Ultrasonographic evaluation of knee joint synovitis in two patients with palindromic rheumatism.

Abstract The aim was to evaluate synovial proliferation ultrasonographically in order to identify the period of conversion from palindromic rheumatism to the early-stage of rheumatoid arthritis. Two patients, a 35-year-old man and a 44-year-old man, had been suffering from episodic attacks and remission of oligoarthralgia for 15 years and 6 years, respectively. Both patients were negative for rheumatoid factors, and exhibited slightly elevated levels of C-reactive protein and erythrocyte sedimentation rate at the times of the attacks. Radiograms of the affected joints showed no erosion of the bones in either patient. Ultrasonographic examination revealed both synovial effusion and synovial proliferation in the 35-year-old patient, suggesting conversion from palindromic rheumatism to rheumatoid arthritis, whereas only synovial effusion was found in the 44-year-old patient, suggesting the persistence of palindromic rheumatism. Ultrasonographic evaluations of synovial proliferation in the knee joints provide data that can be used to identify the period of conversion from palindromic rheumatism to the early-stage of rheumatoid arthritis.

Studies on spatial orientation and posture control and changes in otolith function due to linear acceleration loading.

Otolith function is directly affected by weightlessness at the time of movement in outer space, and changes occur in the mode of response. It has been known for some time that such changes occur in the posture and gait of astronauts just after they return from a trip into space. It is thought that the cause of these changes is disuse atrophy of the antigravity muscles. However, in the present study, experimental subjects underwent repeated linear acceleration loading over a long period of time, and instability of the head and a decrease in posture control, especially in relation to the gait, were observed for the first time. To date, it has been said that the otolith function has a close relationship with ocular counter rolling. However, when the otolith organ was stimulated, the response was seen to be head instability and an irregular effect on the gait. It is surmised that these findings will facilitate future research into the otolith function under gravity-free conditions.

[Postoperative MRSA infections in digestive tract surgery].

MRSA strains were first isolated in 1981 and have increased markedly from 1985 in our surgical ward. One hundred and ninety four strains of MRSA were isolated and 81 cases developed critical infections which were associated with enterocolitis, pneumonia and sepsis. There were many cases in esophageal cancer patients. Bacteriological features of the MRSA strains clearly changed in 1985 from IV to II coagulase type, accompanied with high resistance for antibiotics. Our management against nosocomial infection for MRSA started from April 1988. The number of MRSA cases decreased in 1989, increased in 1990 and decreased again in 1991. We are confident that our management is effective and we will take further efforts to choose the most adequate antibiotics after surgery in our surgical ward.

[A cases of antithrombin III (ATIII) deficiency associated with extrahepatic portal occlusion undergoing operation for esophgogastric varices].

A 23-year-old woman developed thrombosis of the superior mesenteric vein and underwent an extensive enterectomy. She was diagnosed to have ATIII deficiency with extrahepatic portal vein thrombosis and esophagogastric varices. She was admitted to our department and underwent esophageal mucosal transection and splenectomy. Her activities of ATIII were 46%, but ATIII activities of her family were over 90%. ATIII activities during perioperative period were kept more than 70% following administration of ATIII drug. After splenectomy thrombocythemia which was over 300 x 10(4)/mm3 appeared with severe headache and slight pain of hands. She was discharged on 76th postoperative day with no complications and collapse of esophageal varices.

[A case of Pickwickian syndrome with improvement of obesity-related sleep apnea following vertical banded gastroplasty].

The patient was 22-year-old male who had suffered from hypermotility during sleep and excessive daytime sleepiness, and 270% in excess body weight. Values of arterial blood gas analysis during sleep were 65mmHg in PaCO2 and 19mmHg in PaO2. He was diagnosed as morbid obesity with Pickwickian syndrome and underwent vertical banded gastroplasty. His body weight decreased from 170kg to 113kg four months after surgery and 107kg one year after surgery. The whole-night polyhypnographic sleep study was performed before and after operation and showed dramatic improvement of apnea index which was calculated by dividing the number of apneas by the total sleep time. We analyzed 199 case reports which had noted symptoms of Pickwickian syndrome between 1963 and 1989 in Japan. In many reported cases, body weight decreased transiently but returned to the level before medical treatment. Under these considerations, gastroplasty is a beneficial surgical treatment for the morbid obesity with Pickwickian syndrome.

Assortment of posthepatectomy hyperbilirubinemia by the occurring time with reference to indication of plasma exchange.

This study was undertaken to assort the group of posthepatectomy hyperbilirubinemia by occurring time for helping elucidate its indication of plasma exchange (PE). PE was carried out for 14 cases among 198 hepatectomized patients. The 14 cases were classified for 3 groups due to the period between operation and PE. 1: Early type (less than 2 weeks), 2:Intermediate type (2 less than-less than 8 weeks), 3: Late type (greater than 8 weeks). The results were as follows. Number (liver cirrhosis (LC)) [table: see text]. The effect was expected for the early groups since PE would remove overload against the regenerating residual liver. However, there were no survival cases among the early group or LC group. These results suggest that PE may be effective for the slowly increasing hyperbilirubinemia in not cirrhotic patients and that the state of hyperbilirubinemia is the terminal stage for LC patients even under the particular situation such as posthepatectomy.

Clinical experience of double filtration plasmapheresis for drug refractory neurological diseases.

The effect of therapeutic double filtration plasmapheresis (DFPP) was clinically investigated for drug refractory neurological disorders. DFPP therapy was performed 181 times for 10 patients who were treated with medical therapy of steroid or immunosuppressive drugs without any improvement of their symptoms. After the induction of DFPP therapy the neuromuscular disturbances were soon ameliorated in 9 cases of them. After DFPP, serum levels of IgG, IgA or IgM were decreased as follows: IgG 0.53 +/- 0.16; IgA 0.60 +/- 0.11; IgM 0.59 +/- 0.09 (M +/- SD). After the DFPP therapy there was no relapse in improved 9 cases. But we could not regard the immunologic markers as the index of efficacy of DFPP. Because serum levels of IgG, IgA or IgM showed a tendency to decrease by using drugs, when we didn't observe any improvement of symptoms. These results suggest that DFPP is a beneficial therapy for neurological diseases who had no effect with drug therapy, however, serum concentrations of the immunologic markers were not necessarily correlated to the severity.

[A case of fatal graft-versus-host disease following blood transfusion in esophageal cancer documented by homozygous changes of HLA typing].

A 72 year-old Japanese male with esophageal cancer underwent esophagectomy. After seemingly uneventful recovery, he developed high fever on 11 post-operative day (POD), rashes over the whole body on 13 POD and leukopenia on 15 POD. On 22 POD, thrombopenia and parenchymal bleeding of lungs were noted. He died on 26 POD after progressive hypoxia and hypotension. HLA type of peripheral lymphocytes on him changed homozygously to that of the transfused fresh blood. Skin biopsy showed mild leukocyte infiltration in the epidermis and the dyskeratotic keratinocytes were associated with a contiguous lymphocyte, the so-called satellite cell necrosis. In the findings of autopsy, aplastic bone marrow and atrophied spleen, whose weight was 14g, were noted. Based on the clinical picture, skin biopsy and HLA study findings, we diagnosed this case as post-transfusion GVHD. We think that high age, operative injury and preoperative irradiation might be inducement to reveal post-transfusion GVHD in this case.

[Benefits and risks associated with dissection of three regional lymph nodes (bilateral cervical, thoracic and abdominal) in thoracic esophageal carcinoma].

To obtain curability safely, we have employed dissection of three regional lymph nodes (the bilateral cervical, thoracic and abdominal lymph nodes) since 1983. The subjects were 111 (three regional group) of 158 patients with thoracic esophageal carcinoma operated on our department till 1988. When compared to 207 patients treated during the period from 1973 to 1982 (control group), the background factors of the subjects revealed that the three regional group included more patients with advanced carcinoma and more elderly patients over 70 years of age. Operative results were more favourable in the three regional group (5.3% vs 2.7%), although mean operative time was longer (5 hrs and 2 min vs 8 hrs and 38 min) and mean blood loss was higher (1,098ml vs 1,407ml). Moreover, the incidence of recurrent nerve paralysis was higher. Overall 5-year survival was 20.4% vs 22.3%, showing no significant difference. However, when stage distribution is taken into consideration, results in the three regional group may be regarded as improved. After dissection of the three regional lymphnodes, the pattern of lymph node metastasis of thoracic esophageal carcinoma has been made clearer to give useful information on the site in which further dissection of lymph node is required.

[Perioperative water and electrolyte metabolism and its abnormalities in aged patients].

The number of aged surgical patients is increasing due to the increase of aged people in the general population. Aged surgical patients above 65 years of age constituted about 30% of all ICU patients in our institution. Perioperative care for aged patients has now become one of the most important clinical activities in the ICU. The perioperative management for those aged patients should be performed with great care because these patients have some abnormalities in water and electrolyte metabolism. Aged patients showed decreased blood levels of atrial natriuretic peptide (ANP) and decreased creatinine clearance even in the preoperative period. The ANP level and the creatinine clearance showed significant negative correlation, indicating that one of the reasons for impaired renal function among aged patients could be the decreased ANP level in blood. The intraoperative insults to the aged surgical patients undergoing radical operation for esophageal cancer tended to be smaller compared to that in the younger patients. Intraoperative infusion volume and urinary output were also smaller in the aged group compared to those in the younger group. The postoperative infusion therapy in the ICU mainly consisted of intravenous hyperalimentation with decreased Na content and the transfusion of fresh frozen plasma. This regimen should be more suitable for the aged patients. Even though the aged and the younger group received the same infusion therapy during their postoperative ICU stay up to the 7th day, the aged patients showed the tendency of Na and Cl retention and increase in anion gap. However, these abnormalities in water and electrolyte metabolism were not so severe as to cause clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of bifemelane on central dopaminergic and cholinergic systems in rats].

The study served to examine the effects of bifemelane on central dopaminergic-cholinergic neuronal mechanisms in rats. Bifemelane (5-20 mg/kg) evoked yawning responses, the frequency being low. Bifemelane (10 mg/kg) as well as bromocriptine (2.5 mg/kg) potentiated physostigmine (0.2 mg/kg)-, bromocriptine (2.5 mg/kg)- or apomorphine (0.1 and 0.5 mg/kg)-induced yawning but completely inhibited pilocarpine-induced yawning. Pretreatment with sulpiride (20 mg/kg) and a low dose of haloperidol (0.02 mg/kg) reversed the stimulatory effect of bifemelane on physostigmine-induced yawning and the inhibitory effect of the drug on pilocarpine-induced yawning, whereas atropine (5 mg/kg) diminished these yawning responses. SK&38393 (2.0 mg/kg), a dopamine D-1 receptor agonist, markedly potentiated bifemelane- and bromocriptine-induced yawning but inhibited physostigmine-induced yawning, and did not affect pilocarpine-induced yawning. The increased yawning responses were blocked by atropine and a low dose of haloperidol. Bifemelane (10 mg/kg) and bromocriptine (2.5 mg/kg) tended to increase apomorphine (5 mg/kg)-induced oral stereotypy, such as licking and biting, but the increase was not significant. These results suggest that the effects of bifemelane on central dopaminergic and cholinergic neurons may be similar to those of bromocriptine.

Effects of age on behavioral responses to dopamine agonists in the rat.

This study served to examine the differential effects of age (rats aged 2 or 12 months) on behavioral responses induced by bromocriptine and apomorphine. Intraperitoneal (i.p.) injection of bromocriptine or apomorphine produced a lower frequency of yawning responses, in 12-month-old rats than in 2-month-old rats. Apomorphine produced a more pronounced stereotyped behavior in 12-month-old rats than in 2-month-old rats. Apomorphine, at 0.1 mg/kg administered after bromocriptine (1.0-20 mg/kg) potentiated yawning behavior. The frequency of yawning in 2-month-old rats was pronounced at 2.5 mg/kg of bromocriptine but only at 5 mg/kg 12-month-old rats. Apomorphine (0.1 mg/kg) did not produce perioral behavior in 2-month-old rats but did in 12-month-old rats. The apomorphine (1.0 mg/kg)-induced stereotypy was stimulated dose dependently by bromocriptine in 2-month-old-rats but not in 12-month-old rats. Bromocriptine did not produce this behavior when administered alone. Pretreatment of 2-month-old rats with reserpine, a catecholamine depletor, plus alpha-methyl-p-tyrosine, a tyrosine hydroxylase inhibitor, inhibited the yawning induced by bromocriptine but potentiated that induced by apomorphine. Such treatment did not significantly alter either bromocriptine or apomorphine-induced yawning responses in 12-month-old rats. The apomorphine-induced stereotypy in 2-month-old rats was markedly potentiated by catecholamine depletion but was not affected in 12-month-old rats. These results suggest that the increasing effect on stereotypy and decreasing effects on yawning in the 12-month-old rats seem to result in an alteration of potency and of the ratio of D-2 versus D-1 receptor activity.

Long term result of LDL selective plasma adsorption therapy on familial hypercholesterolemia.

A newly developed low density lipoprotein (LDL) selective adsorption column from the separated plasma was applied to one patient of heterozygous familial hypercholesterolemia for 20 months at intervals of two weeks. LDL selective adsorption column, Liposorber LA-40, contains 400 ml of swollen dextran sulfate cellulose beads. The long-term, 20 month results of treatment with LDL selective plasma adsorption therapy are reported. LDL selective plasma adsorption therapy by Liposorber is useful in decreasing LDL-cholesterol of familial hypercholesterolemia and is more specific and produces a smaller loss of useful components of the serum than the double filtration plasmapheresis treatment. This treatment is effective in improving clinical conditions of familial hypercholesterolemia. In spite of our lengthy treatment with this therapy, no blood transfusion and no replacement of fluids was done in 20 months.

Adsorption of lipoprotein containing apolipoprotein-B through plasma separation for treatment of familial hypercholesterolemia.

For the treatment of familial hypercholesterolemia, Liposorber LA-40 was clinically applied. The Liposorber is a commercially developed affinity adsorbent for plasma perfusion which selectivity adsorbs low density lipoproteins and very low density lipoproteins and is specially designed for plasmapheretic treatment of hypercholesterolemia. The Liposorber column, containing activated cellulose beads having an affinity for lipoprotein containing apolipoprotein-B, has an excellent adsorption capacity, excellent selectivity, minimum albumin loss. This new apheresis system was applied to 2 clinical cases. After seven months of trial perfusion every 2 weeks, patient condition was good, with a level of total cholesterol under 300 mg/dl. No replacement fluids were given during or after treatment. In this paper, clinical results of these patients were shown and the mechanism of adsorption of this specific adsorbent was discussed.