[Isolated coronary artery bypass grafting in octogenarians].

We evaluate the outcomes of isolated coronary artery bypass grafting (CABG) in high-risk octogenarians. There are 20 cases in 5 years, which contain 1 re-operation case, and 10 emergency cases. Nineteen cases were performed off-pump CABG (OPCAB), and conventional CABG was performed for only 1 case because of unstable hemodynamics with intraaortic balloon pumping (IABP). We generally performed CABG with aorta no-touch technique. There is no death case, and no serious complication like stroke. We used 23 artery and 11 vein grafts for CABG, and mean number of grafts per patient was 1.8+/-0.7. And "hybrid therapy" with percutaneous transluminal coronary angioplasty (PTCA) was done for 5 cases. Octogenarians are at increased risk for perioperative morbidity and mortality after CABG, but we have performed OPCAB for them and have had good results. And we think that aorta no-touch technique, proper selection and use of graft are important.

Giant coronary artery aneurysm arising from sinus node artery.

A giant coronary aneurysm arising from the sinus node artery is reported. Diagnosis of this lesion by computed tomography and angiography is illustrated. The operative management is described. "Off-pump" aneurysmectomy was successfully performed. The role of occlusion test of the aneurysm inflow tract is emphasized.

Correlation between induction of the mac25 gene and anti-proliferative effects of 1alpha,25(OH)2-D3 on breast cancer and leukemic cells.

In the differentiation of a myelomonocytic cell line U937 treated with 1alpha,25-dihydroxyvitamin D3 [1alpha,25(OH)2-D3], transient proliferation was observed prior to cell growth arrest. The expression of the p21 and p27 genes increased transiently and decreased quickly in the proliferation, suggesting that other genes may contribute to the growth arrest of the cell line after reduction of the p21 and p27 genes. The mac25 gene was isolated as a gene associated with cellular senescence and growth suppression. Despite a previous report that retinoic acid (RA) induced the mac25 gene, the mac25 gene did not increase in U937 cells treated with RA but did increase in the cells treated with 1alpha,25(OH)2-D3. The high level of the expression of the mac25 gene was detected for four days after the 1alpha,25(OH)2-D3 treatment. Therefore, mac25 may contribute to the growth arrest of U937 cells treated with 1,25-D3. The growth responses to 1alpha,25(OH)2-D3 and the expression of the mac25 gene of three other cancer cell lines (Saos-2, U2OS and MCF7) were studied. Although the growth suppression was observed in MCF7 cells treated with 1alpha,25(OH)2-D3 dose-dependently (1-100 nM of 1alpha,25(OH)2-D3), the treatment of 100 nM of 1alpha,25(OH)2-D3 had no effect on the growth of Saos-2 and U2OS cells. The expression of the mac25 gene was up-regulated in MCF7 cells treated with 100 nM of 1alpha,25(OH)2-D3, whereas no transcript of the mac25 gene was detected in Saos-2 and U2OS cells even when they were treated with 100 nM of 1alpha,25(OH)2-D3. These results suggest that the cellular response to 1alpha,25(OH)2-D3 may depend on the induction of the mac25 gene.

Characterization of the promoter of the murine mac25 gene.

It is important to know the regulation of the expression of the mac25 gene because of its reduced expression in several cancer cells and of its induction by some hormonal factors. We cloned the promoter region of the murine mac25 gene and found five repeats of CCAAT sequences, four Sp1 sites, a TATA-like sequence, and an initiator (INR) sequence. Analysis using luciferase reporter plasmids indicated that CCAAT repeats have a strong enhancer activity and the second to fourth Sp1 sites are essential for basal activity of the expression of the mac25 gene. The 1 kb region that contains the promoter and exon 1 of the mac25 gene was in a typical CpG island. As hypermethylation and reduced expression of the mac25 gene were reported in murine liver tumors, methylation of this CpG island may be directly associated with the expression of the mac25 gene and tumorigenesis.

Deep venous thrombosis after posterior spinal surgery.

STUDY DESIGN: A prospective clinical study using venography to evaluate deep venous thrombosis after posterior spinal surgery. OBJECTIVES: To demonstrate the prevalence of deep venous thrombosis after posterior spinal surgery with no prophylaxis. SUMMARY OF BACKGROUND DATA: There have been few studies about the occurrence of deep venous thrombosis after spinal surgery in which venography was used for screening. METHODS: Of the enrolled 134 patients undergoing posterior spinal surgery, 110 (82.1%) were examined with complete surveillance for deep venous thrombosis by venography. There were 64 males and 46 females. The average age at operation was 59.0 years (range, 14-86 years). The levels of the operation were cervical in 54, thoracic in 7, and lumbar in 49. All procedures were performed with patients under general anesthesia. Neither mechanical methods nor anticoagulation medications were used for prophylaxis against thromboembolism. Bilateral ascending venography was performed within 14 days after surgery. RESULTS: There were no patients with clinical signs of deep venous thrombosis and pulmonary embolism. However, 17 patients (15.5%) showed venographic evidence of deep venous thrombosis, of whom 16 had distal thrombi, and only one had a proximal thrombus. Deep venous thrombosis was venographically evident in 3 (5.6%) of 54 patients who underwent cervical procedures, and it was evident in 13 (26.5%) of 49 patients who underwent lumbar procedures. This difference was statistical significant (chi2 test, P = 0.003). Statistical comparison between patients who did and did not have deep venous thrombosis showed that age was statistically significant (Mann-Whitney test; P < 0.05). CONCLUSIONS: The prevalence of deep venous thrombosis after posterior spinal surgery is higher than generally recognized. Therefore, further study is necessary to clarify the appropriate method for screening and the effect of prophylaxis against thromboembolism after spinal surgery.

Inverted left atrial appendage.

An unexpected left atrial mass was found during postoperative echocardiography in a 17-years old man following aortic valve replacement, suggesting thrombus, vegetation and neoplasm. Reoperation showed that the mass to be an inverted left atrial appendage. Left ventricular venting may cause such inversion. To prevent this complication, we suggest the use of careful monitoring and intraoperative transesophageal echocardiography.

[Aortic valve replacement for aortic valve stenosis due to congenital bicuspid aortic valve with abnormal positioning of coronary orifice, pseudotendon, and persistent left superior vena cava, report of a case].

A patient was a 65-year-old female who had a complaint of palpitation was diagnosed aortic valve stenosis due to congenital bicuspid aortic valve with pseudotendon by the echocardiographic examination. We suspected left single coronary artery by the aortography and the coronary artery angiography. Aortic valve replacement and resection of pseudotendon was performed with Carbomedics supra-annular aortic valve (21 A). During surgery, persistent left superior vena cava was detected. High-posterior take-off right coronary artery was casually detected at aortic closure. Ventricular fibrillation due to insufficient supply of cardioplegic solution at right coronary area frequently occurred after cardio-pulmonary bypass and percutaneous cardiopulmonary support was required. The patient was discharged 32 days after the operation. Preoperative and intraoperative evaluation was important in the case of aortic valvular disease.

[A case of successful reoperation for distal aortic arch pseudoaneurysm after replacement of descending aorta].

The patient was a 69-year-old man who had undergone replacement of descending aorta under close clump technique. Hoarseness occurred 8 years after the operation. Computed tomography and aortography revealed a saccular aneurysm of the distal aortic arch. During surgery, the pseudoaneurysm originated from a intimal defect close to the proximal anastomotic site of the graft. Total aortic arch replacement was successfully performed under retrograde and selective cerebral perfusion. The postoperative course has been uneventful.

Combined superior-transseptal approach versus conventional approach for mitral valve surgery.

OBJECTIVE: This study was designed to evaluate the safety and effectiveness of the combined superior-transseptal approach for mitral valve surgery. METHODS: We compared the preoperative status, operative factors, and postoperative outcomes among patients having mitral valve operations with three atrial incisions. The incisions were transseptal (n = 40), combined superior-transseptal (n = 33), and left atrial (n = 22). RESULTS: The cardiopulmonary bypass time and cross-clamp time were significantly higher in the superior-transseptal group compared with the transseptal group. No significant difference in blood loss was found among the three groups. The incidence of sinus node dysfunction in the early postoperative period was more common in the superior-transseptal group. The maintenance of sinus rhythm at the mid-term follow-up in patients with preoperative sinus rhythm was not significantly different among the three groups. On the other hand, a few patients in the superior-transseptal and transseptal groups with the preoperative sinus rhythm developed sick sinus syndrome requiring permanent pacemaker implantation. CONCLUSIONS: The use of the combined superior-transseptal approach was safe and effective, and was not associated with a higher incidence of rhythm disturbance. Because this approach provided an optimal exposure of the mitral valve and subvalvular apparatus, it has been positively adopted for use in patients undergoing complex and difficult mitral valve operation. To use this approach for patients undergoing mitral valve surgery through this approach, however, further follow-up study of the sinus node function is necessary.

Bioabsorbable poly-L-lactide costal coaptation pins and their clinical application in thoracotomy.

BACKGROUND: To gain a wider operation field, ribs often are fractured as the intercostal retractor is expanded. Thoracotomy through the periosteal bed and other procedures have been performed to prevent rib fractures, and rib resections occasionally have been required. METHODS: We designed a poly-L-lactide costal coaptation pin. We used this pin in 184 thoracotomies and carried out long-term observation after insertion to evaluate its clinical efficacy and safety. Postoperative observation periods ranged from 1 to 58 months (mean +/-standard error, 21.6+/-1.2 months). We evaluated the costal pin according to its degree of fixation, categorizing it as "good," "fair," or "poor" in this respect. We also judged its lateral shift. RESULTS: We judged fixation as "good" in 130 cases (70.7%), and found no lateral shift in 103 cases (56%). Our overall evaluation indicated satisfactory results in 172 cases (93.5%). CONCLUSIONS: Rib fixation was secured in nearly all cases, and no side effects were encountered. We can confirm that the poly-L-lactide costal coaptation pin is a highly effective and safe device.

[A case of tuberculous granulomatous mediastinitis and constrictive pericarditis simulating malignant mediastinal tumor].

A case is 40-year-old man. He presented anterior chest pain. Pericardial effusion was pointed out and a tuberculin skin test was positive. Tuberculous pericarditis was highly suspected, so INH and RFP were medicated. After 6-month medication pericardial effusion decreased, but right pleural effusion appeared on chest X-ray. Chest CT revealed a thickening of pericardium extend to anterior mediastinal mass. Echocardiogram revealed a pressure gradient in right ventricle, which was compressed by the thickened pericardium. We underwent median sternotomy in order to rule out neoplastic diseases. Intraoperative pathologic diagnosis was granulomatous mediastinitis and pericarditis, so we resected granuloma as much as possible to decompress the heart. Although Mycobacterium tuberculosis was not found in the resected granuloma, it was most probable pathogen. He received additional antituberculous chemotherapy for 6 months.

[Simultaneous operation of intra-descending aorta bypass grafting and brachiocephalic artery reconstruction in a patient of aortitis syndrome].

A 42-year-old woman underwent concomitant intra-descending aorta bypass grafting and brachiocephalic artery reconstruction successfully. She was diagnosed as aortitis syndrome with brachiocephalic artery obstruction, severe stenosis of descending aorta and stenosis of right upper renal artery. Chief complaint was chest oppressive feeling, but none of brain nor upper extremity ischemia. Catheterization showed 100 mmHg pressure gradient across stenosis of descending aorta and 100 mmHg pressure gradient between ascending aorta and right brachial artery. In order to relieve hypertension and prevent right head and upper extremity ischemia, concomitant vascular reconstruction was performed using woven Dacron prostheses. Hypertension had subsided postoperatively, and she was relieved from any symptom.

[Cost-effectiveness analysis of prostatic cancer screening].

BACKGROUND: To evaluate how much mass screening for prostatic cancer (PC) would benefit the nation economically, cost-effectiveness of PC screening was analyzed. METHODS: The cost per life-year saved (cost-effectiveness ratio; CER) was compared between PC screening and other 5 already established cancer screenings in Japan by an analytical simulation model to estimate cost and effectiveness of various screening programs, which was proposed recently by Hisamichi and Kamae. RESULTS: Although CER in PC screening amounted 204 x 10(3) yen for males aged from 55 to 59 years of age, among males more than 60 years of age. CER became negative, which meant a positive balance might be obtained economically by the adoption of screening. CER of PC screening was similar to that of colorectal cancer screening, while was 2 to 14 times lower than that of the remaining 4 established cancer screenings. According to the sensitivity analysis, the rate of the prevalence of PC, as well as the rate of the examinees for the secondary study influenced remarkedly the cost-effectiveness of PC screening. CONCLUSION: The morbidity and mortality of PC has seriously increased in the past years in Japan and the number of PC patients in 2015 is anticipated to show a 5.19-fold increase of that in 1990. According to such considerable increase of PC patients in the near future, PC screening is thought to be an economically well-balanced public activity.

Metabolism of anandamide, an endogenous cannabinoid receptor ligand, in porcine ocular tissues.

Anandamide (arachidonylethanolamide) is an endogenous ligand for cannabinoid receptors, and exerts various cannabimimetic activities. Since cannabinoids and anandamide were pharmacologically active with the eye, we examined metabolism of anandamide in a variety of porcine ocular tissues. In the presence of ethanolamine, [14C]arachidonic acid was converted to [14C]anandamide by a homogenate of retina, choroid, iris, optic nerve and lacrimal gland with a specific enzyme activity of 1.9-4.2 nmol min-1 mg-1 protein at 37 degrees C. On the other hand, [14C]anandamide was hydrolysed to [14C]arachidonic acid by a homogenate of each tissue with a specific enzyme activity of 1.2-3.5 nmol min-1 mg-1 protein. Thus, both activities of anandamide synthase and hydrolase were found in these ocular tissues. As for the subcellular distribution, the two enzyme activities were mostly recovered in particulate fractions rather than the cytosol. With the retina microsome palmitic acid was converted to its ethanolamide at a lower rate than arachidonic acid, and palmitoylethanolamide was less active than anandamide as a substrate for the hydrolase.

[A histiocytosis X without histological findings: a new entity of histiocytosis X].

Histiocytosis X is a disorder of the reticuloendothelial system with manifestations usually present in the form of one of three entities, namely; Letterer-Siwe disease, Hand-Schüller-Christian disease and eosinophilic granuloma of the bone. A 32-year-old female was admitted to our hospital in July 1990 because of a bilateral diffuse granular abnormal shadow in the chest. She had a history of bilateral pneumothorax in July 1987. She had been suffering from diabetes insipidus since October 1987, and amenorrhea since January 1989. Miliary tuberculosis, fungus disease, pneumoconiosis, sarcoidosis and collagen disease of the lung were excluded by laboratory examinations, and by observation of the clinical course. Histiocytosis X often combines pneumothorax, diabetes insipidus, amenorrhea and an abnormal radiograph of the chest. We suspected this case was one of Histiocytosis X. But, in her lung biopsy, neither Langerhans cells nor Birbeck granules were found. Furthermore S100 protein immunoperoxidase stain was negative. Therefore, we posit the existence of a new and different subtype of Histiocytosis X without histological findings.

[Characterization of Rickettsia tsutsugamushi strains newly isolated in Ehime Prefecture, Japan].

Five strains of Rickettsia tsutsugamushi were isolated in Ehime Prefecture during December 1987 to January 1990. Of these, two strains, the Yamazaki and Noma-3, were isolated at Noma area of Imabari city and three strains, the Kakiwara-10, -11, -12, at Kakiwara area of Uwajima city. The Yamazaki strain was isolated from a patient of tsutsugamushi disease and the other strains from wild rodents (Apodemus speciosus). These strains showed virulence in euthymic mice. The calculated LD50 of the Yamazaki and Kakiwara-10 strains showed 10(-3.0) and 10(-1.8), respectively. The immunofluorescent antibody test using thirty monoclonal antibodies to six representative strains, the Gilliam, Karp, Kato, Irie, Hirano and Shimokoshi, revealed that two strains isolated at Noma area, the Yamazaki and Noma-3, were identified as the Karp type and three strains at Kakiwara area, the Kakiwara-10, -11, -12, were identified as the Kato type. It was clarified that the serotypic differences were present among the strains isolated in Ehime Prefecture. Moreover, these five strains isolated in Ehime Prefecture did not react with the serotype-specific monoclonal antibodies to the Irie, Hirano and Shimokoshi strains known as the representative strains of so-called new type of tsutsugamushi disease, showing antigenic differences.

Analysis of immunological characteristics of newly isolated strains of Rickettsia tsutsugamushi using monoclonal antibodies.

Since 1975, there has been an increase in the number of patients with tsutsugamushi disease in Japan, and marked antigenic heterogeneity has been found among newly isolated strains of Rickettsia tsutsugamushi. For antigenic analysis of these strains, we produced monoclonal antibodies against the Irie strain isolated in 1971, and the Hirano and Shimokoshi strains isolated in 1980. In all, 34 monoclonal antibodies were produced and their reactivities were determined by the immunofluorescent antibody test. The serological reactivity of the antibodies against these three strains and classic representative strains (Gilliam, Karp and Kato) showed varied reactive characteristics, i.e., serotype-specific, species-specific and intermediate reactivities. It was revealed that these strains are antigenically different from the classic ones. Moreover, by using the serotype-specific monoclonal antibodies, nine strains newly isolated in Miyazaki Prefecture were classified into the Irie and the Hirano types. The antigenicity of the Shimokoshi strain differed from those of the other strains used in this study. From these results, the strains of R. tsutsugamushi used in this study fell into six serotypes including the classic strains. SDS-PAGE and immunoblotting were performed to determine the molecular sizes of the antigenic polypeptides. The results revealed that the serotype-specific antigens belong to the 60-kDa class whereas the species-specific antigens belong to the 61-kDa, 60-kDa or 44-kDa class.

[The first case of tsutsugamushi disease in Ehime Prefecture].

The first case of tsutsugamushi disease in Ehime Prefecture was experienced in December 1987 with successful isolation of the causative agent. The patient was taken ill twelve days after infection. Immunofluorescent antibody tests using the isolate, Yamazaki strain, and Gilliam, Karp, Kato, Irie and Shimokoshi strains as antigens revealed that the specific antibodies against these antigens appeared and increased in the blood of the patient during the course of the disease. And the antibody titers to the Yamazaki antigen were the highest of these antigens. Agglutinin for Proteus OXK did not appear in the blood of the patient. The immunofluorescent antibody test using type-specific monoclonal antibodies to Gilliam, Karp, Kato, Irie and Shimokoshi strains and these five strains and the Yamazaki strain as antigens revealed that the Yamazaki strain was identified as Karp type of Rickettsia tsutsugamushi.