Exact Location of the Branching Bundle in the Living Heart

Aims: The His bundle electrogram is believed to reflect the exact location of the His bundle. However, the distinction between distal His bundle potential and proximal right bundle branch potential is challenging. The aim of this study was to pinpoint the location of the branching point of the His bundle, and to compare that site with the site of recording of the largest His bundle electrogram (LH) during sinus rhythm.
Methods: We hypothesized that the site of earliest His activation (EH) during retrograde conduction via the left bundle branch is the branching point. We studied 15 nonconsecutive patients (mean age = 40 ± 22 years; eight men). We performed a programmed stimulation from right ventricular apex until retrograde right bundle branch block appeared. At that point we measured (1) the distance between antegrade LH site and retrograde EH site and (2) the atrial-to-ventricular amplitude ratio (A/V ratio) at both sites.
Results: EH was recorded at the proximal electrode of the His bundle catheter in all patients. Mean distance between EH and LH was 9.8 ± 2.5 mm. The mean A/V ratios at the EH site and the LH site were 1.01 ± 0.42 and 0.08 ± 0.06, respectively.
Discussion: This study showed that the EH site is located approximately 10-mm proximal to the LH site. The mean A/V ratio at the EH site during sinus rhythm is approximately 1.0. These observations suggest that the majority of His potentials reflect proximal right bundle activation. Before delivering radiofrequency energy in the para-Hisian area, attention should be paid to the presence of a His potential and to the A/V ratio, rather to the amplitude of the His electrogram.     

Proliferative activity in intrahepatic metastasis of hepatocellular carcinoma

To assess the characteristics of intrahepatic metastatic lesions (IML) in hepatocellular carcinoma (HCC), we analysed both the histological features and proliferative activities of 15 resected cases of HCC accompanied by IML. The histological features of the IML were essentially the same as those observed in the main nodules in 12 (80%) of 15 cases. In 13 (87%) of 15 cases, the labelling index of proliferating cell nuclear antigen (PCNA) in the IML was either higher than or the same as in the main nodules. In 10 (77%) of 13 cases, the MIB-1 labelling index in the IML was either higher than or the same as in the main nodules. The results indicate that the histological features of the IML are essentially the same as those of the main nodules, while the proliferative activities in the IML were generally higher than those in the main nodules. Such characteristics may thus provide a clue to help distinguish intrahepatic metastasis from the multicentric occurrence of HCC.     

Night-time hypnopompic visual hallucinations related to REM sleep disorder

Abstract We encountered three patients who had experienced hypnopompic visual night-time hallucinations. Their clinical manifestations resembled Charles Bonnet's syndrome and the content of their experiences were understood as attempts at wish fulfillment. However, abnormal REM findings were recognized on polysomnogram at the occurrence of visual hallucination in two cases. We speculated that dysfunction of REM sleep mechanism might contribute to the night-time occurrence of such kind of visual hallucination and that their visual experiences might be reflected by dream content.     

Hydronephrosis due to ureteral endometriosis treated by transperitoneal laparoscopic ureterolysis

Ureteral obstruction secondary to endometriosis is relatively uncommon. We present a 43-year-old multiparous woman who suffered from periodic left loin pain in the terminal period of her menstruation. Excretory urogram demonstrated left hydronephrosis and hydroureter and obstruction of the lower left ureter just inferior to the left sacroiliac joint without urolithiasis. An enhanced computed tomography scan showed soft tissue density mass around the left ureter at the level of the stenosis. She underwent transperitoneal laparoscopic ureterolysis and adhesiotomy of the left ureter under the diagnosis of ureteral endometriosis. Because blueberry spots were clearly observed on the pelvic brim, the fibrous tissue surrounded the ureter was removed with peritoneal bleeding spots. Histological examination of the surrounding tissue confirmed the ectopic endometriosis. Even though retroperitoneoscopy is frequently used for ureteral lesion, transperitoneal laparoscopy has an advantage for resection of ectopic endometriosis surrounding the ureter.     

Trials of bright light exposure and melatonin administration in a patient with non-24 hour sleep-wake syndrome

Abstract We report a patient with non-24 h sleep-wake syndrome (non-24) whose free-running sleep-wake cycle was successfully treated with both scheduled bright light exposure and melatonin treatment. In the present study, morning bright light as well as evening melatonin phase-advanced sleep-wake cycles and melatonin rhythm. Both these procedures achieved appropriate entrainment to a 24 h day. However, the patient did not continue morning bright light therapy after the discharge. Rising at appropriate times in the morning for bright light therapy was difficult for him to continue. Melatonin treatment was better tolerated because of its ease of application.     

INCREASED SERUM OESTRONE AND OESTRADIOL FOLLOWING SPIRONOLACTONE ADMINISTRATION IN HYPERTENSIVE MEN

The present study was undertaken to evaluate long-term effects of spironolactone on basal serum oestrone, oestradiol, testosterone, LH and prolactin concentrations in hypertensive male patients. Serum prolactin response to TRH was also evaluated. Patients were divided into two groups: a conventional-dosage group, consisting of six males with essential hypertension who took 75 to 150 mg of spironolactone daily for 12 weeks, and a high-dosage group, consisting of two males with idiopathic hyperaldosteronism who took 300 mg of spironolactone daily for more than 40 weeks. In the conventional-dosage group, serum oestrone concentrations significantly increased (P > 0.01) at 12 weeks, serum oestradiol concentrations gradually increased throughout the study period, however, the increments were not statistically significant (P > 0.2). Basal serum testosterone, LH and prolactin concentrations were not significantly changed throughout the study period. Enhancement of serum prolactin response to TRH was not found in any of the patients in the conventional-dosage group. In the high-dosage group, serum oestrone maintained high levels from the beginning of this study, and serum oestradiol concentrations increased with the development of gynaecomastia. Serum testosterone, LH and prolactin concentrations did not show any definite change throughout the study period. Thus, long-term spironolactone treatment increased the serum levels of oestrone and oestradiol in hypertensive men followed by the development of gynaecomastia. The elevations in circulating oestrogens could well explain the oestrogenic side-effects of spironolactone treatment.     

A boy with atrophic thyroiditis of prepubertal onset,who was positive for TSH-binding inhibitor immunoglobulins

A 12 year old boy was admitted to our hospital because of short stature. From the age of 7, his growth velocity decreased and he manifested intolerance to low temperatures, hoarseness, dry skin, and slowness of thought and physical movement. On admission, his height was 129.8 cm (-3 s.d.) and his body weight was 43.2kg (-0.5 s.d.). His clinical features also included relaxation phase of tendon reflexes, periorbital puffiness and cold skin but no struma. His bone age was 9 years. His serum thyroxine (T₄), tri-iodothyronine (T₃), free T₄ and free T₃ were low, while his thyrotropin was high. He was positive for antithyroglobulin antibodies, antimicrosomal antibodies, and TSH-binding inhibitor immunoglobulins. He was diagnosed as having atrophic thyroiditis. We also determined the HLA haplotypes of his family members. His father's HLA haplotypes were A2, BW61(a) and A24, BW52(b), while his mother's haplotypes were A24, BW52(c) and A30, BW61(d). The HLA haplotypes of both the patient and his younger brother showed a and d, while the patient's elder brother's HLA haplotypes showed b and c. His family members all had normal thyroid function, but his father was positive for antimicrosomal antibodies. In summary, we describe a rare case where the onset of hypothyroidism was prepubertal, where the pathogenesis may have involved TSH-receptor blocking antibodies, and where the inheritance of the disease may have been from the paternal side of the family.