A case of emphysematous cystitis with familial amyloidosis

This is a report of the thirteenth known case in Japan of emphysematous cystitis. A 70-year-old man visited our hospital because of pollakisuria and macrohematuria on November 21, 1989. The patient had been known to have familiar amyloid polyneuropathy for the previous 3 years. Urinalysis showed marked hematopyuria. The residual urine was 216 cc, and urine cultures yielded 10,000,000 colonies of Escherichia coli per ml. Laboratory studies revealed systemic inflammatory findings, but no diabetic change. A plain X-ray film of the abdomen and an excretory urogram (DIP) showed small linear and round gas collections in the bladder shadow. A CT scan revealed multiple gas locules within the bladder wall. A diagnosis of emphysematous cystitis was established. The patient was given antibiotics, and there was striking clinical improvement. Histological examination of the endoscopically obtained biopsy specimen of the bladder revealed amyloidosis. We believe that this patient had a cystitis emphysematosa precipitated neurogenic bladder due to amyloid polyneuropathy and amyloidosis of the bladder.     

Disseminated intravascular coagulation in the early stage after severe burn: the role of excessive thrombin generation

The pathogenesis of disseminated intravascular coagulation (DIC) in the early stage after burn injury remains still unclear. We investigated 12 burn injured patients by serial determination of anti-thrombin III (AT-III) activities and thrombin-antithrombin III complex (TAT) levels. Of these patients 4 developed DIC (DIC group) and the others had no hematological complications (non-DIC group). The mean levels of TAT increased markedly and peaked at 6 hr; the increment being more pronounced in DIC group (p less than 0.001). A significant correlation was recognized between TAT and Burn Index (r = 0.871, p less than 0.001). We also observed low AT-III activities those inversely related to Burn Index (r = 0.875, p less than 0.001), whereas closely correlated with serum albumin levels (r = 0.864, p less than 0.001), suggesting that this depression might be caused by both massive infusion and shifts of plasma into the extravascular space rather than consumption. These findings suggest that massive thrombin generation and decrease of anticoagulant activity, correlated to the severity of burns, might concurrently develop. Non-DIC group may remain to latent activation of coagulation cascade where anticoagulants could inactivate thrombin generated. This compensatory mechanism may fail in severe burn patients who have Burn Index of more than 90, developing DIC with high levels of TAT (316.3 +/- 104.5 ng/ml) and low AT-III activities (19.5 +/- 8.7%).     

Anesthesia for cesarean section in patients with fetal anomaly

Twenty-two cases of Cesarean section due to fetal anomaly diagnosed prenatally were reviewed in terms of the anesthetic managements. In 6 cases, diazepam 0.3 mg.kg-1, which provides fetal anesthesia for surgery scheduled immediately after birth, was administered intravenously to the mothers with/without fentanyl (2 general anesthesia and 4 regional anesthesia). The diagnosis of their fetuses was congenital diaphragmatic hernia, congenital cystic adenomatoid malformation of the lung, gastroschisis or omphalocele. No fetal anesthesia was performed in the other 16 cases (15 spinal anesthesia and 1 general anesthesia). Seven of their fetuses were diagnosed as hydrops. Since the general condition of the diseased newborn is known to be deteriorated after receiving various stress and aerophagia, fetal anesthesia in Cesarean delivery has the advantage of stress reduction and prevention of aerophagia. When the newborn is considered to need immediate neonatal resuscitation or intensive care including surgery, fetal anesthesia may be a choice of anesthetic technique.     

Early Gastric Lymphoma Coexisting with Reactive Lymphoreticular Hyperplasia (RLH) -A Case Report-

A 34-year-old female visited our hospital because of epigastralgia. We performed an upper gastrointestinal x-ray examination, and both conventional endoscopy and dye-spraying endoscopy (indigo-carmine contrast method). We diagnosed early gastric lymphoma which simulated Borrmann 3 type gastric cancer with IIb type early gastric cancer on the middle body and reactive lymphoreticular hyperplasia (RLH) of cobble stone-like granular pattern by endoscopic appearance on the lower body. Although dye-spraying endoscopy showed the details of the mucosa, it was very difficult to diagnose the lesions correctly by gross appearance alone. Because gastric lymphoma arises from the mucosal or submucosal layer and spreads in the mucosa diffusely, ultrasonic visualization by echo-endoscopy might be useful in the diagnostic procedure. We report a case of early gastric lymphoma coexisting with RLH; both lesions showed uncommon endoscopic features.     

Endoscopic thoracic sympathicotomy in Japan.

We sent our members questionnaire asking about their activities. From December 1992 to the end of 2000, endoscopic thoracic sympathicotomy (ETS) was utilized in 7,017 cases in 50 hospitals and institutes. Of which 6,776 (96.6%) were performed on hypersweating. There have been no deaths related to ETS either during the hospital stay or following discharge. Intraoperative bleeding was reported in 28 cases (0.3%) and an open chest procedure to stop bleeding was required in 6 cases (0.08%). Short term Horner's syndrome after the operation was found in a few cases, however, permanent symptoms were recognized in only 18 (0.28%). The most common postoperative complaint was compensatory sweating on the chest, back, or abdomen. Most of these patients countered this condition by using several methods of prevention or protection and continued on their daily life with little restriction. However, 83 cases (1.2%) experienced severe compensatory sweating and consulted their doctors repeatedly for more than one year. All operators who perform ETS recognized the excellent results for hand and facial sweating. Further, many doctors prefer this procedure as a first treatment for vascular disorders in upper extremities.     

Combination therapy with an angiotensin-converting enzyme (ACE) inhibitor and a calcium antagonist: beyond the renoprotective effects of ACE inhibitor monotherapy in a spontaneous hypertensive rat with renal ablation.

To assess the renal benefits of combined angiotensin-converting enzyme inhibition and calcium antagonism, we studied the antihypertensive and renoprotective effects of temocapril (TMP) alone or in combination with azelnidipine (AZN) in a spontaneously hypertensive rat (SHR) remnant kidney model of chronic renal failure. Male 5/6-nephrectomized SHR/Izumo rats were randomly assigned to receive vehicle (control group), TMP (TMP group; 10 mg x kg(-1) x day(-1)), AZN (AZN group; 3 mg x kg(-1) x day(-1)), or both (TMP+AZN group) orally for 12 weeks. Systolic blood pressure (SBP) and urinary excretion of albumin (UalbV) were measured every 2 weeks. At the end of the experiment, serum creatinine (Scr), heart weight (HW), and blood urea nitrogen (BUN) levels were measured and the remnant kidneys were examined to determine the index of glomerular sclerosis (IGS). SBP and UalbV in the control group increased progressively throughout the experimental period. TMP, AZN, and TMP+AZN blocked the development of hypertension. TMP+AZN did not enhance the antihypertensive effects of either TMP or AZN used singly. TMP, AZN, and TMP+AZN all significantly decreased the UalbV, Scr, BUN, and HW/body weight (BW) ratio. The level of UalbV and the HW/BW ratio in the TMP+AZN group were significantly lower than those in the TMP and AZN groups, and the level of Scr in the TMP+AZN group was significantly lower than that in the TMP group. TMP, AZN, and TMP+AZN all significantly protected against an increase in the IGS. The IGS in the TMP+AZN group was significantly lower than that in the TMP and AZN groups. These results indicate that both TMP and AZN have antihypertensive and renoprotective effects in this model. They also suggest that simultaneous administration of TMP and AZN provides greater renoprotective effects than TMP alone.     

Kinin-generating Cascade in Advanced Cancer Patients and in vitro Study

The role of the bradykinin-generating system in the pathogenesis of cancer was explored by simultaneously measuring plasma prekallikrein (PK), the precursor of kallikrein, which is the major enzyme responsible for kinin generation, and plasma kininogens (KNG), which are precursors of kinin, in patients with various cancers. The mean value of plasma PK in healthy volunteers was 2.5 ± 0.5 (mean ± SD) units/mg plasma protein and that in cancer patients (all stage IV) was 1.7 ± 0.7 units/ mg plasma protein. The mean value of plasma KNG in healthy volunteers was 12.5 ± 2.0 ng kinin equivalents/mg plasma protein and that in cancer patients was 10.9 ± 2,8 ng. These data showed that plasma PK and plasma KNG values were significantly lower in cancer patients compared with healthy volunteers ( P < 0.0005 for PK; 0.0005 < P < 0.005 for KNG; n = 28 for healthy subjects; n = 29 for cancer patients). These data appear to indicate that conversion of PK to kallikrein would probably occur with concomitant consumption of KNG by newly generated kallikrein for kinin generation in cancer patients. Early stage cancer patients showed little difference from healthy volunteers. For the in vitro study, activation of purified Hageman factor (HP) and PK was examined by using cancer cell lines and virus-transformed cells that produced plasminogen activator (PA) at a high rate. Both HF and PK were activated in the presence of plasminogen. Diploid cell lines and primary fibroblasts, which did not produce PA, activated neither HF nor PK. Taking all these data together, we conclude that kinin generation does occur in the plasma of patients with advanced cancer, and that one of the initiation mechanisms of the kinin-generating cascade appears to be mediated by plasmin and to depend on cancer cell-derived PA activity.