Pattern classification in kampo medicine.

Pattern classification is very unique in traditional medicine. Kampo medical patterns have transformed over time during Japan's history. In the 17th to 18th centuries, Japanese doctors advocated elimination of the Ming medical theory and followed the basic concepts put forth by Shang Han Lun and Jin Gui Yao Lue in the later Han dynasty (25-220 AD). The physician Todo Yoshimasu (1702-1773) emphasized that an appropriate treatment could be administered if a set of patterns could be identified. This principle is still referred to as "matching of pattern and formula" and is the basic concept underlying Kampo medicine today. In 1868, the Meiji restoration occurred, and the new government changed its policies to follow that of the European countries, adopting only Western medicine. Physicians trained in Western medicine played an important role in the revival of Kampo medicine, modernizing Kampo patterns to avoid confusion with Western biomedical terminology. In order to understand the Japanese version of traditional disorders and patterns, background information on the history of Kampo and its role in the current health care system in Japan is important. In this paper we overviewed the formation of Kampo patterns.

Dementia with Lewy bodies showing advanced Lewy pathology but minimal Alzheimer pathology--Lewy pathology causes neuronal loss inducing progressive dementia.

The present study concerns an autopsied case of dementia with Lewy bodies (DLB) showing advanced Lewy pathology but minimal Alzheimer pathology. The patient was a 50-year-old Japanese male without inheritance. His initial symptoms at the age of 43 suggested the diagnosis ofjuvenile idiopathic Parkinson's disease (PD), but were followed by memory disturbance 1 year later. He showed parkinsonism, dementia, personality change, fluctuating cognition and visual hallucinations 3 years later. Neuroradiological examination revealed moderate brain atrophy, predominantly in the frontal and temporal lobes. Neuropathological examination demonstrated a widespread occurrence of Lewy bodies (LB) with LB-related neurites not only in the brainstem but also in the cerebrum. The present case showed Lewy pathology which corresponded to stage IV by our staging and was parallel to neuronal loss. There was marked neuronal loss with many LB-related neurites in the CA2 of the hippocampus. Neurofibrillary tangles (NFT) were almost restricted to the entorhinal cortex, while senile plaques were absent. Consequently, the present case was pathologically diagnosed as having DLB of the neocortical type, pure form. In the present study, we suggest that Lewy pathology in the cerebral cortex could be responsible for progressive dementia.

The palmar pocket method: an adjunct to the management of zone I and II fingertip amputations.

In 1979 Brent reported a new replantation method, without vascular anastomosis, that used a subcutaneous pocket. Brent chose the contralateral chest wall as a pocket site, but in other clinical reports, the abdominal wall was used. For both sites there were complications such as stiffness in the wrist, elbow, and shoulder joints and anxiety about pulling out the pocketed finger. To overcome these problems, we chose the ipsilateral palm and named this method the palmar pocket method. We used this method in 16 cases in which a digit other than the thumb had been amputated between the tip and lunula. In 13 cases the method was completely successful, and in 3 cases there was a small area of tip necrosis. The palmar pocket method is a simple and reliable operation for fingertip reattachment and more comfortable for patients than pocketing in the chest wall or abdominal wall.

Glial involvement in the degeneration process of Lewy body-bearing neurons and the degradation process of Lewy bodies in brains of dementia with Lewy bodies.

Glial involvement in the degeneration process of Lewy body (LB)-bearing neurons and the degradation process of LBs in the cerebral cortex and amygdala in brains of dementia with Lewy bodies was investigated immunohistochemically. HLA-DR-positive microglia frequently extended their processes to degenerated neurons with alpha-synuclein-positive LBs, while some GFAP-positive astroglial processes attached to weakly alpha-synuclein-positive extracellular LBs. Some intracellular LBs were immunoreactive to anti-C4d antibody, and these LB-bearing neurons were involved by activated microglia. About half of the intracellular LBs were immunoreactive to anti-chromogranin-A (CGA) antibody, and most of CGA-positive LB-bearing neurons were surrounded by microglia. Although we could find no evident participation of TNF-alpha, a candidate cytokine that is up-regulated by microglia following CGA stimulation, in the degeneration process of LB-bearing neurons, some intracellular LBs were immunoreactive to the antibody to NF-kappaB, a transcriptional factor activated by cytokines. These findings suggest that microglia participate in the degeneration process of LB-bearing neurons via varying immunogenic elements including complement proteins, CGA and probably some cytokines, and that astroglia participate in the degradation process of LBs.

Expression of CD40 in the brain of Alzheimer's disease and other neurological diseases.

We have investigated immunohistochemically the expression of CD40 in post-mortem human brain tissues. In control brain, the blood vessels were stained weakly for CD40. Vascular expression of CD40 was enhanced in the lesions of Alzheimer's disease and some other neurological diseases. In such diseases, reactive microglia were also positive for CD40. The results of this study suggest that CD40 expression by microglia is up-regulated upon a variety of brain insults and is not limited to lesions with amyloid beta-protein deposits.

A decrease in membrane tension precedes successful cell-membrane repair.

We hypothesized that the requirement for Ca(2+)-dependent exocytosis in cell-membrane repair is to provide an adequate lowering of membrane tension to permit membrane resealing. We used laser tweezers to form membrane tethers and measured the force of those tethers to estimate the membrane tension of Swiss 3T3 fibroblasts after membrane disruption and during resealing. These measurements show that, for fibroblasts wounded in normal Ca(2+) Ringer's solution, the membrane tension decreased dramatically after the wounding and resealing coincided with a decrease of approximately 60% of control tether force values. However, the tension did not decrease if cells were wounded in a low Ca(2+) Ringer's solution that inhibited both membrane resealing and exocytosis. When cells were wounded twice in normal Ca(2+) Ringer's solution, decreases in tension at the second wound were 2.3 times faster than at the first wound, correlating well with twofold faster resealing rates for repeated wounds. The facilitated resealing to a second wound requires a new vesicle pool, which is generated via a protein kinase C (PKC)-dependent and brefeldin A (BFA)-sensitive process. Tension decrease at the second wound was slowed or inhibited by PKC inhibitor or BFA. Lowering membrane tension by cytochalasin D treatment could substitute for exocytosis and could restore membrane resealing in low Ca(2+) Ringer's solution.

Looped device for inferior vena cava taping through a right parasternal approach.

In small adults and infants, inferior vena caval taping through the right parasternal approach for minimally invasive cardiac operations is often difficult with conventional methods. We present a new convenient method to simplify this critical step.

The mechanism of facilitated cell membrane resealing.

Disruption of the plasma membrane evokes an exocytotic response that is required for rapid membrane resealing. We show here in Swiss 3T3 fibroblasts that a second disruption at the same site reseals more rapidly than the initial wound. This facilitated response of resealing was inhibited by both low external Ca2+ concentration and specific protein kinase C (PKC) inhibitors, bisindolylmaleimide I (BIS) and Gö-6976. In addition, activation of PKC by phorbol ester facilitated the resealing of a first wound. BIS and Gö-6976 suppressed the effect of phorbol ester on resealing rate. Fluorescent dye loss from a FM1-43 pre-labeled endocytotic compartment was used to investigate the relationship between exocytosis, resealing and the facilitation of resealing. Exocytosis of endocytotic compartments near the wounding site was correlated with successful resealing. The destaining did not occur when exocytosis and resealing were inhibited by low external Ca2+ concentration or by injected tetanus toxin. When the dye loaded cells were wounded twice, FM1-43 destaining at the second wound was less than at the first wound. Less destaining was also observed in cells pre-treated with phorbol ester, suggesting newly formed vesicles, which were FM1-43 unlabeled, were exocytosed in the resealing at repeated woundings. Facilitation was also blocked by brefeldin A (BFA), a fungal metabolite that inhibits vesicle formation at the Golgi apparatus. Lowering the temperature below 20 degrees C also blocked facilitation as expected from a block of Golgi function. BFA had no effect on the resealing rate of an initial wound. The facilitation of the resealing by phorbol ester was blocked by pre-treatment with BFA. These results suggest that at first wounding the cell used the endocytotic compartment to add membrane necessary for resealing. At a second wounding, PKC, activated by Ca2+ entry at the first wound, stimulated vesicle formation from the Golgi apparatus, resulting in more rapid resealing of the second membrane disruption. Since vesicle pools were implicated in both membrane resealing and facilitation of membrane resealing, we reasoned that artificial decreases in membrane surface tension would have the same result. Decreases in surface tension induced by the addition of a surfactant (Pluronic F68 NF) or cytochalasin D facilitated resealing at first wounding. Furthermore, Pluronic F68 NF restored resealing when exocytosis was blocked by tetanus toxin. These results suggest that membrane resealing requires a decrease in surface tension and under natural conditions this is provided by Ca2+-dependent exocytosis of new membrane near the site of disruption.

Sutureless ringed graft replacement of descending thoracic aorta with extensive calcification.

A 79-year-old hypertensive woman, with fusiform shaped atherosclerotic aneurysm in the descending thoracic aorta whose medial layer was maintained by an extensive solid calcium plate (porcelain aorta), was successfully treated using a sutureless intraluminal ringed graft. Spools of the ring were fixed by circumferential ligatures at both proximal and distal sites of anastomosis and a dilated segment of the aorta was replaced with the tube graft.

Aminopeptidase-like protease released from oocytes affects oocyte surfaces and suppresses the acrosome reaction in establishment of polyspermy block in oocytes of the mussel Mytilus edulis.

Suppression of the acrosome reaction of sperm on fertilized oocytes inhibits sperm-oocyte binding and is considered one of the three mechanisms responsible for polyspermy block in oocytes of the mussel Mytilus edulis (Togo et al., 1995). When unfertilized oocytes were inseminated in the presence of aminopeptidase inhibitors and the fertilized oocytes were inseminated again, neither the acrosome reaction nor sperm binding to fertilized oocytes were suppressed, suggesting that aminopeptidase-like protease participates in suppression of the acrosome reaction. The supernatant solution obtained after centrifuging a suspension of fertilized oocytes hydrolyzed aminopeptidase substrates, and these activities were inhibited strongly or effectively by aminopeptidase inhibitors. When unfertilized oocytes were incubated with this supernatant solution and inseminated, both the number of sperm bound and the acrosome reaction rate decreased, and these effects were reversed by conducting this treatment in the presence of aminopeptidase inhibitors. These results suggest that aminopeptidase-like protease released from the oocyte at fertilization affects the oocyte surface to suppress the acrosome reaction and consequently inhibits sperm-oocyte binding.

Effects of cardiac surgery on intellectual function in infants and children.

Intellectual function was evaluated by Gesell's developmental quotient (DQ) and Binet's intelligence quotient (IQ) in 161 infants and children (61 ventricular septal defects, 49 tetralogies of Fallot, 15 transpositions of the great arteries, seven atrial septal defects, five complete atrioventricular canals, five double outlet right ventricles and 19 shunt cases; average age 3.6 years) before and after cardiac surgery. There were no significant differences in preoperative DQs and IQs among the patient groups. Although average DQ scores in 21 infants with hypothermic (13-24 degrees C) total circulatory arrest (36-70 min) were not significantly different from the preoperative values, 13 patients with an arrest time > 50 min showed a significant decrease in DQ scores. The postoperative DQ and IQ scores in patients without circulatory arrest or in shunt cases were not significantly impaired after surgery. It was concluded that cardiac surgery did not impair intellectual function in infants and children, although cerebral dysfunction might occur if circulatory arrest was > 50 min.

[Acute aortic dissection with leg ischemia].

From January of 1987 to July of 1994, 83 patients with acute aortic dissection were treated at our institution. Of these, 7 patients (8%) sustained acute leg ischemia. Angiography showed that one patient had arterial occlusion at the abdominal aorta, three had occlusion at the right common iliac artery, and one had severe right common iliac artery stenosis. Four patients with acute type A dissection underwent emergency replacement of the aortic arch and/or ascending aorta. Three of them were discharged, but one patient died due to renal failure and multiple organ failure. In three patients with acute type B dissection, one with aortic rupture was successfully treated by replacement of the descending thoracic aorta; of the other two who received bypass operations for leg ischemia, one died due to myonephropathic metabolic syndrome and sepsis which were caused by a delay in surgery. In conclusion, emergency thoracic aortic repair should be performed in acute type A dissection with leg ischemia, whereas bypass operation for ischemic leg should be considered in patients of acute type B dissection with leg ischemia when they are not complicated with rupture or visceral ischemia.

Aneurysm of a patent ductus arteriosus in an adult.

An adult patient with a spontaneous aneurysm of a patent ductus arteriosus was successfully treated. The lumen of the aneurysm communicated with the distal aortic arch and the pulmonary artery. Closure of the pulmonary arterial orifice of the ductus arteriosus and replacement of the inferior wall of the distal aortic arch and proximal descending aorta with prosthetic graft were performed under partial cardiopulmonary bypass using a centrifugal pump. The postoperative recovery was uneventful.

[Supra-annular mitral valve replacement for a patient with prosthetic valve endocarditis].

Supraanular mitral valve replacement with a 29 mm CarboMedics prosthetic valve was performed for a 58-year-old patient of prosthetic valve endocarditis. He has received mitral valve replacement 2 years ago, and was admitted because of high fever and severe heart failure diagnosed mitral regurgitation due to valve dehiscence. An annular abscess was observed and the new 29 mm CarboMedics prosthetic valve was sutured to the left atrial wall approximately 10 mm above the original annulus in order to secure the firm suturings for valve implantation and to left the infected annulus intact. The patient, however, underwent reoperation because of valve dehiscence from atrial wall 6 months after surgery. Infectious abscess at the native mitral annulau was observed to be completely cured, and a mitral prosthesis was implanted at the annulus. The patient is discharged under satisfactory condition.

[Surgical management of vascular ring in 5 cases].

Five cases of vascular ring are presented. Three cases have double aortic arch and two cases have right aortic arch with aberrant left subclavian artery. Other congenital heart diseases are complicated in four cases. MRI was useful for the evaluation of tracheal and esophageal compression.

[Aortitis syndrome with left coronary ostial occlusion and aortic regurgitation: a case report].

A 22-year-old woman with left coronary ostial occlusion and aortic regurgitation due to aortitis syndrome was reported. The coronary artery bypass grafting, using saphenous vein and aortic valve replacement were performed. The distal anastomosis of saphenous vein was performed to left anterior descending artery (Seg. 6), just distal to the origin of circumflex artery. The postoperative course was uneventful. There was no peri-prosthetic valvular leakage and bypass graft was patent.

[Surgical management of infective endocarditis in childhood].

From 1971 to 1993, four patients, 7 to 13 years of age, underwent intracardiac operation for infective endocarditis. Two patients underwent mitral valve replacements, one was tricuspid replacement and one received tricuspid valvulectomy. There was no operative death but one late death occurred (correction of occurred) due to cerebral bleeding. Surgical treatment of infective endocarditis in childhood could be performed safely by adequate selection of operative methods.

[Concomitant replacement of the complete aortic arch with coronary artery bypass grafting and ilio-femoral bypass grafting by means of selective cerebral and coronary perfusion technique].

A seventy-two-year-old male patient was diagnosed to have major three kinds of atherosclerotic disease including transverse aortic arch aneurysm, ischemic heart disease and stenosis of left external iliac artery. Complete graft replacement of aortic arch was performed concomitantly with the coronary arterial bypass grafting and iliofemoral bypass grafting under selective cerebral and coronary perfusion technique. In addition, the graft used for iliofemoral arterial reconstruction was tailored to have two branches, which facilitate the insertion of the inflow cannula for a bypass and the occlusion balloon catheter. His postoperative course was uneventful and was discharged under a satisfactory condition.