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Acute pulmonary embolism is a serious perioperative complication. Current guidelines focus on hemodynamic stabilization and rapid restoration of pulmonary artery blood flow. However, various complications, most notably bleeding, are associated with treatment of the embolism. We report a case of acute pulmonary embolism with cardiopulmonary arrest during orthopedic surgery. Prompt thrombolysis and gaining control of both thrombolytic therapy-induced bleeding from the wound and a hepatic cyst enabled the patient to recover without neurological deficits.

We attempted to assess coronary artery flow using adenosine-stress and dual-energy mode with dual-source CT (DE-CT). Data of 18 patients with suspected coronary arteries disease who had undergone cardiac DE-CT were retrospectively analyzed. The patients were divided into two groups: 10 patients who performed adenosine stress CT, and 8 patients who performed rest CT as controls. We reconstructed an iodine map and composite images at 120 kV (120 kV images) using raw data with scan parameters of 100 and 140 kV. We measured mean attenuation in the coronary artery proximal to the distal portion on both the iodine map and 120 kV images. Coronary enhancement ratio (CER) was calculated by dividing mean attenuation in the coronary artery by attenuation in the aortic root, and was used as an estimate of coronary enhancement. Coronary stenosis was identified as a reduction in diameter of >50% on CT angiogram, and myocardial ischemia was diagnosed by adenosine-stress myocardial perfusion scintigraphy. The iodine map showed that CER was significantly lower for ischemic territories (0.76 ± 0.06) or stenosed coronary arteries (0.77 ± 0.06) than for non-ischemic territories (0.95 ± 0.21, P = 0.02) or non-stenosed coronary arteries (1.07 ± 0.33, P

症例は64歳，女性．糖尿病の既往がある．2002年6月血痰，喀血が出現し，当院を受診した．胸部CTにて左上葉中心に淡いスリガラス様陰影を認めた．気管支動脈造影にて2カ所血管の拡張部を認め，塞栓術を施行した．その後血痰は減少し，肺の陰影も消退したが，左上葉に8×5mm大の小結節影が残存した．経過観察となったが，2003年1月再び喀血が出現し，胸腔鏡補助下に左上葉切除術を施行した．病理組織検査にて肉芽形成を伴う気管支炎像があり，一部にムコールの菌塊が充満する像を認め，肺ムコール症と診断した．手術後6年2カ月を経過し，再発なく糖尿病外来に通院中である．肺ムコール症の頻度は稀で，免疫能低下状態で発症することの多い予後不良な疾患である．自験例は糖尿病があり二次性といえるが，左上葉の小結節影にムコールが付着・増殖した腐生性の要因も考えられた．

症例は68歳女性．慢性副鼻腔炎の既往がある．2003年11月，胸部CT検査にて右S9に5cm大の結節影とS8に小結節影を指摘された．2004年4月，CTにて右S9の腫瘤は増大し，内部に空洞と液面形成を認めた．また，両肺野に新たな小結節の増加を認めた．気管支鏡検査にて悪性所見なく，確定診断目的に開胸下右下葉切除術を施行し，diffuse large B-cell lymphoma（DLBL）の診断を得た．肺原発悪性リンパ腫は既存の肺構造を破壊することなく病変が広がる特徴があり空洞形成を呈することは稀である．しかし，自験例を含め空洞形成をきたした症例は数例ありいずれもDLBLであった．肺原発悪性リンパ腫のうち大部分が低悪性度のmucosa-associated lymphoid tissue（MALT）lymphomaであり，より悪性度の高い稀なDLBLでは壊死傾向を示し空洞形成をきたす可能性が考えられた．

症例は73歳, 男性. 1999年, 胃癌にて胃全摘術を受けた既往がある. 2004年5月, 全身倦怠感から近医を受診し肺炎を指摘され, 6月2日当院内科入院. 入院後イレウスと間質性肺炎を指摘された. 6月9日, イレウスの悪化がありイレウス管挿入し改善が認められた. しかし6月12日, 強い腹痛と上腹部に可動性のある腫瘤を触知するようになった. 腹部CT検査にて腸重積症と診断し, 緊急手術を行った. 空腸に約20cmにわたる順行性の重積があり, 用手整復は不可能で空腸部分切除術を施行した. イレウス管留置により発症した腸重積57例のうち胃切除症例が19例と多いものの, Billroth I法再建後が12例と最多で胃全摘後は3例であった. 胃全摘後症例では残胃が無くループをつくる余裕が少ないため腸重積を発症し易いが, 上部小腸に可動性が保たれており, Billroth I法に比べ発症が少ないものと考えられる. 胃全摘後症例のイレウス管留置には注意が心要である.

We evaluated the image quality and diagnostic performance of late iodine enhancement (LIE) in dual-source computed tomography (DSCT) with low kilo-voltage peak (kVp) images and a denoise filter for the detection of acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE) magnetic resonance imaging (MRI). The Hospital Ethics Committee approved the study protocol. Before discharge, 19 patients who received percutaneous coronary intervention after AMI underwent DSCT and 1.5 T MRI. Immediately after coronary computed tomography (CT) angiography, contrast medium was administered at a slow injection rate. LIE-CT scans were acquired via dual-energy CT and reconstructed as 100-, 140-kVp, and mixed images. An iterative three-dimensional edge-preserved smoothing filter was applied to the 100-kVp images to obtain denoised 100-kVp images. The mixed, 140-kVp, 100-kVp, and denoised 100-kVp images were assessed using contrast-to-noise ratio (CNR), and their diagnostic performance in comparison with MRI and infarcted volumes were evaluated. Three hundred four segments of 19 patients were evaluated. Fifty-three segments showed LGE in MRI. The median CNR of the mixed, 140-, 100-kVp and denoised 100-kVp images was 3.49, 1.21, 3.57, and 6.08, respectively. The median CNR was significantly higher in the denoised 100-kVp images than in the other three images (P

To address a possible link between systemic and coronary inflammation in the setting of acute coronary syndromes, the authors examined both levels of 3 inflammatory mediators such as high sensitive C-reactive protein (hs-CRP), interleukin (IL)-6, and matrix metalloproteinase (MMP)-9 in patients with the early phase of acute myocardial infarction (AMI). In total, 20 patients with AMI showing minimal elevation of cardiac enzymes were studied. Before angioplasty, peripheral blood and culprit coronary thrombus were sampled to compare systemic and coronary levels of hs-CRP, IL-6, and MMP-9. Relation of systemic levels of hs-CRP and IL-6 to culprit coronary morphology was also evaluated by the use of intravascular ultrasound. Systemic and coronary levels of hs-CRP were nearly equivalent (4.3 +/- 5.0 vs 4.7 +/- 5.4 mg/L, p = 0.279), whereas IL-6 and MMP-9 showed higher in coronary levels than in systemic levels (169 +/- 154 vs 93 +/- 107 microg/mL, p = 0.002 and 164 +/- 116 vs 103 +/- 94 ng/mL, p = 0.018, respectively). Systemic levels of hs-CRP were correlated with coronary levels of IL-6 (r = 0.566, p = 0.009). Culprit coronary plaque area demonstrated a positive relation with systemic levels of hs-CRP (r = 0.466, p = 0.038) and also IL-6 (r = 0.707, p0.001). The present study may provide an important insight into the link between systemic and coronary levels of inflammation, which is also associated with vulnerable coronary morphology in the setting of acute coronary syndromes.

Two rare cases, each with a solitary brain metastasis from breast cancer with extensive nodal metastases as the first site of distant metastasis, were locally treated with surgery and irradiation. The outcome of the two treated cases indicated an excellent and non-recurrent post-therapeutic survival period of more than 3 and 8 years, respectively. In a 50-year-old woman (Case 1), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with doxorubicin and tegafur-uracil (UFT) and hormonal therapy with tamoxifen for left breast cancer. The brain metastasis was treated twice surgically followed by radiotherapy. One year and 6 months later, local recurrence of the brain metastasis appeared and was treated surgically again. No other treatment was done thereafter. Since then, no other distant or lymph node metastasis occurred, and to date her outcome has been non-eventful for 8 years and 5 months. In a 63-year-old woman (Case 2), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with cyclophosphamide, epirubicin and fluorouracil (CEF) for right breast cancer. The brain metastasis was treated locally with surgery and irradiation of 50 Gy. She thereafter received no further treatments. Since then neither distant metastases nor local recurrence have developed, and to date the post-treatment outcome has been uneventful for 37 months. Our findings suggest that patients who developed a solitary brain metastasis as the first site of distant metastasis from breast cancer have a chance of achieving long-term disease-free survival when treated with aggressive local therapy, even in the presence of extensive lymph node metastases at the primary surgery site for breast cancer.

Objective The aim of this study was to evaluate the efficacy of the objective radiologic analysis of high-resolution computed tomographic images of small peripheral non-small cell lung cancer and to select the candidates for curative limited resection. Methods High-resolution computed tomographic images of 146 surgically resected T1 N0 M0 peripheral non-small cell lung cancers were analyzed by using National Institutes of Health image software and classified on the basis of the percentage of ground-glass opacity within the tumor. Results Eighty-seven percent of tumors with ground-glass opacity ratios of 90% to 100% (type I) were diagnosed as noninvasive bronchioloalveolar carcinoma, whereas 55.6% of tumors with ground-glass opacity ratios of 50% to 89% (type II) consisted of adenocarcinoma. Tumors with ground-glass opacity ratios of 50% or more (type I/II) had no nodal involvement, whereas nodal metastases were identified in 20.0% of tumors with ground-glass opacity ratios of 10% to 49% (type III) and 24.4% of tumors with ground-glass opacity ratios of less than 10% (type IV). No tumors with ground-glass opacity ratios of 50% or more showed vessel infiltration, except for one lesion with a ground-glass opacity ratio of 50%. The 3-year disease-free survival was 97.7% for type I/II, 86.1% for type III, and 78.5% for type IV tumors. Conclusions The objective quantitative radiologic analysis with National Institutes of Health image software exhibited a good correlation with the histologic classification, pathologic invasiveness, and postoperative outcome of small peripheral lung cancer. Patients with tumors that have ground-glass opacity ratios of greater than 50% are considered to be possible candidates for limited pulmonary resection.

Study objectives: Cardiac sympathetic nerve dysfunction is related to poor clinical outcome in patients with several different heart diseases. However, it is not clear whether cardiac sympathetic nerve activity is useful for predicting the onset of congestive heart failure (CHF) in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the prognostic value of performing 123 I-labeled metaiodobenzylguanidine (MIBG) scintigraphy in patients with HCM in comparison with other conventional prognostic variables. Methods 123 I-labeled MIBG images were obtained from 84 HCM patients without prior CHF. After measurement of cardiac function, the patients were followed up for 9 to 86 months in our hospital. Results: According to the cutoff values for the heart/mediastinum ratio (H/M) on delayed images of control subjects ( ie , mean − 1 and 2 SDs), the patients were subdivided into the following three groups: group A (H/M, > 2.11; 34 patients); group B (H/M, 2 test revealed that the delayed H/M was the most powerful predictor of CHF among the variables. Conclusion: Cardiac sympathetic nerve activity is useful for predicting the onset of CHF in patients with HCM.

標準的医療の実施と医療費削減を目的としてクリニカルパス (CP) の導入がすすんでいるが, 呼吸器外科領域では悪性腫瘍を対象としたCPはまだ普及していない.我々は肺癌に対する胸腔鏡補助下肺葉切除術のCPを作成しその有用性と安全性を検討した.2000年6月から2001年12月までに胸腔鏡補助下肺葉切除術を施行した肺癌64症例に対してCPを用いた術後管理を行った.術後在院日数はCP導入前の79例と比較して有意に短縮した.主なバリアンスは7例 (10.9%) に発生したが, 合併症はCPに関連するものはなかった.入院診療費用はCP導入前後で差はなかったが1日あたりの診療費用はやや増加する傾向にあった.胸腔鏡補助下肺葉切除術におけるCPの実施は安全であり, 入院期間の短縮, 治療の標準化に有用であると思われた.

症例は50歳男性.器質化肺炎に対する胸腔鏡下肺生検後の経過観察中に胸部X線検査で右中肺野に異常影を認め, 精査目的で当科入院となった.胸部CT検査で右上葉の腫瘍と縦隔リンパ節腫大を認め, 右肺癌と診断し, 右上葉切除術およびND2aリンパ節郭清を行った.病理検査の結果, 上葉の腫瘍は肺腺癌であったが#3, 4縦隔リンパ節は大細胞癌と診断された.縦隔リンパ節癌の原発巣を検索するも発見できず, 肺腺癌 (pT1N0M0 stage I A) と原発不明縦隔リンパ節癌の同時性重複癌と診断した.術後23ヵ月無再発生存中である.本邦において肺門あるいは頚部リンパ節癌を伴わない縦隔リンパ節単独の原発不明癌は自験例を含め22例の報告があるが, 組織型の異なる原発肺癌を重複した症例は報告がない.

We report a rare and unique case of possible extrapulmonary tuberculosis in an 83-year-old man who had cardiac tamponade and paroxysmal atrial flutter. The patient was admitted to our hospital because of syncope. The cardiac tamponade and paroxysmal atrial flutter were treated by pericardiocentesis and drainage of bloody pericardial fluid. Mycobacterium tuberculosis was not detected in diagnostic specimens, nor was any evidence of malignancy found. The remarkable elevation of adenosine deaminase and the predominance of lymphocytes in the pericardial fluid, considering the past history of tuberculosis, led to a diagnosis of extrapulmonary tuberculosis. After receiving standard antituberculous therapy by ethambutol, isoniazid, and rifampicin, the patient recovered and has remained well up to the present day. Thirty-six months have passed since his recovery without the recurrence of cardiac tamponade or any other cardiac events.

Background With recent advances in low-dose helical computed tomography (CT), detection of ground-glass opacity (GGO) has increased. The aim of this study was to correlate high-resolution CT (HRCT) findings with pathologic features and to evaluate the efficacy of thoracoscopic limited resection for focal GGO, which were selected based on HRCT findings. Methods Focal GGO lesions were classified into two subtypes based on HRCT findings: pure type and mixed type. Ninety-six patients with persistent GGO 2 cm or less in diameter underwent pulmonary resection from January 1997 to December 2001. Among these, thoracoscopic wedge resection was performed prospectively between June 2000 and December 2001 in 33 patients with pure GGO lesions that were 1 cm or less. Results Thoracoscopic wedge resection was completed with complete safety. The histologic diagnoses of these 33 lesions were adenocarcinoma in 1, bronchioloalveolar carcinoma (BAC) in 23, and atypical adenomatous hyperplasia (AAH) in 9. No patients have had any evidence of tumor recurrence to date. Of the total 96 GGO lesions, 93.0% (53/57) of pure GGO 1 cm or less were BAC or AAH, whereas 38.5% (15/39) of pure GGO larger than 1 cm or mixed GGO were adenocarcinoma. Conclusions Pure GGO 1 cm or less was characteristic of noninvasive lesions. Thoracoscopic limited resection for small GGO lesions selected by HRCT was valid.

The incidence of pulmonary embolism(PE)has been increasing although it considered lower in Japan than in the West. We report 5 cases of PE after gastrointestinal surgery from January 1994 to March 2001 representing 0.2% of surgically treated patients during that period. In 4 cases except a light PE patient it oc‑ curred when they first walked after surgery. 1 case of PE occurred despite using intermittent pneumatic compression(IPC)during surgery to prevent it. We diagnosed PE by pulmonary perfusion scintigraphy or thoracic computed tomography(CT) . We conducted anticoagulant therapy using heparin and thrombolytic therapy using urokinase or tissue plasminogen activator(t‑PA)immediately after the diagnosis. We could save 3 patients including 1 with light PE and 2 treated by t‑PA. Serious complications in thrombolytic therapy occurred in 3(2 massive bleedings and 1 extensive cerebral hemorrhage). PE is the most critical complication after gastrointestinal surgery so more prevention as low‑dose unfractionated heparin or elastic stockings may be necessary in high risk group of PE.

This study was designed to compare the efficacy of bevantolol, a beta(1)-selective blocker with alpha-blockade and vasodilating activity, with that of metoprolol, a beta(1)-selective receptor blocker, for the treatment of idiopathic dilated cardiomyopathy (DCM). Forty-one patients with DCM were enrolled to receive either bevantolol or metoprolol in addition to the standard therapy for DCM. They were classified into two groups: 16 patients were treated with bevantolol and 25 were treated with metoprolol. Echocardiographic parameters and atrial and brain natriuretic peptides (ANP, BNP) were measured before treatment and after 6 months of treatment. Left ventricular dimension at end-diastole and end-systole was significantly lower and fractional shortening was significantly higher after treatment than before treatment in both groups. The plasma ANP and BNP levels were significantly decreased in both groups. Changes in all variables, except for systolic blood pressure, showed no significant differences between the two groups. In conclusion, bevantolol showed parallel beneficial effects to those of metoprolol on cardiac function and natriuretic peptides in patients with DCM.

Arterial compliance is associated with the first stage of hypertension and atherosclerosis. We propose here a compliance index, which measures pulsating renal blood flow distribution using a power Doppler ultrasound (US). We assessed the relationship between the compliance index and blood pressure and between the compliance index and risk factors of atherosclerosis. The subjects consisted of 136 consecutive patients (96 males, 40 females) who underwent a physical checkup. Ages ranged from 40 to 60 years with a mean of 50.1 years. Patients with past renal disease and/or renal dysfunction were excluded. Using a power Doppler US combined with an ECG-gated and echo-tracking system, we recorded the vascular distribution of the renal parenchyma at 8 to 10 time points during an interval of the R wave of the ECG. Using a color pixel counting technique, we calculated the area (A) corresponding to the colored vascular distribution at power Doppler US. The relationships between A and the time points (t) were fitted to a quadratic equation. The compliance index of renal parenchymal vessels was obtained by twice differentiating the quadratic equation obtained above (d2A/dt2), and taking the result as a new hemodynamic index. In the univariate correlation analysis, the compliance index was correlated with age (r=-0.26, p=0.002), systolic blood pressure (r=-0.33, p=0.0001), diastolic blood pressure (r=-0.45, p

Insulin-like growth factor-1 (IGF-1) is important in the hypertrophic response of the myocardium, so the present study was designed to elucidate whether the circulating levels of IGF-1 and its binding proteins (IGFBPs) are related to the disease condition of patients with hypertrophic cardiomyopathy (HCM), in particular the occurrence of congestive heart failure (CHF). The study group comprised 124 patients with HCM and 15 healthy control subjects. The HCM patients were subdivided into 3 groups: 39 with hypertrophic obstructive cardiomyopathy (HOCM), 67 with hypertrophic non-obstructive cardiomyopathy (HNCM), and 18 with HCM and a history of CHF (HF-HCM, n=18). Serum levels of IGF-1 and IGFBPs (IGFBP-1 and -3) were compared between groups. IGF-1 levels were significantly higher in patients with HOCM and HNCM, and lower in patients with HF-HCM than in control subjects (p

This study was performed to evaluate whether thallium-201 myocardial scintigraphy (Tl-201) and iodine-123-metaiodobenzylguanidine (MIBG) myocardial scintigraphy could predict the usefulness of beta-blocker therapy in patients with dilated cardiomyopathy (DCM). Tl-201 and MIBG were performed in 47 patients before beta-blocker therapy. Patients were classified into group A, if their cardiac function improved, and group B, whose function remained unchanged. Two types of extent score (ES) by Tl-201 were proposed to quantitate myocardial damage, mean-2SD (ES-2) and mean-3SD (ES-3). The ES difference between ES-2 and ES-3 was calculated, and according to ES and ES difference, DCM cases were classified into 3 groups: mild-defect type (mild-type), moderate-defect type (moderate-type) and severe-defect type (severe-type). The heart-to-mediastinum (H/M) MIBG uptake ratio was evaluated, and the percent washout ratio of myocardial MIBG was obtained from these data. Group A comprised 18 mild-type, 14 moderate-type and 1 severe-type cases, and group B comprised 5 mild-type, 4 moderate-type and 5 severe-type cases. A significant relation was observed between the defect type on Tl-201 and the response to beta-blocker therapy (p=0.0090). Both H/M MIBG uptake ratios and washout ratio were not significantly different in the 2 groups. Tl-201 may be useful for predicting the response to beta-blocker therapy in patients with DCM.

Purpose: The purpose of this study was to investigate the utility incremental diagnostic value of combined assessment with coronary CT angiography (CCTA) and myocardial CT perfusion imaging (CTP) using dual-energy technology with an Adenosine Triphosphate (ATP) load technique. Materials and methods: Twenty-one patients underwent ATP-provocation dual-energy CT and CAG. We compared the diagnostic accuracy with CAG, for ischemic region due coronary stenosis by CCTA alone and CCTA combined with CTP (Combined CCTA/CTP). Results: All of 21 patients CTP images could be evaluated, however 8 CCTA images could not be evaluated by calcification and motion artifact, so assessability was 61.9% (13/21) for CCTA alone, and 100% for Combined CCTA/ CTP. With CAG results as a comparison, the sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 83.3% (20/24), 74.4% (29/39), 66.7% (20/30), and 87.8% (29/33) for CCTA alone, and 66.7% (16/24), 92.3% (36/39), 84.2% (16/19), and 81.8% (36/44) for combined CCTA/CTP. The diagnostic accuracy of the two methods were 77.8% (49/63) and 82.5% (52/63). Conclusion: Dual-energy CT may be a useful modality for perfusion assessment and correlated well with the severity of stenosis on CAG. This technique may even be of use in cases of severe calcification in the coronary artery wall.

A 65-year-old Japanese woman with dilated cardiomyopathy, hypothyroidism and refractory sustained ventricular tachycardia experienced a near-death hypoglycemic syncope. The attack seemed to be induced by a high level of serum insulin, probably due to cibenzoline and by concomitant use of an angiotensin converting enzyme inhibitor (ACEI). Additionally, decreased food intake because of a severe toothache may have contributed to the deterioration of her condition. This case warns cardiologists that a combined cibenzoline and ACEI therapy can provoke serious adverse effects such as hypoglycemic syncope in the elderly. Therefore, the possibility of a hypoglycemic attack associated with these drugs should be explained to patients who are in poor condition.

The effect of cibenzoline on left ventricular diastolic function was investigated in patients with hypertrophic cardiomyopathy (HCM). Before and 2 h after an oral administration of 200 mg of cibenzoline, echocardiographic, apexcardiographic and gated radionuclide angiographic studies were performed in 12 patients with hypertrophic obstructive cardiomyopathy (HOCM) and 7 with hypertrophic nonobstructive cardiomyopathy (HNCM). After administration of cibenzoline, the left ventricular pressure gradient decreased from 96+/-33 mmHg to 29+/-22 mmHg (

原発性肺癌に対する胸腔鏡補助下肺葉切除術 (以下VATS葉切) の意義について検討した. 当施設では1995年4月から2000年12月までに98例の肺癌症例にVATS葉切を施行した. 対象例の臨床病期はIA 80例, IB 13例, IIA 2例, IIIA 2例, IIIB 1例で, 病理病期はIA 65例, IB 18例, IIA 4例, IIB 3例, IIIA 7例, IIIB 1例であった. VATS葉切に要した手術時間は183.7±52.5分 (95～330分), 術中出血量は203.9±230.0ml (15～1345ml) であった. cIA期VATS葉切施行例を同時期に開胸によって葉切を施行したcIA 57例と比較すると, 3年生存率は開胸症例が73.0%, VATS葉切が91.7%で有意にVATS葉切が予後良好であった (p=0.02). 無再発3年生存率および腫瘍径2cm以上の症例の無再発3年生存率は差がなかった. 術後在院日数はVATS葉切が10.8±4.1日で有意に短かった (p

This study sought to clarify major complications associated with acetylcholine testing. Serious major complications, such as sustained ventricular tachycardia, shock, and cardiac tamponade were determined in 4 of 715 patients (0.56%), but no cases of death or irreversible complications occurred. The spasm provocation test using acetylcholine should be performed carefully, although it is considered a safe and reliable method.

The clinicopathologic characteristics of atypical adenomatous hyperplasia (AAH) remain unclear. A total of 137 patients underwent resection for adenocarcinoma of the lung at our institution. Examination of resected lung tissue showed that in addition to adenocarcinoma AAH was present in 26 cases and was not present in 111 cases. All nonsmokers with AAH ( n =13) had earlier-stage disease (stage IA, IB, IIA, and IIB) and no history of respiratory disease. Among patients with stage IA disease, the relapse-free and overall survival curves for those with AAH ( n =14) tended to be better than for those without AAH ( n =40), but the difference was not statistically significant ( P =0.056 and 0.087, respectively). Concurrent presence of AAH may be a favorable prognostic indicator in patients with stage IA adenocarcinoma.

This study sought to compare the clinical usefulness of the hyperventilation plus cold stress test or the hyperventilation combined with accelerated exercise test with other single tests in patients with coronary spastic angina. The study examined 24 patients (23 men, mean age 66 years) with angiographically confirmed coronary spastic angina and less than 50% stenosis. Moreover, none had spontaneous ST segment elevation before the study. Under no medication for at least 24 h prior, 4 procedures were performed from 09.00 h to 11.00 h: (i) a hyperventilation test for 5 min (HV(5)); (ii) HV(5) combined with a cold stress test for the last 2 min (HV(5)+CS(2)); (iii) a treadmill exercise test based on Bruce's protocol (TM(3)); and (iv) a treadmill exercise test accelerated at 1 min intervals according to Bruce's protocol immediately after HV(5) (HV(5)+TM(1)). The rate of appearance of chest pain and ischemia-induced ECG changes due to HV(5)+TM(1) were significantly higher than the other 3 tests. HV(5)+CS(2) was not superior to HV(5) alone. The incidence of provoked ST segment elevation due to HV(5)+TM(1) was higher than with the other 3 procedures. Thus, in patients with coronary spastic angina, no spontaneous ST segment elevation and near normal coronary arteries, HV(5)+CS(2) was no more useful than HV(5) alone. It is recommended that the newly designed HV(5)+TM(1) combination test be used for documenting evidence of ischemia in patients with coronary spastic angina, low disease activity and near normal coronary arteries.

非小細胞肺癌切除例において転移リンパ節個数による予後解析を行い, 現行の解剖学的広がりによるN因子と予後因子としての有用性を比較した. 当院で切除した非小細胞肺癌180例を転移リンパ節個数により0個, 1～3個, 4～7個, 8個以上の4群に分類し予後を比較したところ, 転移個数が増えるほど予後不良の傾向があり, 1～3個群と8個以上群の間に有意差を認めた (p=0.02). 縦隔リンパ節転移陽性例においても1～3個群は他の陽性群より予後が良好な傾向にあり, 長期生存例も存在した. 他の臨床病理学的因子との多変量解析の結果, 転移リンパ節個数は現行のpNnumberと同等の独立した予後規定因子であると考えられた. しかし, 転移個数は解剖学的広がりと相関すること, 臨床病期診断には用いられないこと, 郭清範囲によって個数が変わることなどを考慮すると, 実際のN因子として用いるには現行の解剖学的分類のほうがより簡便で適切であると考えられた.

To the Editor: The new onset of right bundle branch block (RBBB) was identified as a potent predictor of adverse outcome in patients with ST-segment elevation myocardial infarction (STEMI) in the thrombolytic era ([1][1]). In the primary percutaneous coronary intervention (PCI) era ([2][2]), well

An 80-year-old woman being treated with anti-hypertensive drugs developed eruption and itching of the skin. High fever and lymph node enlargement subsequently developed in spite of discontinuing all antihypertensive drugs, and she was admitted to our hospital. At the initial examination, multiple papules were noted over the entire body, and the skin showed thickening and lichenification with scratch marks. There was also generalized enlargement of the superficial lymph nodes. From these findings, her condition was diagnosed as chronic prurigo due to drug allergy. Laboratory tests showed inflammatory findings, anemia and a high serum level of IgE. Analysis of the surface marker of peripheral lymphocytes revealed no abnormalities. Bacteriologic cultures of blood revealed methicillin-resistant Staphylococcus aureus (MRSA). Histologic examination of the lymph nodes revealed chronic reactive lymphadenitis with a follicular pattern. She was strongly suspected of having MRSA septicemia, and so combination chemotherapy with vancomycin, minocycline and cefoperazone/sulbactam was started. However, 1 month after initiation of chemotherapy, the low-grade fever, eruption and moderate inflammatory findings persisted, and culture of the eruptions revealed MRSA. The prurigo was therefore considered to be the source of the septicemia, and daily application of diflucortolone ointment containing 3% acetic acid was started. Thereafter, the clinical and laboratory findings showed a rapid improvement. MRSA infections usually occur in compromised patients who are receiving antibiotics during prolonged hospitalization. The present case, who did not have any underlying disease, indicates that old-age is also an important factor for the development of MRSA septicemia.

Indications of thoracoscopic surgery has been increasingly extended with the improvement in the instrument and operative procedure. Recently we successfully resected a large mediastinal teratoma which extended to the neck by thoracoscopic surgery with collar incision of the neck. A 35-year-old man was admitted to the hospital because of a tumor shadow on a chest X-ray film. Computed tomography and magnetic resonance imaging revealed that the tumor was a large mediastinal teratoma extending to the neck. Aiming at a minimally invasive surgery, we performed a thoracoscopic surgery combined with collar incision of the neck. After the upper portion of the tumor extending to the neck was divided by the transcervical approach, the tumor was extirpated by the thoracoscopic procedure. It is thought that the method is safe and minimally invasive even for large mediastinal benign tumors.

1985年から1993年の間に臨床病期1期と診断し切除した原発性肺癌109例について検討した.術前病期診断の正診率は59.6%であり, 不一致の原因となった因子はNが最も多く, ついでpmであった.特に腺癌においては, 腫瘍径が30mmを超すとNおよびpm陽性率が有意に高率であった.予後についても, 腺癌, 扁平上皮癌ともに腫瘍径が30mmを超える症例では有意に不良であった.以上より, T2肺癌はより積極的な診断手技を用いて正確な病期診断を行い適切な治療法の選択が必要であると考えられた.一方, 末梢型TINO肺癌ではN2例は少数であり, 侵襲の少ない術式の選択が可能であると思われた.

341:217–225. 6. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, Aylward P, Topol EJ, Califf RM. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. N Engl J Med 1999;341:226–232. 7. Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, Fioretti PM, Simoons ML, Battler A. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin: The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23:1190–1201.

A 72-year-old woman who had idiopathic interstitial pneumonia was admitted due to general fatigue. Echocardiography revealed asymmetric septal hypertrophy and systolic anterior movement of the mitral valve. In addition, Doppler echocardiography revealed a pressure gradient of 52 mmHg in the left ventricular outflow tract. Hypertrophic obstructive cardiomyopathy was diagnosed. Because she had a respiratory disease, she was treated with cibenzoline instead of beta-blockers. After treatment her pressure gradient decreased to 10 mmHg, but respiratory symptom remained unchanged. This finding suggests that cibenzoline is useful for patients with hypertrophic obstructive cardiomyopathy complicated with respiratory disease.

An 18-year-old male patient with biventricular hypertrophic obstructive cardiomyopathy (HOCM) had successful reduction of the pressure gradients by cibenzoline. At 11 months after birth, he was first diagnosed with cardiac murmurs and by the age of 5 years, he was diagnosed with subpulmonic infundibular stenosis with a pressure gradient of 10 mmHg by cardiac catheterization. At the age of 14, re-catherterization revealed hypertrophic cardiomyopathy with isolated obstruction of the right ventricular outflow tract, with a pressure gradient of 70 mmHg, but no obstruction in the left ventricle. He began daily treatment with 30 mg propranolol. At the age of 18, he was admitted for cardiac evaluation. An echocardiogram revealed left mid-ventricular and subpulmonic obstructions associated with pressure gradients of 88 mmHg and 65 mmHg, respectively. A single oral dose of 200 mg of cibenzoline decreased the pressure gradients in the left and right ventricles (38 mmHg and 36 mmHg, respectively). He was then given 300 mg daily of cibenzoline, and both pressure gradients remained low without any complications 8 months later at the time of discharge. (Circ J 2002; 66: 1173 -1175)

After 1990's, the development of new generation anti-cancer agents produced encouraging improvement of prognosis in inoperable or relapsed stomach cancer and colorectal cancer. However, non-hematological toxicity, such as peripheral neuropathies, become a new dose-limiting toxicity. In several new generation drugs, measures for controlling peripheral neuropathy had not been established besides dose modification or schedule modification. We tried to control the peripheral neuropathy induced by anti-cancer agents with the assistance of an adjuvant analgesics ladder. A total of 18 digestive cancer patients who presented with peripheral neuropathy of grade 1 or more(NCI-CTCAE ver 3.0), in the chemotherapy including Taxol or Oxaliplatin, were enrolled. The first stage of the adjuvant analgesics ladder was set as the antidepressant(amoxapin), the second stage was anticonvulsive drugs(valproic acid or clonazepam) and the third stage was antiarrhythmic drug(mexiletine). In each stage, if the drug turned out to be ineffective after two / weeks follow-up, it shifted to the next stage. The response rate of each step was 61.1%(11/18)of the first stage, 50.0%(5/10)of the 2nd stage, 50.0%(2/4)of the 3rd stage, and the overall response rate was 77.8%. The discontinuance of cancer treatment by peripheral neuropathy was observed only in 1 patient 5.5%(1/18)in the Taxol administered group. The toxicity profile was skin eruption and drowsiness, but the skin eruption was observed only in 1 patient at the 3rd stage and the drowsiness in 2 patients at the 2nd stage. It appears that the method to control the peripheral neuropathy induced by anti-cancer agents with the assistance of adjuvant analgesics ladder was effective and safe, but a large-scale clinical trial was warranted.

反回神経麻痺を契機に発見された肺癌患者19例について, 反回神経麻痺の原因となった病変の胸部単純写真と胸部断層写真, CTによる検出能を比較検討した. 胸部単純写真では, 反回神経麻痺の原因となった肺癌病変をまったく読影困難なものが1例, 見落とし易いと思われたものが2例あった. CT像では全例で反回神経麻痺の原因となった病変が明瞭に描出されていた. 反回神経麻痺を訴える患者で, 耳鼻科領域に原因となる病変を指摘できない時, 胸部単純写真では異常を指摘し得なくても肺癌が原因となっている場合があり, CT検査は不可欠と考えられた.

Intussusception is rare in adults. We describe a 47-year-old man with ileal schwannoma that led to ileocolic intussusception. Abdominal ultrasonography, abdominal CT scan and barium enema confirmed an ileal tumor. Colonoscopy revealed a peduncular submucosal tumor (SMT) 75 mm long with an ulcerated apex at the ascending colon. The provisional diagnosis was a gastrointestinal stromal tumor of the terminal ileum. Ileocecal resection was carried out and the tumor was histologically diagnosed as schwannoma. Abdominal pain resolved postoperatively. This case reminds us that ileal schwannoma should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

Background Although video-assisted thoracoscopic surgery (VATS) has been applied to pulmonary resection for pulmonary metastases, the clinical validity of this approach remains controversial. The purpose of this study was to evaluate the validity and problems of VATS for pulmonary metastasectomy. Methods From January 1993 to December 2003, VATS for pulmonary metastasectomy was performed in 53 resections for 48 patients at our institution. The medical records of these patients were retrospectively reviewed. Results The primary tumor was colorectal cancer in 23 patients, renal cell carcinoma in 6, breast cancer in 6, germ cell tumor in 5, head and neck cancer in 2, and others in 6. Thirty-six cases had a solitary lesion, 8 had unilateral multiple lesions, and 9 had bilateral multiple lesions. The following procedures were performed: 7 lobectomies, 5 segmentectomies, and 41 wedge resections. There was no major postoperative morbidity related to VATS. At a median follow-up period of 29.0 months, 13 patients were alive without recurrences. The 3-year overall survival rate and the 3-year intrathoracic disease-free survival rate were 59.8% and 33.4%, respectively. Five cases had recurrence at the surgical stump or at the port sites, but these recurrences have not been found in the recent period since June 1997. Intrathoracic recurrences within 3 months after VATS occurred in four. Conclusion VATS for pulmonary metastases is not superior to the conventional open thoracotomy and is not recommended as a standard procedure. Further studies with a larger number of cases performed by skilled surgeons familiar with VATS are needed.

Since positive coronary artery remodeling with large plaque burden is associated with subsequent coronary events, the authors tested their hypothesis that secondary prevention of coronary events by a statin may be associated with inhibition of the process of positive coronary artery remodeling in underlying coronary atherosclerotic lesions in patients with coronary artery diseases. They evaluated the intravascular ultrasound imaging in angiographically normal coronary lesions at baseline and after 6 months of therapy in 64 patients with coronary artery diseases. External elastic membrane area was defined as the vessel area, and the difference between the vessel and lumen area was calculated as plaque area. The relative echogenicity of coronary plaque to adventitia was evaluated as acoustic characteristics of coronary plaque. Twenty-five patients were treated with a statin and 39 patients did not receive a statin. In patients treated with a statin, plaque area decreased by 12% (p=0.013) compared to an increase in plaque area of 13% (p=0.023) in those who did not receive a statin. The vessel area was not enlarged in patients treated with a statin but did show positive remodeling in patients who had plaque progression without a statin. The relative echogenicity of plaque was unchanged in patients treated with a statin but significantly decreased in patients not receiving a statin. A statin may prevent positive coronary artery remodeling via inhibition of plaque progression in underlying coronary atherosclerotic lesions in patients with coronary artery diseases.

Background The aim of this study was to identify the clinical characteristics of multiple primary adenocarcinomas and to evaluate the efficacy of surgical treatments. Methods Three-hundred sixty-nine patients who underwent pulmonary resection for adenocarcinoma from January 1994 to December 2002 were reviewed. Results Thirty-one patients (8.4%) were determined to have multiple primary adenocarcinomas that could be detected on chest x-rays or computed tomography (CT). Twenty-six patients were synchronous and five patients were metachronous with a median interval of 59.0 months. Forty-nine (72.1%) of the total 68 lesions exhibited ground-glass opacity on high-resolution CT (HRCT). Pathologically well-differentiated adenocarcinoma with mixed bronchioloalveolar pattern was the most common subtype (39.7%). Taking into consideration pulmonary function, size, location, and HRCT findings of the lesions the procedures performed were lobectomy with mediastinal lymph-node dissection for 32 patients, segmentectomy with hilar node dissection for 8 patients, and wedge resection for 28 patients. Of 17 patients with bilateral synchronous cancers, simultaneous bilateral pulmonary resection was performed in 14 patients including simultaneous bilateral video-assisted thoracic surgery (VATS) in 11 patients. After a median follow-up period of 27.7 months, the 3-year overall survival rate was 92.9% and the 3-year disease-free survival rates of synchronous cancer and metachronous cancer were 77.9% and 100%, respectively. Conclusions The incidence of multiple primary adenocarcinomas was relatively common. Early radiographic detection and surgical excision could yield a favorable prognosis. The use of VATS, even for synchronous bilateral patients, was a safe and beneficial procedure.

Atypical adenomatous hyperplasia (AAH) has been reported to be a precancerous lesion of pulmonary adenocarcinoma. Cyclooxygenase-2 (COX-2), Fas and Fas ligand (FasL) are believed to be involved in the pathogenesis and progression of cancer.We examined the expression of COX-2, Fas and FasL in 31 tissue specimens of adenocarcinoma and 9 of AAH using an immunohistochemical method.COX-2 staining was observed in 20 (65%) specimens of adenocarcinoma and 2 (22%) of AAH. There was a significant difference in incidence of expression between these two groups (p = 0.025). All tumor specimens obtained from three patients with simultaneous multiple adenocarcinoma showed positive COX-2 staining. In two patients having both adenocarcinoma and AAH, COX-2 expression was detected in adenocarcinoma but not in AAH. Fas was expressed in 5 (16%) adenocarcinoma and 2 (22%) AAH specimens. FasL was detected in 3 (9.7%) adenocarcinoma and 1 (11%) AAH specimen.These findings suggest that COX-2 might play a role in the progression from AAH to adenocarcinoma.

To examine the effect of the addition of a beta-blocker in the treatment of chronic heart failure due to dilated cardiomyopathy, we compared the change of left ventricular remodeling and the prognosis between patients treated with angiotensin-converting enzyme inhibitors and patients who had beta-blockers added to angiotensin-converting enzyme inhibitors. Fifty-seven patients were treated with an angiotensin-converting enzyme inhibitor in addition to combination therapy with furosemide, spironolactone and digoxin. In 60 patients, a beta-blocker was administered in addition to combination therapy with furosemide, spironolactone, digoxin and an angiotensin-converting enzyme inhibitor. Changes of left ventricular dimensions at end-diastole and end-systole, fractional shortening, cardiac events and death were examined during the follow-up periods. The mean follow-up periods were 4.9 +/- 4.1 years in the angiotensin-converting enzyme inhibitor group and 3.9 +/- 2.5 years in the beta-blocker group, respectively. Baseline hemodynamic characteristics showed no significant differences between the two groups. After the treatment, the heart rate significantly decreased in both groups and the systolic blood pressure increased in the beta-blocker group. Both left ventricular dimensions at end-diastole and end-systole significantly decreased in both groups. Fractional shortening increased from 17.0 +/- 7.6 to 19.8 +/- 8.9% (p = 0.017) in the angiotensin-converting enzyme inhibitor group and from 16.6 +/- 7.2 to 24.7 +/- 8.0% (p0.0001) in the beta-blocker group, respectively. Changes of left ventricular dimensions at end-diastole and at end-systole, and fractional shortening were all greater in the beta-blocker group than in the angiotensin-converting enzyme inhibitor group. The event-free rate and the cumulative survival rate during the follow-up periods were markedly better in the beta-blocker group than in the angiotensin-converting enzyme inhibitor group (p = 0.0019 and p = 0.0099, respectively). These results indicate that the suppression of left ventricular remodeling and the improvement of prognosis in patients with dilated cardiomyopathy are markedly stronger in the beta-blocker group than in the angiotensin-converting enzyme inhibitor group. Thus, beta-blocker should be added to patients with dilated cardiomyopathy treated with an angiotensin-converting enzyme inhibitor.