% of graft inclusion technique vs 11.1% of graft exclusion technique. The distal patent false lumen was the lowest (12.5%) with type I dissecting aneurysm of ascending and total arch replacement using graft exclusion technique. In type IIIb dissecting aneurysm, the rate of patent false lumen was 66.7% of acute stage vs 29.4% of chronic stage, 30% of graft exclusion technique vs 40% of graft inclusion technique. The size of false lumen preoperatively were larger (11.1 +/- 4.5 cm2) in patients with distal patent false lumen than that (6.7 +/- 3.2 cm2) of in patients with distal occlusive false lumen.(ABSTRACT TRUNCATED AT 250 WORDS)


[Coronary artery bypass surgery in patients with severely impaired left ventricular function]. The efficacy and problem of coronary artery bypass grafting (CABG) in patients with severely impaired left ventricular function (left ventricular ejection fraction < or = 30%) were assessed in 27 patients of whom 17 (group 1) underwent emergent CABG and 10 (group 2) elective between Jan 1984 to Aug 1990. As a whole, history of myocardial infarction (24/27, 88.9%), large left ventricular volume with reduced ejection fraction (LVEDVI 126.08 +/- 25.91 ml/m2, LVESVI 93.04 +/- 21.02 ml/m2, LVEF 25.04 +/- 4.75%) and multiple vessel disease with at least one vessel total occlusion (20/27, 74.1%) were characteristically seen in these patients. The patients of group 1 were significantly older (mean 66.12 +/- 5.68 vs 57.10 +/- 8.08, p < 0.01) and needed more frequent preoperative support with IABP (17/17 vs 4/10, p < 0.01). Using Thallium-201 scintigraphy, in 10 patients of group 1 and 9 of group 2, myocardial viability in the proposed bypass area was evaluated before operations. Average 2.37 +/- 0.79 grafts were placed and continuous retrograde cold blood cardioplegia via the coronary sinus was employed for myocardial protection. Two mitral annuloplasty (MAP) for ischemic mitral regurgitation and 2 cryoablation for the treatment of ventricular tachycardia were performed concomitantly. Operative mortality was 47.1% in group 1 and none in group 2 (p < 0.05). Two cases of MAP died, but two cases of cryoablation survived. Postoperative LVEF was improved significantly only in group 2 (p < 0.05), but during the follow-up period of 7 months to 6 years, all 19 survivors expect one remains with NYHA class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)


[Results of surgical repair by muscle flap closure for poststernotomy mediastinitis]. Between 1984 and 1991, 30 patients developed poststernotomy mediastinitis after cardiac or mediastinal operations. Sixteen of these patients were treated with debridement and open drainage or primary closure following mediastinal irrigation (drainage group). Fourteen patients were treated with debridement, and delayed or primary wound closure by the technique of pectoral or rectus abdominus muscle flap mobilization (muscle flap group). The purpose of this study was to compare the results of the different treatment of poststernotomy mediastinitis. Although the pre- and perioperative profile, complications and risk factors for mediastinal infection were the same, the mortality of muscle flap group was significantly lower than that of drainage group (Fisher exact probability test, p < 0.05). Pulmonary function of the patients who received muscle flap mobilization did not decrease from the function before surgery, despite the defect of sternal bony stabilization. We conclude that muscle flap mobilization may be a superior method as the treatment for poststernotomy mediastinitis after cardiac operations, and may not decrease respiratory function of the patients.


[A case of thymoma with thymic cyst].

[A case of thymoma with thymic cyst]. A 43-year-old man was pointed out an abnormal shadow on chest X-ray film. Chest CT showed a solid mass and a cyst at anterior superior mediastinum. Operation revealed a capsulated thymoma and a multilocular thymic cyst. PTH and CA19-9 level in the cystic fluid was elevated. Histological examination demonstrated the clear separation of the mixed type thymoma and the thymic cyst. There were few reports for cases of thymoma with a thymic cyst.


[A case of pulmonary rupture with primary pulmonary leiomyosarcoma--management by emergency surgical intervention]. We report a case of 18-year-old boy who was admitted to our hospital for hemoptysis and hemothorax caused by rupture in the pulmonary tissue. A tumoral mass was found protruding from the inferior aspect of the left lower lobe towards the diaphragma. A large hematoma was seen in the vicinity of the tumoral mass. An emergency left lower lobectomy was performed and the hematoma was removed. The tumor was yellow in color, soft and 7 cm in diameter. The histological diagnosis was that of primary pulmonary leiomyosarcoma. The resected lobe had a liver-like hard consistency due to extended infiltration of blood resulting from hemorrhages within the tissue located in and around the tumoral mass. Microscopically, the tumor was composed of the spindle-shaped cells with multinucleation along with some clear cell patterns. Recurrence of the tumor appeared six months after the operation, and a second resection of the recurrent leiomyosarcomatous tissue was performed. The patient is still alive for 1 year and 6 months after the first operation.


[Acute aortic dissection in a patient with Marfan's syndrome and severe pectus excavatum--emergency surgical repairs of ascending aortic dissection and aortic regurgitation complicated by pectus excavatum in Marfan's syndrome]. A case of acute aortic dissection Stanford Type A occurring in a patient with Marfan's syndrome, complicated with aortic regurgitation and severe pectus excavatum, is reported with successful surgical correction. The patient was a 33-year-old woman, who suffered from severe back pain riding to work. An emergency operation consisting of Cabrol's procedure for aortic dissection Stanford Type A and sternal turnover for pectus excavatum was performed simultaneously. Because of the postoperative mediastinal bleeding the implanted sterno-costal complex was removed on the second POD and the prosthetic sternum was reimplanted on the tenth POD. The two-stage operation seems preferable in such an emergency case to avoid postoperative bleeding and infection.


[Clinical experience of a percutaneous ventricular support for profound heart failure following acute myocardial infarction--a case report]. Percutaneous biventricular support with centrifugal pump was applied to a 59-year-old man with profound heart failure following acute myocardial infarction. Direct coronary angioplasty was performed under percutaneous cardiopulmonary support (PCPS). After angioplasty, he could not be weaned from PCPS under IABP. We used percutaneous left ventricular support (PLVS) with transseptal left atrial cannulation. PLVS could not maintain effective assist flow and he developed a cardiogenic shock again. PCPS was added to PLVS, and percutaneous biventricular support was started. Assist flow ranged 1.7-3.0 L/min in PLVS, and 1.7-2.0 L/min in PCPS, and total assist flow was 3.4 L/min. Pulsatile pressure was obtained by adding IABP. The patient was successfully weaned from PCPS in 26 hours and PLVS in 118 hours. Patient is alive and well one year after PLVS. Combination of PLVS and PCPS is an effective ventricular support system, being less invasive than conventional method with thoracotomy, and may be useful for profound heart failure.


[Coronary artery bypass surgery in a patient with hypopituitarism]. Patients with hypopituitarism are prone to perioperative complications resulting from adrenal insufficiency or hypothyroidism. Coronary artery bypass grafting was performed safely in a 53-year-old woman with postinfarction unstable angina and hypopituitarism. Cortisol and thyroid hormone were administered to maintain normal adrenal and thyroid function during and after the operation. Hydrocortisone was administered intravenously the day before surgery and for 2 weeks postoperatively and then was administered orally. Perioperative replacement thyroxine therapy was administered to avoid acute myocardial ischemia. Optimal thyroid replacement was achieved after surgery. No perioperative complications were seen. The patient remains free of angina with postoperative cortisol and thyroid hormone replacement therapy.


[A case of complete circumferential aortic rupture due to blunt chest trauma]. A case of complete circumferential rupture of the thoracic aorta due to blunt chest trauma is presented. A 46-year-old woman was admitted after a traffic accident. The admission chest X-ray film demonstrated rib fractures and mediastinal widening. CT scanning and aortography were performed, but acute rupture of the aorta was not detected. Twelve days later, aortography was performed again and an aneurysm was noted at the aortic isthmus. Surgery was performed immediately and aorta was found to be completely disrupted for a length of 1 cm. A short segmental prosthesis was interposed between the two ends of the aorta under temporary bypass. Patients with aortic rupture due to blunt chest trauma are increasing, but only a few cases treated in the acute stage have been reported. To our knowledge, this is the 6th case of complete aortic disruption which has been treated successfully in the acute stage in Japan.


[Development of constrictive pericarditis 20 years after closed mitral commissurotomy--a case report]. Pericardial constriction has emerged as an infrequent but well documented late complication of cardiac surgery. A rare case of constrictive pericarditis developed 20 years after closed mitral commissurotomy was observed. The patient had been treated for the poorly controlled ascites of unknown origin associated with crural edema and mild congestive liver cirrhosis. The long interval between the previous cardiac operation and the clinical manifestation of constriction made it difficult to establish the diagnosis. Extensive resection of the calcified pericardium through a median sternotomy with cardiopulmonary bypass standby relieved the ascites and crural edema.


[A case of ascending aortic dissection after aortic valve replacement in congenital bicuspid aortic valve]. Congenital bicuspid aortic valve is a risk factor of aortic dissection, but the case is rare in Japan. Several reports described ascending aortic aneurysm after aortic valve replacement. In these reports, most of aneurysms were false aneurysm, but the cases of ascending aortic dissection were rare. In this case, dissecting aneurysm of the ascending aorta occurred 4 years after aortic valve replacement, which was performed with mechanical prosthesis because of infective endocarditis, and it was repaired successfully by the modified Cabrol's method. This case was congenital bicuspid aortic valve, and had already been complicated with moderate aortic dilatation in the ascending aorta. In patients of congenital bicuspid aortic valve with aortic dilatation, consideration of complete replacement of the ascending aorta with aortic valve replacement is important.


[Recurrent thymic carcinoid tumor--report of a case and review of the literature]. A case is presented of a 48-year-old male patient with thymic carcinoid tumor who was operated on twice and followed for 12 years. The original tumor was removed in 1979, and a recurrent tumor was removed 4 years later. Multiple metastases to the lungs, pleura and lymph nodes of the neck were found in 1988; chemotherapy (BAPP) and radiation therapy were not effective, and there was subsequent subcutaneous invasion of the anterior chest. We also discuss the 153 cases of thymic carcinoid tumor reported in the Japanese literature in the Niigata Carcinoid Registry.


[A case of aortitis syndrome treated by simultaneous procedure of Bentall's operation and aortic arch replacement]. The case is a 22-year-old man, in whom chest X-P pointed out aortic and cardiac shadow enlargements. Aortography revealed extensive aortic aneurysm involving the ascending, arch, and proximal descending portions of the aorta, accompanied with annulo-aortic ectasia, aortic regurgitation, and stenosis of the left common carotid and left subclavian arteries, suggesting lesions due to aortitis syndrome. For this case, Bentall's operation and replacement of the aortic arch and the proximal descending aorta were performed simultaneously, using hypothermic selective cerebral perfusion. Favorable postoperative course and absent neurological abnormality enabled the patient to return to his former social work. Steroid therapy has been continued up to the present, 5 years postoperatively, with neither recurrence of inflammation nor occurrence of cardiac murmur.


[A successful operative case of congenital mitral stenosis associated with double outlet right ventricle, patent ductus arteriosus, persistent left superior vena cava and severe pulmonary hypertension in adult]. A 29-year-old woman, who was diagnosed as congenital mitral stenosis associated with DORV, PDA, PLSVC and severe pulmonary hypertension, was reported. The mitral valve, consisting of leaflet dysplasia, shortened and thickened chordae tendineae, obliteration of interchordal spaces, under-development of papillary muscle, and stenotic supravalvular membrane, was replaced with 25 SJM prosthesis. Simultaneously, patch closure of VSD and intrapulmonary direct closure of PDA was performed. Her postoperative course was uneventful and systolic pulmonary arterial pressure fell down from 95 mmHg to 56 mmHg. She is doing well after correction. To our knowledge, this is very rare corrective case with congenital mitral stenosis in adult to be reported in the literature in Japan.


[Cellular schwannoma of the lung].

[Cellular schwannoma of the lung]. A case of cellular schwannoma of the lung in 31 years-old Japanese male is presented in this paper. Cellular schwannoma differs from classic schwannoma in several histologic features. In addition, it has often been misdiagnosed as malignancy, though White's follow-up study confirmed its benign nature. It usually originates from the retroperitoneum and posterior mediastinum. No case originating from the lung has been reported in the world literature. Cellular schwannoma has to be added to differential diagnosis of the lung tumors.


[Thymic carcinoid tumor--report of 3 operative cases]. Three cases of thymic carcinoid were surgically treated in our hospital. All 3 cases belonged to stage IVb (Masaoka's classification) because of anterior lymph nodes metastasis. A 44-year-old male patient died of multiple metastasis of bone and liver in 94 months after the operation. A 45-year-old female patient who had undergone operation 4 years ago, was re-operated on for recurrent carcinoid tumor but complete resection of the tumor could not be performed because of the tumorous invasion to superior vena cava, pericardium and costal bone. After the operation she has been treated by radiotherapy and any re-growth of the tumor has never been detected for 1 year. Another 50-year-old male patient who had been operated and treated by chemo-radiotherapy for thymic carcinoid before 50 months was diagnosed as recurrent tumor at left interpectoral lymph node. Radiotherapy is now preparing for this patient. 160 cases of thymic carcinoid reports in Japan were reviewed. 37 cases were stage IVb and 36 cases had supraclavicular or mediastinal lymph nodes metastasis. Those cases which had been underwent complete resection followed by radiotherapy seemed to have better prognosis. We conclude that patients of thymic carcinoid should be treated with complete resection including supraclavicular and mediastinal lymph nodes dissection, followed by radiotherapy.


Alcohol can inhibit effect of IL-4 on activated murine B cells. Ethanol addition to B lymphocytes in vitro inhibits antigen-induced antibody secretion and antigen-induced cell proliferation. We tested the hypothesis that ethanol can inhibit the effect of interleukins on B-cell proliferation by adding ethanol to in vitro functional assays for IL-2 and IL-4. Ethanol does not inhibit IL-2-induced B-cell differentiation, but it does inhibit IL-4-induced B-cell proliferation and IL-4-induced Ig class switching.


Major histocompatibility complex-linked transport proteins and antigen processing. The major histocompatibility complexes of mice, rats and humans each contain a pair of related genes, Tap-1 and Tap-2, that encode members of a large superfamily of proteins having similar structure and function. The TAP-1 (previously called HAM1 in the mouse) and TAP-2 (HAM2) proteins each contain 6-8 predicted membrane-spanning alpha helices, and a cytoplasmic domain containing a putative ATP-binding site. Recent evidence suggests that a functional TAP-1/TAP-2 heterodimer is required for efficient presentation of antigens to CD8+ cytotoxic T cells. This heterodimer resides in the membrane of the endoplasmic reticulum (ER), and probably functions to transport peptides (produced in the cytoplasm) into the ER lumen for binding to MHC class I molecules.


Histocompatibility antigens and natural killer susceptibility. The central question of the nature of the structure(s) involved in the recognition of targets by natural killer (NK) cells remains unresolved. Although NK-mediated cytotoxicity is not MHC-restricted, it has been suggested that these cells could recognize the targets more effectively in the absence of MHC class I antigens. In this paper we review the contradictory results obtained when studying the NK susceptibility of cell lines which constitutively express different levels of MHC antigens, or which have been induced to express MHC antigens by gene transfection or gamma-interferon treatment. Taken together, the results indicate that MHC antigens play a differential role in NK lysis depending on the nature of the target cells used; MHC class I antigens play a role in the NK resistance of cells from a hematopoietic lineage, but this does not extend to cells from other origins. The data reviewed also support the hypothesis that MHC class I antigens induced NK resistance by interfering with target structures, and that multiple NK molecules are involved in NK-mediated lysis as part of a possible advanced recognition system.


Ocular tissue involvement in HIV infection: immunological and pathological aspects. The CNS afflictions in AIDS are myriad and suggest a tropism of HIV to neural tissue. Ocular involvement is a frequent manifestation of the HIV infection, resulting in a high incidence of blindness within this patient population. Ocular lesions include cotton wool spots, presumably from HIV-induced microvasculopathy, retinal hemorrhage in cytomegalovirus retinitis and conjunctival Kaposi's sarcoma. These manifestations have been noted in up to 71% of AIDS patients. In fact, ocular disease is often the presenting symptom in an HIV-infected individual. Despite the high incidence of ocular involvement in AIDS patients, the etiology and pathogenesis of these manifestations are not well understood. The immunosuppressive action of HIV is the most likely primary cause for the development of ocular complications in AIDS. Here we review some of the important immunological and pathological features of AIDS affliction in the eye.


Effects of polyunsaturated fatty acids on interleukin-2-dependent T cell growth. Cellular membranes, in addition to serving as structural constituents of cells, also provide precursors for a number of chemical messengers involved in intracellular signal transduction. This includes the eicosanoids (prostaglandins and leukotrienes) and diacylglycerol, and activator of protein kinase C (PKC). Changes induced in the fatty acid profile of lymphocytes can influence vital metabolic processes in cells. Such changes, independent of the function of fatty acids as prostaglandin and leukotriene precursors, can alter the development and regulation of immune responses. In this report we study the effects of the polyunsaturated fatty acids (PUFA) on proliferation and signal transduction in the interleukin-2 (IL-2)-dependent murine T cell line CTL.L-2. Culture of CTL.L-2 cells in the presence of specific PUFA resulted in their incorporation into the cellular phospholipids. IL-2-induced proliferation of CTL.L-2 cells was markedly suppressed in a dose-dependent fashion by incubation in media supplemented with dihomogammalinolenic acid (an n-6 PUFA) slightly inhibited proliferation, while eicosapentaenoic acid (an n-3 PUFA) had no effect. Neither indomethacin (a cyclooxygenase inhibitor) nor nordihydroguaiaretic acid (NDGA, a lipoxygenase inhibitor) reversed the effect of DGLA. In contrast, phorbol 12-myristate 13-acetate (a phorbol ester and activator of PKC), blocked, in a dose-dependent manner, the antiproliferative effect of DGLA. This study presents evidence that PUFA alter signal transduction in cells in a manner which is separate from their function as eicosanoid precursors. The botanical lipid-derived DGLA has a potent suppressive effect on IL-2-driven T cell proliferation and may alter signal transduction by modification of second messenger or PKC activity.


IgG autoantibodies to C1q do not detectably influence complement activation in vivo and in vitro in systemic lupus erythematosus. The influence of IgG antibodies to C1q (C1qAb) on activation of the classical pathway of the complement system was investigated in patients with systemic lupus erythematosus (SLE). In in vivo experiments, a prototype for immune complexes was administered intravenously to 14 patients and 9 healthy controls. Eight SLE patients had increased C1qAb titers. The increase of C3a levels, which was measured as a parameter of C1 activation, was significantly lower in SLE patients than in the healthy controls (p = 0.01). No correlation was found between C3a increases and C1qAb titers. In in vitro experiments the influence on C1 activation of monomeric IgG isolated from serum of 11 SLE patients, 7 of whom had increased C1qAb titers, was measured in a C4 consumption assay. The presence of C1qAb did not influence C4 consumption. The results demonstrate that C1qAb do not influence C1 activation by immune complexes in SLE patients.


Complement profile in primary biliary cirrhosis. PBC is a chronic progressive liver disease of unknown etiology. Several abnormalities found in PBC support the hypothesis that it may be considered an autoimmune disease. Despite the complex and interesting relationship that exists between autoimmune disorders and the complement system, very few reports on the level of the serum complement component in PBC have been published, and most of these comprised only a few patients or analyzed only a scant number of the complement components. In the present study, sera of 73 PBC patients were analyzed for the levels of 10 complement components. It was found that the levels of most of the serum complement components, including C1q, C2, C3, C5, C7, properdin and factor B were significantly elevated in patients with PBC in comparison to healthy controls. The level of C4 was slightly lower than that of the normal controls (p = 0.019), while the levels of C6 and C8 were within the normal range. The number of PBC patients with serum levels of C4 and C6 < 60% of normal pooled serum was higher than in the respective control groups (6/69 compared with 0/26 and 4/71 compared with 0/27, respectively). However, the difference was not statistically significant. Thus, our study shows alterations in the levels of most complement components in PBC, the reasons for which are discussed.


An unexpected growth pattern: considerations in management. A case study spanning 16 years is presented. Routine treatment with serial extraction and an edgewise appliance for a Class I crowded occlusion began when the patient was 8 years old. By the time the patient was 17, his dentition had evolved, because of unanticipated growth, into a Class III malocclusion with complete-arch crossbite. The question of whether it is most appropriate to treat this patient in one or two surgical procedures is discussed, and some controversial aspects and concerns are presented.


Lingual nerve injury associated with superior border wire fixation. The sagittal ramus osteotomy of the mandible is the most frequently performed orthognathic surgical procedure. Stabilization of the osteotomy may be accomplished by rigid internal or wire fixation. This article illustrates lingual nerve injury following a bilateral sagittal ramus osteotomy of the mandible and fixation with a superior border wire. The etiology and surgical management of this injury are described.


The Dentofacial Deformity Program of the University of Michigan: organization, analysis of data, and benefits of program. The Dentofacial Deformity Program of the University of Michigan was established in 1984 to provide a consulting service for the diagnosis, treatment recommendations, and management of patients with dentofacial deformities. This program was designed as a service commitment for the patient, referring doctors, and the medical and dental communities. Educational and research aspects of the program provide benefits for orthodontic and oral and maxillofacial surgery graduate students, and the dental school faculty. The organization, data analysis, and education, research, and service benefits of this program are discussed.


Surgical-orthodontic correction of mandibular deficiency: five-year follow-up. Changes in dental and skeletal relationships at 5 years postsurgery were evaluated in a group of 35 patients whose mandibular deficiency had been corrected by the same surgeon, using sagittal split osteotomy of the mandibular ramus. From 1 to 5 years postsurgery, there was a small (0.9-mm) but statistically significant mean decrease in mandibular length (condylion to point B). In six patients, the decrease in mandibular length was 2 to 4 mm, and in two it was more than 4 mm, but only one of these individuals had more than a 2-mm increase in overjet. There was no mean change in overjet, but three patients had a 2 to 4-mm increase. Of these, one had 3.2 mm shortening of the mandible, one had 1.4 mm shortening of the mandible, and one had no change in mandibular length but repositioning of the incisors. Most patients had a deep overbite initially, and there was a tendency for the bite to deepen between the first and fifth years postoperatively, more as a result of extrusion of incisors than of mandibular rotation. Remodeling of the gonial angle area, with vertical and/or horizontal repositioning of gonion, was noted in more than half the subjects. It appears that morphologic changes related to continued skeletal remodeling, often compensated for by small changes in mandibular posture or tooth positions, continue after 1 year postsurgery for many patients.


Simultaneous orthognathic and temporomandibular joint surgery: review of selected cases. The pros and cons of, and treatment considerations for, simultaneous orthognathic and temporomandibular joint surgery are discussed. Several cases of patients treated with simultaneous orthognathic and temporomandibular joint surgery are presented.


Densitometric evaluation of changes in the soft tissue of the chin and the lower lip during the treatment of Class III malocclusion. The aim of this study was to use densitometry of lateral skull teleradiographs to evaluate the changes that occurred in the lower lip and chin after orthodontic or orthodontic-surgical treatment of Class III malocclusion. Forty teleradiographs from 20 patients with mandibular prognathism were made at the beginning and end of treatment. In ten of these patients the treatment was exclusively orthodontic with an edgewise appliance, and in another ten the treatment was orthodontic with a straight wire appliance combined with orthognathic and mentoplastic surgery. In the patients who were only treated orthodontically, a significant increase in density of the lower lip and the chin was found after treatment. This seemed to be related to an increase of muscular tension in these areas. Patients treated with orthognathic surgery and the straight wire appliance showed a decrease in density of the chin after treatment, but not of the lip. This can be interpreted as a consequence of muscular normalization after this procedure was accomplished.


The reliability of computerized cephalometric soft tissue prediction following bimaxillary anterior subapical osteotomy. The accuracy of predicting the results of orthodontic-surgical treatment following bimaxillary anterior subapical setback osteotomy was analyzed retrospectively. Comparisons of pretreatment prediction tracings of the lateral cephalograms with the 6-month postsurgical cephalograms of 38 patients showed that there was no statistically significant difference between the actual and predicted dentoalveolar setback in both arches. The computer-generated soft tissue predictions were generally accurate, with the exception of the horizontal position of the lower lip, which was underestimated, and, to a lesser extent, the vertical position of the upper lip, which was also underestimated. Computerized cephalometric prediction following bimaxillary anterior subapical osteotomy is sufficiently accurate to be of value to be used routinely in treatment planning for the horizontal upper lip prediction, but some modifications are advisable to obtain a more accurate horizontal lower lip prediction.


[In vitro study on the effect of sex steroid and growth factor on growth and laminin, collagen IV, and tissue plasminogen activator production of normal endometrial cells and endometrial cancer cells in culture]. The mechanism of the invasion and proliferation of endometrial cancer is closely related to interactions between the endometrial glands and stroma. In this study, we examined the biological role of sex steroids (estradiol; E2, progesterone; P) and growth factors (epidermal growth factor; EGF, transforming growth factor-beta; TGF-beta) on cell growth and laminin, collagen IV and tissue plasminogen activator (t-PA) production of normal endometrial cells and endometrial cancer cells in culture. Normal endometrial gland cells and stromal cells, and endometrial cancer cell lines (Ishikawa, OMC-2) were used. E2, P, EGF and TGF-beta were added to the culture in physiological concentrations. The growth of normal endometrial gland cells was promoted by E2 and EGF, whereas that of Ishikawa cells and OMC-2 cells was promoted by EGF. E2 enhanced the effects of EGF in normal endometrial gland cells. The growth of normal endometrial stromal cells was not affected by them. OMC-2 was inhibited by anti-EGF receptor antibody. On the other hand, the production of laminin and collagen IV of these cultured cells was inhibited by EGF and promoted by TGF-beta, whereas that of t-PA was promoted by EGF and inhibited by TGF-beta. These results suggest that the growth of normal endometrial gland cells with estrogen receptor (ER) is controlled by both E2 and EGF, whereas that of endometrial cancer cells is affected only by EGF, and those cells without ER depend particularly on the autocrine growth mechanism of EGF.(ABSTRACT TRUNCATED AT 250 WORDS)


[Analysis of DNA synthetic cells in endometrial carcinoma cases treated with progestogen]. It is well known that the proliferation of endometrial adenocarcinoma is inhibited by progestogens. We often use medroxyprogesterone acetate (MPA) as endocrine therapy for advanced endometrial carcinoma. In the present study, we administered 400-600mg of MPA/day on 14 days as a progestogen challenge test (PCT) to 37 cases of endometrial carcinoma. We analysed the variation in the percentage of S phase cells by flow cytometry and also conducted an immunohistochemistry analysis with anti-BrdU monoclonal antibody before and after the administration of MPA. The percentage of S phase cells in endometrial carcinoma tended to decrease with much greater variation after PCT than before. The percentage of BrdU positive cells tended to decrease after PCT. The cases with a good histological effect such as 1) basal vacuolization 2) clear staining cytoplasm 3) homogenus finding of cells and nucleus by PCT had a better prognosis than the cases with no histological effect due to PCT.


[Assessment of pre-term uterine contractions by characterization of the power spectra of abdominal surface potentials (ASP)]. The prognosis of pre-term labor in the absence of complications such as PROM is dependent on the strength of the uterine contractions, which are dependent on the sensitivity of the myometrium, expressed in terms of bio-electric potentials. Our electromyography were obtained from pregnant ewes, and these were correlated with abdominal surface potentials (ASP) obtained from human volunteers, to see if impending premature labor could be detected and the prognosis predicted. 1) The EMG tracings obtained from pregnant ewes were submitted to a power spectrum analysis. 2) EMG tracings revealed an increase in power output with the advance of labor, but power spectra varied with the stage of labor. 3) Uterine contractions not leading to cervical ripening had a low power output with a low frequency range. 4) Ewes in true labor had EMG's at a high power output of low frequency waves. 5) Ewes in pre-term labor leading to cervical ripening had power outputs similar to ewes in true labor, but the power spectra of the former were wider in range. 6) ASP tracing revealed an increasing power output with increasing uterine contractile activity and power spectra correlated well with the EMGs obtained from ewes. In conclusion, since ASP findings were in good correlation with EMGs obtained directly from the myometrium, we hope that this method may be developed into a practical non-invasive method for detecting and assessing uterine contractions.


[Analysis of HLA antigens and immunotherapy for infertile couples who failed to conceive after in vitro fertilization-embryo tubal replacement (IVF-ETR)]. The results of IVF-ETR strongly suggest the existence of implantation failure of unknown etiology. A selected group of 41 couples with long-standing infertility who had one or more failed IVF-ETR cycles were analysed for HLA antigen sharing, and 19 wives were immunized with their husband's purified lymphocytes just before the subsequent trial. Both the number and frequency of shared HLA antigens in these patients were significantly increased, compared with control couples of normal fertility (p < 0.05). After immunization, 7 patients (36.8%) conceived by IVF-ETR, and 5 (71.4%) delivered a healthy baby at term. The pregnant couples shared significantly fewer HLA antigens compared with those who failed to conserve (p < 0.05). Interestingly, the MLR blocking effect was enhanced in the pregnant group after immunization, suggesting the induction of blocking antibodies which are believed essential for the survival of the developing fetus. In contrast, the blocking effect was rather decreased in the nonpregnant group. These results implicate that HLA sharing and inadequate maternal anti-paternal immunity may be related to implantation failure, and immunotherapy can be used to potentiate the maternal immune response, leading to successful implantation in selected patients.


[Influence of low calcium diet on the vascular response to angiotensin II in pregnant and non-pregnant rabbit vascular endothelium]. This study was conducted in order to evaluate the influence of low calcium intake on the vascular response to angiotensin II (A-II) in pregnant and non-pregnant rabbits. Both were fed on a regular and a low calcium diet, respectively, for a period of at least 25 days. By using the common iliac arterial rings of each of the rabbits, and further classifying the respective arterial rings into those with intact endothelium and those with denuded endothelium, the response to A-II in the rings was compared. A greater degree of refractoriness to A-II was observed in the intact endothelial rings than in the denuded rings regardless of the difference in calcium intake, in both pregnant and non-pregnant rabbits. The refractoriness was however, particularly remarkable in the pregnant arterial rings. Therefore refractoriness to A-II in arterial rings on a low calcium diet is higher than that in the rings on a regular calcium diet regardless of the presence of endothelial cells, in both pregnant and non-pregnant rabbits. It is clear that reduction in the calcium intake results in an increase in the response to A-II, which is caused by increased reactivity of the vascular smooth muscle layer.


[Effect of gonadotropin releasing hormone agonist (Gn-RHa) on steroidogenesis in human and rat ovaries]. The effects of Gn-RHa on rat granulosa cells and on human granulosa and luteal cells were examined. (I) In rat granulosa cells: 1) Gn-RHa inhibited the stimulating effect of PMSG on progesterone and estradiol production. 2) In a tracer experiment, Gn-RHa inhibited PMSG-stimulated progesterone production by stimulating 20 alpha-hydroxyprogesterone production. On the other hand, Gn-RHa inhibited estradiol production by inhibiting PMSG-stimulated aromatization. 3) On 20 alpha-hydroxysteroid dehydrogenase activity, it appears that Gn-RHa accelerates the maximum velocity and decreases the affinity of the enzyme to 20 alpha-hydroxyprogesterone as the substrate. (II) In man: 1) In granulosa cells during the ovulatory phase, Gn-RHa inhibited PMSG-stimulated progesterone and estradiol production. 2) In luteal cells, Gn-RHa inhibited hCG-stimulated progesterone production. 3) The affinity of Gn-RH receptor in the corpus luteum was lower than that in rat ovaries. These results suggest that in the human ovary as well as in the rat ovary, Gn-RHa might have a direct effect on the development of the follicle.


[Assessment of fetal lung maturity using newly developed immunological measurement of fetal pulmonary surfactant apoprotein-A in amniotic fluid]. The level of immunoreactive lung surfactant apoprotein A (SP-A) was determined with a newly developed one-step ELISA kit (TDR-20) in 217 samples obtained by transabdominal or transvaginal amniocentesis from 217 pregnant women with high risk pregnancy. The lecithin/sphingomyelin ratio (L/S ratio) by two-dimensional thin layer chromatography, disaturated phosphatidylcholine (DSPC) values, shake test and the stable microbubble method were done simultaneously to compare diagnostic reliability in estimating fetal lung maturity. Amniotic fluid SP-A levels increased with advancing gestational age and correlated well with the values obtained by the other methods. When the cut-off SP-A value for the assessment of lung maturity was set at 1,700ng/ml in the amniotic fluid obtained within 24h before delivery, the true-negative rate for RDS was 71% and the true-positive rate for non-RDS was 83%. The sensitivity, specificity and accuracy were 100%, 83% and 88%, respectively. These results are comparable with those for the L/S ratio, DSPC determination and the stable microbubble method, and were slightly better than those for the shake test. In conclusion, this newly developed ELISA kit for the measurement of amniotic fluid SP-A is more effective than other methods currently available for the evaluation of fetal lung maturity, when it is considered that it requires only 0.2ml of amniotic fluid and provides results in only 2h without technical difficulties.


A computerised bronchoscopy database providing reporting and auditing facilities. The bronchoscopy reporting and auditing procedure has been computerised using dBASE IV software on a portable microcomputer and printer system. Although entering the data into the computer tends to prolong the reporting procedure slightly, the additional effort is rewarded by a more comprehensive, attractive and accurately documented report; together with rapid access to correct clinical and medical audit statistics. The ease of access to the patient data is proving useful at clinical review meetings and in the production of quality assurance statistics of operator technique.


A computerized system for acquisition and evaluation of polysomnographic recordings. A computer system has been designed for acquisition and evaluation of polysomnographic recordings. The aim is to create a system running on a microcomputer emulating all functions of a conventional chart recorder and offering the advantage of making computer assisted evaluations. We have done 87 investigations in the first year of operation and were fully satisfied by the performance of the system. The standard signals we recorded were SaO2, heart rate, respiratory effort, nasal and oral airflow and ECG, as well as EOG, EMG and EEG. Due to this new method, evaluation of the recording can be done in less time than with strip chart recordings and the use of hundreds of pages of paper per night can be avoided.


Eight year's experience with automated anesthesia record keeping: lessons learned--new directions taken. For the past eight years, an automated anesthesia record keeping system, COMANDAS (COMputerized ANesthesia Data Acquisition System) has been used in the cardiovascular operating rooms at Mayo Clinic. The automated anesthesia record is designed to match the traditional hand-written record and becomes part of the official medical record. COMANDAS is interfaced with the physiologic monitor and mass spectrometer in each OR, and a number of other computers within the Mayo Medical Center. Since the introduction of COMANDAS over 24,000 surgical procedures have been charted. The anesthesia record is more complete, consistent in organization, and legible when compared to a hand-written record. Recently, it was determined that the computers and peripherals that make up COMANDAS were wearing out and that the vendors would no longer support or replace the equipment. A process to find a replacement for COMANDAS was then begun. Although the cardiovascular anesthesia group was satisfied with the automated anesthesia record, there were a number of areas in which improvement was desired. A systematic evaluation of the system was begun with a survey of the users. The majority of those surveyed felt that COMANDAS was a useful system which made parts of their job easier. The user interface, method of manual data entry, time to produce the record and difficulty learning the system were the source of the greatest dissatisfaction. Artifacts, networking, interfacing with other devices and computers were also issues for the replacement system. Most commercial systems were found wanting in one or more areas of significance. The most practical solution appeared to be the modification of a currently available intensive care unit patient data management system.


PADS (Patient Archiving and Documentation System): a computerized patient record with educational aspects. Rapid acquisition and analysis of information in an Intensive Care Unit (ICU) setting is essential, even more so the documentation of the decision making process which has vital consequences for the lives of ICU patients. We describe an Ethernet based local area network (LAN) with clinical workstations (Macintosh fx, ci). Our Patient Archiving and Documentation System (PADS) represents a computerized patient record presently used in a university hospitals' ICU. Taking full advantage of the Macintosh based graphical user interface (GUI) our system enables nurses and doctors to perform the following tasks: admission, medical history taking, physical examination, generation of problem lists and follow up notes, access to laboratory data and reports, semiautomatic generation of a discharge summary including full word processor capabilities. Furthermore, the system offers rapid, consistent and complete automatic encoding of diagnoses following the International Classification of Disease (ICD; WHO, [1]). For educational purposes the user can also view disease entities or complications related to the diagnoses she/he encoded. The system has links to other educational programs such as cardiac auscultation. A MEDLINE literature search through a CD-ROM based system can be performed without exiting the system; also, CD-ROM based medical textbooks can be accessed as well. Commercially available Macintosh programs can be integrated in the system without existing the main program thus enabling users to customize their working environment. Additional options include automatic background monitoring of users learning behavior, analyses and graphical display of numerous epidemiological and health care related problems. Furthermore, we are in the process of integrating sound and digital video in our system. This system represents one in a line of modular departmental models which will eventually be integrated to form a decentralized Hospital Information System (HIS).


Inform: conceptual modelling of intensive care information systems. Intensive care of a patient requires heavy monitoring and versatile therapeutic actions. These produce a huge amount of patient information. A problem exists in managing this data and other information from all supporting activities creating a need for an automated information management system. To have a sound basis for future automated information systems in intensive care unit (ICU), a conceptual model is created to cover both the clinical and other activities of the ICU. The conceptual model consists of data flow diagrams and entity-relationship diagrams with underlying common data dictionary. A modern CASE tool is utilized to build the model. The work forms a part of AIM-INFORM project, which has a purpose to develop information management and decision support systems for high dependency environment.


Microprocessor-based near real-time bedside blood chemistry monitor. A microprocessor-based instrument which integrates the function of a volumetric infusion pump with a blood chemistry analyzer has been developed. Presently, the instrument is capable of measuring Na+, K+, Ca++ and pH within approximately 40 sec at a frequency of up to every 2 min. The system is set up as an intravenous (IV) infusion pump with the addition of an array of disposable sensors placed at the distal end of the IV set. An isotonic IV solution is used to keep the site patent while also serving as a calibrant for the sensors. The instrument first calibrates the sensors, then withdraws approximately 0.6 ml of blood to come in contact with the sensors. Within approximately 15 sec, it displays the results, flushes the blood back into the patient and resumes normal infusion. There is no blood loss to the patient and no need to handle blood. The system was first validated with known aqueous controls and then used on-line in a variety of animal studies where dynamic fluctuation of electrolytes and pH occurred. Excellent correlation was found with off-line samples tested on conventional STAT analyzers. Some preliminary patient data is also presented.


Primary immunodeficiencies.

Primary immunodeficiencies. Primary immunodeficiencies are rare immune system disorders that present with recurrent and chronic infections of the head and neck. Otitis media, sinusitis, and upper respiratory tract infections develop frequently and present in early childhood. The purpose of this report is to classify and define the primary immunodeficiencies as well as to examine the clinical manifestations, evaluation, and treatment of these disorders.


Living wills and orders not to resuscitate: what is the difference? There is confusion about the meaning of living wills and orders not to resuscitate. Both are very important concepts which allow patients to control some of the decisions at the end of life. Living wills are valid until revoked, have the same meaning throughout Louisiana, and are implemented when a patient becomes incompetent and qualified (certified in writing as having a terminal and irreversible condition). Orders not to resuscitate are policy matters in each hospital, thus they vary throughout the state. They are implemented at the time of cardiac arrest.


Evaluation of urinary incontinence in the elderly. Urinary incontinence affects millions of elderly American men and women. This paper reviews the causes of urinary incontinence and the evaluation that can be easily accomplished as an outpatient with minimal expense and morbidity.


The uses of simulation in anesthesiology training: a review of the current literature. Can anesthesia simulation be used successfully in training to improve the abilities of anesthesiologists and so result in decreased morbidity and mortality due to human error? In this review, computer simulation is examined as a training technique to reduce human error during the administration of anesthesia and as a method for studying how anesthetic accidents occur. Simulation is used successfully in other fields, such as aviation pilot training. A discussion of what defines human error will enable understanding of how computer simulation may be used to reduce it. Simulation of the anesthesia environment has been only recently developed. At this time there are at least two simulators which have been developed for the anesthesia environment. The two simulations are different in that one is strictly computer based. One reproduces the anesthesia monitors using computer graphics. The other, the Comprehensive Anesthesia Simulation Environment (CASE) simulation, attempts to reproduce the entire operating room. These two available simulators are discussed. It is presently unknown whether or not the use of simulation in anesthesia training improves the quality of that training. However, simulators necessary to answer this question are either available now or will be in the near future.


The mortality experience of Dow Chemical Louisiana Division employees, 1956-1986. A major objective of the epidemiology department of the Dow Chemical Company is to report at periodic intervals the cause-specific mortality experience of its employees. This study analyzed the cause-specific mortality experience of 4,229 male and female employees of the Louisiana Division who were employed for at least 1 year from 1956 through 1986. Regardless of the comparison population used to calculate expected numbers (United States, Louisiana, or the surrounding five parish area), fewer deaths were observed for all causes combined as well as for all malignant neoplasms, diseases of the circulatory system, and external causes of death.


The hard-of-hearing patient in office practice. The hard-of-hearing patient may represent difficult evaluation and management decisions. This article will serve as a review for the primary care physician. Included will be a description of the various types of hearing losses, their causes, evaluation, and treatment.


Preoperative management of sickle cell patients. During a 12-year period, 59 patients with sickle cell disease underwent a total of 73 operative procedures. There was a total of 30 non-sickle-cell-related and 7 sickle-cell-related complications for an incidence of 41% and 10% respectively. There were no deaths. When complications were compared between patients that were transfused and those not transfused, there was no difference in the incidence of sickle-cell-related complications with an 8% incidence for the non-transfused group and 10% for the transfused group. A higher incidence of non-sickle-cell-related complications (46% versus 32%) was noted in the transfused group, with atelectasis being the most common complication (p = .29). The type of transfusion therapy did not influence morbidity, since the complication rates in the simple and exchange transfusion groups were similar. In conclusion, our data indicate that routine preoperative blood transfusion does not appear to be beneficial in the surgical sickle cell patient, since preoperative blood transfusions did not reduce the incidence of sickle-cell-related complications.


Putting the 'manage' into managed care.

Putting the 'manage' into managed care. Managed care is part of our modern medical vocabulary just like Medicare and Medicaid were 20 years ago. Other areas of the country are significantly impacted by managed care. Now the concept of businesses and industries representing large numbers of patients and potential patients have become an integral component of nearly every physician in Louisiana. Most physicians are out of their "comfort zone" when contracts with managed care providers are discussed. This article provides guidelines for selecting and solving problems with managed care providers.


Common human phobias.

Common human phobias. The kernel of realistic fear present in the common phobias arises from phylogenetic as well as ontogenetic roots. A phobia's full development depends upon life experience, the role of the symbolization process in expressing personal conflict, and individual temperamental and familial factors.


Alcohol consumption in the guinea pig is associated with reduced megakaryocyte deformability and platelet size. Mild thrombocytopenia is common in alcoholic individuals. Ethanol appears to impair platelet production primarily by affecting the maturing megakaryocyte compartment. We recently showed that guinea pigs have an unusually large number of elongated platelet forms even under conditions of steady-state thrombopoiesis, and a portion of their mature (stage IV) megakaryocytes yield extremely long extensions on micropipette aspiration. This study evaluates the effect of a moderately low level of ethanol consumption by guinea pigs on platelet size and form and megakaryocyte deformability. Adult Duncan Hartley guinea pigs took ethanol 2.5% (vol/vol) ad libitum for 4 weeks under environmentally controlled conditions, never reaching detectable blood ethanol levels (< 0.01%); the platelet count fell 16%. Elongated platelet forms constituted 29% of the cardiac puncture platelets of control animals, but only 3% of the cardiac puncture platelets of animals given ethanol; discocytic platelets of ethanol-treated animals were also significantly smaller. Individual stage III and IV megakaryocytes were aspirated into 5 microns diameter micropipettes by stepwise increment in pressure from 10 to 200 cm water. The extensions drawn from megakaryocytes of ethanol-exposed animals were significantly shorter than the extensions from control megakaryocytes. Extremely long extensions over 50 microns in length were drawn from 21% of the control megakaryocytes but less than 1% of ethanol-exposed megakaryocytes. Moderately low level ethanol consumption was associated with reduced platelet count and size, along with rigidity of mature megakaryocytes in guinea pigs. Few ethanol-exposed megakaryocytes yielded extremely long cell extensions, nor were elongated platelet forms prevalent in the circulation of animals given ethanol.(ABSTRACT TRUNCATED AT 250 WORDS)


Secretion of hyaluronic acid from synovial fibroblasts is enhanced by histamine: a newly observed metabolic effect of histamine. We obtained evidence for the presence of histamine H1 and H2 receptors in normal synovial fibroblasts. Histamine enhanced proliferation of these synovial fibroblasts and stimulated the release of hyaluronic acid from these tissues. The molecular weight of hyaluronic acid decreased with this stimulation. The release of lower molecular weight hyaluronic acid from the synovium by histamine may be an important factor in joint disease.


Serum proteins and acid-base equilibria: a follow-up. A mathematic model that described the acid-base behavior of blood plasma has been revised to incorporate pK values of individual histidine residues on human serum albumin determined by nuclear magnetic resonance spectroscopy. With the insights derived from the model a method for evaluation of the strong ion difference has been developed. Thus if pH, PCO2, and the concentrations of serum albumin and phosphate are measured, all independent variables, which physically determine "acid-base balance" in plasma, can be quantified. New ways to evaluate "unidentified anions" in metabolic acidosis can be explored with this approach.


Low blood glutathione levels in healthy aging adults. The objective of this investigation was to test the hypothesis that blood glutathione levels are lower in aging human subjects as previously found in blood and tissues of standard rodent models of aging. Thus a study was conducted with 39 men and 130 women, 20 to 94 years old, who were selected by the criteria of being ambulatory, healthy, and free from diabetes mellitus, thyroid disease, anemias, and cancer. The reference group was comprised of the 20- to 39-year-old subjects, whose blood glutathione levels were 547 +/- 53.5 micrograms/10(10) erythrocytes (mean +/- SD) for 40 individuals and defined the reference range (95% confidence limits) of 440 to 654. Based on the 440 micrograms/10(10) erythrocyte cutoff, the incidence of low blood glutathione content in the older subjects increased significantly, particularly in the 60- to 79-year-old group. Their glutathione levels were 452 +/- 86.8 micrograms/10(10) erythrocytes, 17% lower than the reference group (p < 0.001). These findings demonstrate an increased incidence of low glutathione levels in apparently healthy elderly subjects, who thus may be at risk because of a decreased capacity to maintain many metabolic and detoxification reactions mediated by glutathione.


The contribution of factor V to the coagulant property of pleural fluid. Intrapleural fibrin deposition commonly accompanies pleural injury and may contribute to the organization of exudative pleural effusions, which leads to lung entrapment. Previous investigators have observed an increase in procoagulant proteins in pleural effusions but very little thrombin formation. FVa is the protein cofactor in the prothrombinase complex that dramatically enhances the generation of thrombin from prothrombin by the serine protease fXa. The presence of fVa within the pleural space could influence fibrin formation and pleural scarification. We examined pleural fluids obtained from patients who had lung cancer, CHF, and empyema for the presence of fV/fVa. The fV antigen was increased in exudative pleural fluids, in comparison with transudates. However, the specific activity of fV antigen present in exudates was significantly less than that observed for the lower concentration of antigen present in transudate and could not be activated to the same degree by thrombin. Immunoblots of fV antigen in exudates indicated that fV was partially cleaved and inactivated by unidentified proteases. We conclude that although fV is present in pleural fluid, it may be present in a degraded form, which may partially account for a lack of thrombin-generating capacity in these pleural fluids. The presence of fV does not necessarily correlate with pleural loculation.


Inhibition of the activation of Hageman factor (factor XII) by extracts of Schistosoma mansoni. How intravascular helminth parasites evade host hemostatic defense mechanisms and survive within the circulating blood has not been adequately explained. Previous reports have described an inhibitor of the intrinsic clotting pathway in extracts of adult Schistosoma mansoni. Using a purified preparation of Hageman factor, we examined the ability of schistosome extracts and secretory products to inhibit the activation of human Hageman factor (factor XII) in an amidolytic assay. Both schistosome extracts and secretory products inhibited the activation of purified Hageman factor by more than 95%. Schistosome extracts inhibited activation of Hageman factor both by ellagic acid and by bovine sulfatides. In contrast, activated Hageman factor retained full activity in the presence of schistosome extracts as tested both on an amidolytic synthetic substrate and a natural substrate, plasma thromboplastin antecedent (factor XI). Our findings indicate that extracts and secretory products of adult Schistosoma mansoni contain a potent inhibitor of the activation of Hageman factor. Knowledge of a site at which schistosomes inhibit the intrinsic clotting pathway provides added insight into the mechanisms by which the parasites avoid the host hemostatic defense mechanisms.


Respiratory epithelial carbohydrate levels of rats with gram-negative bacillary colonization. One mechanism by which severe illness or stress might facilitate adherence and colonization of GNB to respiratory epithelium is by altering epithelial cell surface carbohydrates. To investigate this possibility we used radiolabeled lectins to quantitate carbohydrate levels on intact buccal and tracheal epithelium. A rat model of GNB colonization, in which renal infarction was performed to produce colonization, was used. Buccal and tracheal epithelial surface carbohydrate levels from normal rats and rats 48 hours after renal infarction were compared. Buccal and tracheal epithelium from the renal infarction animals had decreased amounts of sialic acid and fucose, and decreased levels of these sugars occurred at the same time that heavy oropharyngeal GNB colonization developed. Tracheas obtained from the infarcted animals bound three times more Type 1 piliated GNB than normal tracheas. Sialic acid and fucose levels are decreased early after stress, and we speculate that altered epithelial carbohydrates may predispose to GNB colonization by exposing binding sites for GNB.


Effect of enhanced erythropoiesis on iron absorption. To examine the influence of erythropoiesis on iron absorption, radioiron absorption tests were performed in normal subjects before and after a course of recombinant erythropoietin. The absorption of heme and nonheme iron from a standard meal was measured in nine subjects, and the absorption of a therapeutic dose of ferrous sulfate given with or without food was determined in an additional 11 subjects. The subcutaneous administration of 100 U recombinant human erythropoietin/kg body weight given on 10 successive days over a 2-week period induced a brisk increase in erythropoiesis and a sharp decrease in iron stores. With the standard meal, there was a modest increase in heme iron absorption from 47.0% to 58.6% (p < 0.05) and a dramatic five-fold rise in nonheme iron absorption from 5.9% to 31.8% (p < 0.001). The absorption of 50 mg iron as ferrous sulfate increased from 2.0% to 17.9% when given with food (p < 0.001) and from 7.0% to 24.6% when given with water (p < 0.001). To assess the effect of erythropoiesis independently of the induced changes in iron status, the absorption data were adjusted to a common serum ferritin level. The relative increase in iron absorption was still significant for both dietary nonheme iron (ratio 2.51, p < 0.02) and ferrous sulfate given with food (ratio 2.99, p < 0.01). It is concluded that the striking enhancement of iron absorption following regular erythropoietin administration in normal subjects is related to the combined effect of diminished iron stores and augmented erythropoiesis.


Detection of properdin mRNA in human peripheral blood monocytes and spleen. Properdin serves a critical role in the alternative pathway of complement by stabilizing the C3bBb complex. Early studies to determine the properdin sequence relied on amino acid sequencing of enzymatically cleaved properdin and only yielded partial sequence data. Recently Nolan et al. reported a properdin mRNA sequence obtained from the U937 myelomonocytic cell line. We sought to detect properdin mRNA in two normal human tissues and to compare those sequences with that obtained from the U937 cell line. Cytoplasmic RNA harvested from human spleen and peripheral blood monocytes served as a template for first strand synthesis. The cDNA was then used as a template for polymerase chain reaction. A properdin message was detected in both spleen and peripheral blood monocytes but not in peripheral blood neutrophils. The sequence was nearly identical to that obtained from the U937 cell line. These experiments demonstrate that peripheral blood may be used as a ready source for properdin mRNA and will faster studies to define the defect in properdin-deficient patients.


Histologic studies of splenic megakaryocytes after bone marrow ablation with strontium 90. We previously showed that purified strontium 90 produced sustained bone marrow ablation in mice, lowering platelet levels to less than 10% of normal 11 days after administration. Platelet levels later rose exclusively from splenic production and were maintained at a stable level (58% of normal) from 20 to 115 days after injection. However, there was no change in the total number or ploidy distribution of splenic megakaryocytes, as immunologically detected by flow cytometry. To further study the characteristics of splenic thrombopoiesis after bone marrow ablation by 90Sr, we measured the frequency, cross-sectional area, and endomitotic figures of histologically recognizable megakaryocytes (as well as bare megakaryocyte nuclei) in mouse spleen sections. During the hematopoietic nadir 9 days after injection of yttrium 90-free 90Sr, the size (area) of megakaryocyte cross-sections (mean +/- SD, 1079.3 +/- 661.6 microns 2; normal, 398.7 +/- 192.8 microns 2) was greater than for any other time studied, but megakaryocyte frequency (corrected for size) did not increase until day 16. Overall, splenic megakaryocytes in marrow-ablated mice 16 or more days after 90Sr injection showed substantial increases (p = 0.001 for both comparisons) in mean area (707.5 +/- 386.2 microns 2) and sectional frequency (mean +/- SEM, 4.52 +/- 0.20 per 1.83 mm2; normal, 0.78 +/- 0.06 per 1.83 mm2). Megakaryocyte bare nuclei and endomitotic figures were also more numerous after 90Sr, injection, suggesting acceleration of megakaryocyte maturation and platelet production. The induction of splenic platelet production after bone marrow ablation is associated with increased size of recognizable megakaryocytes, despite lack of change in overall splenic megakaryocyte ploidy.


Mitomycin C-induced colitis in rats: a new animal model of acute colonic inflammation implicating reactive oxygen species. The mechanism of the tissue damage induced by colonic inflammation in ulcerative colitis is not established. We therefore developed and characterized a simple new rat model of acute colonic inflammation induced by a single systemic injection of mitomycin C. After an intraperitoneal injection of mitomycin-C, colon histologic examination revealed transient (3 to 14 days) diffuse, colonic inflammation and injury that, like human ulcerative colitis, was limited to the mucosal layer. The rest of the gastrointestinal tract was spared. Gut permeability, as measured by urinary excretion of orally administered lactulose and mannitol, was unchanged 3 days after injection, when inflammation was already present; permeability was increased at 7 days, when inflammation was maximal. Mitomycin C did not produce inflammation in experimentally bypassed segments of small bowel despite the presence of colonic-type bacteria, suggesting that lack of intraluminal bacteria was not responsible for the absence of inflammation in the small intestine. Chemiluminescence, a means of estimating levels of reactive oxygen species, was greater in the intact, inflamed colon of mitomycin C-treated rats than in bypassed segments. Moreover, inflamed mucosal scrapings produced more in vitro luminol-enhanced chemiluminescence. Furthermore, the reactive oxygen species scavengers allopurinol, catalase, and WR-2721 decreased inflammation severity. We therefore conclude: (1) the mitomycin C-treated rat is a novel, easy to prepare animal model of acute inflammation of colonic mucosa, with morphologic similarities to the acute phase of ulcerative colitis in human beings; (2) increased gut permeability in mitomycin C-treated rats is the result, not the cause, of the inflammation; and (3) reactive oxygen species play an important role in colonic inflammation and tissue injury in this model, and possibly in human ulcerative colitis.


Inhibition of 11 beta-hydroxysteroid dehydrogenase by gossypol and bioflavonoids. The enzyme 11 beta-hydroxysteroid dehydrogenase (11 beta-OHSD) oxidizes hydrocortisone to inactive cortisone in the kidney and is an important regulator of renal K+ clearance. Gossypol, in clinical trials as an antifertility drug for men in China, was associated with episodes of hypokalemia. To learn whether gossypol and other structurally similar compounds in plants can inhibit 11 beta-OHSD activity, purified enzyme from rat liver and in human renal cortical microsomes was studied. Rat liver enzyme was inhibited by glycyrrhetinic acid > gossypol >> morin > quercetin >> rutin. Glycyrrhetinic acid, gossypol, and morin inhibited activity of the human kidney enzyme. Enzyme in microsomes from five human kidneys had an IC50 (S.D.) of 1.5 (1.2) mumol/L for glycyrrhetinic acid; enzyme in microsomes from six human kidneys had a 50% inhibitory doses of 147 (25) mumol/L for gossypol. Our observations indicate that gossypol and other compounds in plants can inhibit 11 beta-OHSD activity and may thereby increase K+ excretion.


Vestibular neurectomy by the infralabyrinthine approach. There are a variety of approaches for treating vertigo with selective vestibular neurectomy but each has definite limitations proving that no ideal technique is yet available. An original posterior-inferior approach to the internal auditory canal (infralabyrinthine approach) has been recently proposed. It attempts to overcome the limitations and to combine the advantages of the previous procedures. This report presents our preliminary results using this particular technique in the management of vestibular symptoms of Menière's disease.


The effect of epidural anaesthesia and size of spinal needle on post-operative hearing loss. Forty-five patients who were to undergo elective urological operations were evaluated. In the pre-operative period and on the third or fourth post-operative day audiometry was performed. Epidural anaesthesia was performed in 15 cases, spinal anaesthesia was performed in 15 cases with 25 G needles, and in 15 cases with 22 G needles. No statistically significant hearing loss was observed in the post-operative period compared to preoperative period in the epidural anaesthesia group. In the post-operative period, the hearing loss observed in the 25 G-spinal anaesthesia group was significantly (P < 0.01) less than that seen in the 22 G group. None of the patients had headache after spinal anaesthesia. It was concluded that pure tone audiometry is a more sensitive indicator of cerebrospinal fluid leakage than post-operative headache.


A conservative approach to the management of otitis media with effusion in cleft palate children. Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.


Surgery of the 'only hearing ear' with chronic ear disease. The management of chronic ear disease affecting the only hearing ear is a controversial subject. The relative scarcity of literature on the subject prompted us to prepare a questionnaire which was sent to European and American otologists and to review 19 cases operated at the ENT Clinic of the University of Parma, Italy, and 16 cases operated at The Baptist Memorial Hospital, Memphis, U.S.A. Surgery of cholesteatoma involving the only hearing ear is advised by all the interviewed otologists without exception, even in the presence of a labyrinthine fistula. The cases from the University of Parma were managed as follows: a classic modified radical mastoidectomy was performed in 10 cases, a staged intact canal wall tympanoplasty was done in four cases, an open tympanoplasty in three and a radical mastoidectomy in the remaining two cases. The cases from The Baptist Memorial Hospital were managed with an intact canal wall tympanoplasty (ICWT) in nine and with an open procedure in seven cases. All the otologists interviewed agreed that surgery of the only hearing ear requires particular attention and experience, and should be performed with extreme care by a very experienced surgeon.


Allergic aspergillus sinusitis with proptosis. Allergic aspergillus sinusitis has recently been increasingly recognized. Five cases are discussed. All presented with proptosis, signs and symptoms of allergic rhinitis and radiological evidence of expansile masses with calcification and bony erosions involving multiple sinuses. Greenish cheesy material was seen at surgery. Histologically the lesions contained eosinophils, Charcot-Lyden crystals and fungal septate hyphae. Aspergillus fumigatus was grown from all cases. Surgical removal with drainage and aeration were performed. The follow-up period ranged between three to 18 months. Recurrence occurred in one patient. Allergic aspergillus sinusitis can mimic malignant disease and should be considered in the differential diagnosis of lesions involving multiple sinuses. It should also be considered in all cases of proptosis.


Spontaneous pain in patients with maxillary sinus carcinoma in relation to T-classification and direction of tumour spread. Spontaneous pain was one of many complaints on initial examination of 845 patients with maxillary sinus carcinoma. The pain was analysed; cheek, teeth, head and eye pain were compared with the T-classification and the anterior-posterior direction of invasion. The incidence of the cheek, teeth, head and eye pain was 48, 39, 29 and 23 per cent respectively. The incidence of both the cheek and teeth pain was increased according to the advancement of T-classification and invasion towards the posterior. Head and eye pain was often referred. In the localized posterior group which tend to be diagnosed late, spontaneous pain occurred in 15 to 48 per cent of the patients. Maxillary sinus carcinoma should always be a differential diagnosis in patients with unclear cheek, teeth, head and eye pain. A careful investigation should be performed in order to diagnose malignant diseases as early as possible.


Ethmoidal scleroma: endoscopic diagnosis and treatment. Twenty patients with medically treated rhinoscleroma and residual ethmoidal manifestations were examined using CT scanning. Cases with positive radiological data of the ethmoids underwent diagnostic and therapeutic nasal endoscopy. It has been found that ethmoidal scleroma is not as rare a condition as was previously thought. The diagnostic and therapeutic value of nasal endoscopy in ethmoidal scleroma is discussed.


Long-term effects of topical corticosteroids in the nose. In a prospective study, biopsies were taken from the septal mucosa in 21 patients of whom 11 had been using topical nasal corticosteroids. In contrast to the effect of long-term treatment with corticosteroids in the skin, but in accordance with previous investigations of the nasal mucosa, no histopathological changes of significance were found, although the biopsies were taken from different sites. These findings do not suggest that topically corticosteroids are harmful to the nasal mucosa.


Penetrating injuries to the oropharynx.

Penetrating injuries to the oropharynx. A review was made of 12 cases of penetrating injuries to the oropharynx seen at Musashino Red Cross Hospital during the period from 1984 to 1988, and their records were compared with those of past cases with similar injuries reported in a survey for the period between 1949 and 1959. Most of the patients were children under the age of four and were injured when they fell with a sharp-edged object in the mouth. Penetrating injuries to the oropharynx occasionally cause severe complications, including retropharyngeal abscess and mediastinitis. This type of injury should be called a 'pencil injury'.


Guillotine and dissection tonsillectomy in children. Tonsillectomy as an outpatient or same day-stay procedure is becoming increasingly popular. A retrospective study was performed on 1,049 children who underwent tonsillectomy and adenotonsillectomy either with guillotine or dissection with snare method. The dissection method was performed both under general anaesthesia and with local anaesthesia, but the guillotine method was performed only with local anaesthesia. Generally, bleeding control required no special intervention in the guillotine method but haemostasis was achieved by ligation and electrocauterization in one-third of the patients in the dissection group operated under general anaesthesia. The greatest percentage of haemorrhage in both methods occurred within the first four post-operative hours. There was a 1.8 per cent incidence of severe reactive haemorrhage required surgical intervention in the dissection group operated under general anaesthesia, but there was no such case in the guillotine group. The results of this study show that in carefully selected children guillotine tonsillectomy with local anaesthesia is a safe, time saving and cost-effective procedure.


Fibromatosis on the dorsum of the nose.

Fibromatosis on the dorsum of the nose. An extremely rare case of fibromatosis in a 25-year-old Indian male is reported. The clinical examination and pre-operative findings were suggestive of a benign neoplasm, probably of neurogenic origin. The mass was well circumscribed and could be shelled out en masse. Histopathological examination showed it to be fibromatosis. An external rhinoplasty approach enabled a complete wide excision to be performed without any resulting cosmetic defect.


Nasopharyngeal Corynebacterium ulcerans: a different diphtheria. A case of toxigenic Corynebacterium ulcerans infection is presented. The diagnosis was delayed and no anti-toxin administered. A nasopharyngeal biopsy was complicated by severe haemorrhage necessitating a post nasal pack. A brief review of the pathology and treatment of Corynebacterium ulcerans is given.


Adrenal suppression with intranasal betamethasone drops. Intranasal betamethasone sodium phosphate drops (Betnesol) are frequently used to relieve nasal congestion due to polyposis. We report a case of significant hypothalamic-pituitary-adrenal suppression secondary to the long-term use of intranasal betamethasone drops. This case emphasizes that the topical application of potent corticosteroids may produce systemic effects.