Pathological changes of adipose tissue in secondary lymphoedema.

BACKGROUND: The pathophysiology of lymphoedema is poorly understood. Current treatment options include compression therapy, resection, liposuction and lymphatic microsurgery, but determining the optimal treatment approach for each patient remains challenging. OBJECTIVES: We characterized skin and adipose tissue alterations in the setting of secondary lymphoedema. METHODS: Morphological and histopathological evaluations were conducted for 70 specimens collected from 26 female patients with lower-extremity secondary lymphoedema following surgical intervention for gynaecological cancers. Indocyanine green lymphography was performed for each patient to assess lymphoedema severity. RESULTS: Macroscopic and ultrasound findings revealed that lymphoedema adipose tissue had larger lobules of adipose tissue, with these lobules surrounded by thick collagen fibres and interstitial lymphatic fluid. In lymphoedema specimens, adipocytes displayed hypertrophic changes and more collagen fibre deposits when examined using electron microscopy, whole-mount staining and immunohistochemistry. The number of capillary lymphatic channels was also found to be increased in the dermis of lymphoedema limbs. Crown-like structures (dead adipocytes surrounded by M1 macrophages) were less frequently seen in lymphoedema samples. Flow cytometry revealed that, among the cellular components of adipose tissue, adipose-derived stem/stromal cells and M2 macrophages were decreased in number in lymphoedema adipose tissue compared with normal controls. CONCLUSIONS: These findings suggest that long-term lymphatic volume overload can induce chronic tissue inflammation, progressive fibrosis, impaired homeostasis, altered remodelling of adipose tissue, impaired regenerative capacity and immunological dysfunction. Further elucidation of the pathophysiological mechanisms underlying lymphoedema will lead to more reliable therapeutic strategies.

Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphoedema.

OBJECTIVES: Indocyanine green (ICG) lymphography has been reported to be useful for the early diagnosis of lymphoedema. However, no study has reported the usefulness of ICG lymphography for evaluation of lymphoedema with lower extremity dysmorphia (LED). This study aimed to elucidate independent factors associated with LED in secondary lower extremity lymphoedema (LEL) patients. METHODS: This was a retrospective observational study of 268 legs of 134 secondary LEL patients. The medical charts were reviewed to obtain data of clinical demographics and ICG lymphography based severity stage (leg dermal backflow [LDB] stage). LED was defined as a leg with a LEL index of 250 or higher. Logistic regression analysis was used to identify independent factors associated with LED. RESULTS: LED was observed in 106 legs (39.6%). Multivariate analysis revealed that independent factors associated with LED were higher LDB stages compared with LDB stage 0 (LDB stage III; OR 17.586; 95% CI 2.055-150.482; p = .009) (LDB stage IV; OR 76.794; 95% CI 8.132-725.199; p < .001) (LDB stage V; OR 47.423; 95% CI 3.704-607.192; p = .003). On the other hand, inverse associations were observed in higher age (65 years or older; OR 0.409; 95% CI 0.190-0.881; p = .022) and higher body mass index (25 kg/m2 or higher; OR 0.408; 95% CI 0.176-0.946; p = .037). CONCLUSIONS: Independent factors associated with LED were elucidated. ICG lymphography based severity stage showed the strongest association with LED, and was useful for evaluation of progressed LEL with LED.

Indocyanine Green Lymphography Findings in Primary Leg Lymphedema.

OBJECTIVES: Indocyanine green (ICG) lymphography has been reported to be useful for the evaluation of secondary lymphedema, but no study has reported characteristic findings of ICG lymphography in primary lymphedema. This study aimed to classify characteristic ICG lymphography patterns in primary lymphedema. METHODS: The study was a retrospective observational study. Thirty one primary lower extremity lymphedema (LEL) patients with a total of 62 legs were studied. ICG lymphography patterns were categorized according to the visibility of lymphatics and dermal backflow (DB) extension. Clinical demographics were compared with categorized ICG lymphography patterns. RESULTS: All symptomatic legs showed abnormal patterns, and all asymptomatic legs showed normal patterns on ICG lymphography. Abnormal lymphographic patterns could be classified into proximal DB (PDB), distal DB (DDB), less enhancement (LE), and no enhancement (NE) patterns. There were significant differences between PDB (16 patients), DDB (6 patients), LE (4 patients), and NE patterns (5 patients) in age (37.3 ± 18.3 vs. 61.8 ± 19.2 vs. 50.8 ± 27.7 vs. 29.2 ± 18.0 years, p = .035), onset of edema (23.9 ± 19.4 vs. 46.8 ± 27.0 vs. 43.0 ± 31.3 vs. 6.6 ± 14.2 years, p = .020), laterality (bilateral; 18.8% vs. 66.7% vs. 75.0% vs. 0%, p » .016), cellulitis history(56.3% vs. 100% vs. 25.0% vs. 0%, p » .007), and LEL index (292.2 ± 32.8 vs. 254.2 ± 28.6 vs. 243.3 ± 9.4 vs. 295.2 ± 44.8, p = .016). CONCLUSIONS: ICG lymphography findings in primary lymphedema could be classified into four patterns withdifferent patient characteristics.

Elevated receptor for activated C kinase 1 expression is involved in intracellular Ca2+ influx and potentially associated with compromised regulatory T cell function in patients with asthma.

BACKGROUND: Regulatory T cells (T(regs)) are activated during anergy in response to T cell receptor (TCR) activation and functional immune suppression. Anergy of paediatric T(regs) is partially dependent on intracellular calcium mobility; following TCR activation, T(regs) do not exhibit increased intracellular Ca(2+) concentration ([Ca(2+) ](i)). OBJECTIVE: We determined whether [Ca(2+) ](i) in adult T(regs) defined their anergy, if intracellular Ca(2+) movement was linked to regulatory functions, whether [Ca(2+)](i) was indicative of asthma pathology, and the potential molecular mechanism responsible for Ca(2+) movement in T(regs). METHODS: T(regs) were purified by the magnetic bead method, and their regulatory functions were assessed by monitoring carboxyfluorescein succinimidyl ester-labelled responder T cell proliferation. The Ca(2+) response of Fura-2-labelled cells was measured using a video image analysis system. To analyse the functions of T(regs) at the molecular level, we generated Jurkat Tet-On(®) clones with doxycycline (Dox)-induced forkhead box P3 (FOXP3) protein expression. RESULTS: CD4(+) CD25(+) CD127(-/low) T(regs) from participants without asthma did not elicit Ca(2+) influx in response to TCR activation, exhibited little proliferation and suppressed proliferation of CD4(+) CD25(-) T cells. In contrast, under similar conditions, T(regs) from patients with asthma exhibited increased [Ca(2+)](i) and robust proliferation with partial loss of regulatory functions. FOXP3 protein levels in Tet-On(®) clones were high after both 2- and 5-day Dox treatment; however, 5-day cells were comparable with T(regs) from patients with asthma, whereas 2-day cells were similar to T(regs) from participants without asthma. Increasing [Ca(2+)](i) induced a high level of receptor for activated C kinase 1 (RACK1) expression in 5-day cells. CONCLUSIONS AND CLINICAL RELEVANCE: We confirmed that T(regs) in patients with asthma are functionally impaired and that the abnormal regulatory functions of these cells can be analysed by [Ca(2+)](i) following TCR engagement. Furthermore, the impaired functioning of T(regs) evident in patients with asthma may be due to a high level of RACK1.

Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema.

BACKGROUND: One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema. METHODS: This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s). RESULTS: A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001). CONCLUSION: LVA reduced the rate of cellulitis in these patients with lymphoedema.

Gemcitabine-based regimen for primary ovarian angiosarcoma with MYC amplification.

Angiosarcoma is a rare and aggressive type of sarcoma, and primary angiosarcoma of the ovary is extremely rare. We report the case of a 29-year-old woman who was diagnosed with ovarian angiosarcoma and possible bone metastases. We treated this patient with a gemcitabine-based regimen as postoperative adjuvant chemotherapy, after which she achieved at least 7 years of progression-free survival, an extremely long duration given the aggressive features of this tumour. We retrospectively performed immunohistochemical analyses and fluorescence in situ hybridization to make a pathology diagnosis and to investigate the tumour features. MYC amplification and c-Myc protein overexpression were positively detected. It might be possible to correlate the effectiveness of the gemcitabine-based chemotherapeutic regimen with MYC gene amplification and c-Myc protein overexpression.

Idiopathic portal hypertension and lower limb lymphedema.

Idiopathic lymphedema is a condition where lymph accumulates in subcutaneous tissue without a clear cause. Likewise, idiopathic portal hypertension is a syndrome where intrahepatic peripheral portal branch obstruction causes portal hypertension without a clear cause. We encountered a 37-year-old man with both idiopathic lymphedema and idiopathic portal hypertension. He had a history of right lower limb edema and epigastric varices since childhood with repeated cellulitis in the affected limb. Lymph accumulation and dilation of collateral lymph pathways in the right lower limb were observed by indocyanine green and lymphoscintigraphy, and a serpentine thoracic duct was observed using MRI. Idiopathic portal hypertension and idiopathic lymphedema were diagnosed, and peripheral lymphaticovenous anastomosis was performed for treatment of lymphedema. The limb circumference improved, and the frequency of cellulitis decreased. It is postulated that an abnormality in the embryonic cardinal vein before lymph vessel differentiation could be a possible mechanism of the dual pathologic conditions.

Regional diagnosis of lymphoedema and selection of sites for lymphaticovenular anastomosis using elastography.

AIM: To evaluate the use of ultrasound elastography as a basis for determining the most appropriate sites for lymphaticovenular anastomosis (LVA) for treatment of lymphoedema. MATERIALS AND METHODS: Preoperative elastography and LVA were performed in 11 patients (11 legs) with leg lymphoedema, including two cases of primary oedema and nine of secondary oedema. RESULTS: The mean number of LVAs applied per leg was 4.4 (range 3-7). The mean reduction in the leg circumference was 91.7%, and 10 of the 11 cases (90.0%) were improved. Hardness was reduced from a mean of 1.6 before surgery to 0.9 after surgery, and improvement was also noted in 10 cases (90.9%). The severity of oedema was determined in five regions in each leg, and was classified as elastography stage (ES) 0 in 11 regions, ES1 in 23, ES2 in 15, and ES3 in six. CONCLUSIONS: These results demonstrate the value of ultrasound elastography for the diagnosis of early-stage lymphoedema and determination of LVA sites. This is the first report of diagnosis of lymphoedema using elastography and the findings suggest that this procedure followed by LVA could be used as a new therapeutic method for early-stage lymphoedema.

Severe lymphedema caused by repeated self-injury.

Lymphedema is divided into primary and secondary forms. Primary lymphedema often develops in young people and may be caused by lymphvascular aplasia, hypoplasia, and hyperplasia. The most frequent cause of secondary lymphedema after lymphatic filariasis is regional lymph node dissection for treatment of a malignant tumor, and this complication occurs most frequently in middle aged or older patients. Here, we describe a relatively young patient (27 years old) in whom collecting lymph vessels in the upper limb were disrupted by repeated self-injury, with resultant lymphedema. There have been very few reports on lymphedema caused by self-induced trauma. This case report illustrates that secondary lymphedema should also be considered and evaluated appropriately when diagnosed in a relatively young patient without a history of cancer or infection.

Video-assisted thoracoscopic sterilization for exacerbation of chronic empyema thoracis.

STUDY OBJECTIVE: To investigate the efficacy of video-assisted thoracoscopic sterilization to treat patients with exacerbation of chronic empyema thoracis. DESIGN: Case reports and literature review. SETTING: Academic department of surgery. PATIENTS: Two elderly, debilitated patients with worsening, chronic empyema thoracis as diagnosed by radiographs, CT, and thoracentesis. Both patients had a history of therapeutic pneumothorax for tuberculosis without bronchopleural fistulas. INTERVENTIONS: Video-assisted thoracoscopic sterilization of the thoracic cavity. MEASUREMENTS AND RESULTS: There was no recurrence of empyema during a 6-year follow-up period for one patient and a 2.5-year follow-up period for the other patient. CONCLUSIONS: Video-assisted thoracoscopic sterilization is a minimally invasive useful treatment for elderly or debilitated patients with exacerbation of chronic empyema thoracis.

Transduction of human islets with the lentiviral vector.

Establishment of an efficient gene delivery system for human pancreatic beta cells is important for the development of diabetes-targeted cell therapies. The human immunodeficiency virus type 1 (HIV-1)-derived lentiviral vector is well documented to be an effective gene transfer tool for various types of cells. Thus, we examined the efficiency of lentivirus-mediated gene delivery for human islets. Human islets were isolated using defined protocols for enzymatic dissociation and purification using discontinuous Ficoll gradients with a refrigerated Cobe 2991 machine. Isolated islets were shipped to Japan, cryopreserved for 3 months, and then subjected to transduction. A vesicular stomatitis virus G-protein (VSV-G)-pseudotyped lentiviral vector LtV-NLS/LacZ was produced in 293T cells under the Fugene6 method. 804G extracellular matrices were applied for monolayer formation of islets. Detection of NLS/LacZ expression was performed using X-gal staining. Lentiviral transduction was effective in these monolayer islets.

[A clinical experience of ofloxacin in patients with respiratory infection].

To a total of 31 patients (18 in- and 13 out-patients) having respiratory infections, we administered ofloxacin (OFLX) orally at a daily dose of 300 to 600 mg and examined its clinical effect. The clinical effect in the 31 cases was as good as 83.9%. Among these cases, 6 cases showed Pseudomonas aeruginosa, thereby indicating the effective rate of OFLX at 50%. In the present examination, we experienced cases in which OFLX-resistant P. aeruginosa appeared in the cases of long-term administration of OFLX. Therefore, our clinic carried out the sensitivity test of P. aeruginosa against OFLX, gentamicin (GM) and imipenem (IPM) in 1987, using clinically-segregated strains of P. aeruginosa obtained by sputum tests. The sensitive strains, which were 100% sensitive to OFLX, GM, IPM respectively in 1985, showed, in segregated strains in 1987, sensitivity of OFLX 57.1%, GM 85.7% and IPM 100%, thus indicating the high resistance-acquiring frequency of P. aeruginosa against OFLX.

[Evaluation of rapidly growing Mycobacteria isolates in a general hospital: reports from the hospital microbiology laboratory].

Forty isolates of rapidly growing Mycobacteria, Mycobacterium fortuitum group including M. fortuitum and M. peregrinum and M. chelonae group including M. chelonae subsp. chelonae and M. chelonae subsp. abscessus at Showa University Fujigaoka Hospital collected between February 1981 and December 1997 were investigated in this study. These isolates were from the patients who were not infected with HIV. The average age of fourteen patients, from whom M. fortuitum group was isolated, was 58 years, ranging from 17 to 80 years old. One patient (71-year-old) with chronic myelogenous leukemia and another (64-year-old) with chronic diabetes mellitus were diagnosed with skin abscesses of M. fortuitum group, which were located on the right site of the neck and in the scar after injecting insulin (injection abscess), respectively. The average age of twenty-six patients, from whom M. chelonae group was isolated, was 57 years, ranging from 32 to 84 years old. One patient (75-year-old) with articular rheumatism was diagnosed with a lung infection of mixed M. chelonae group and Pseudomonas aeruginosa, and another (74-year-old) with diabetes mellitus and kidney failure was strongly suspected of a lung infection. The isolates of the two mycobacteria from the remaining patients were due to colonization, while these patients had the following underlying diseases contributing to infections: pulmonary emphysema; diabetes mellitus; leukemia; collagen diseases; lung cancer; chronic kidney diseases; systemic lupus erythematosus; carcinomatous pleurisy; bronchiectasis; post-tuberculosis. Most isolates of the two mycobacteria were separated from the specimens of patients' respiratory tracts, but since M. chelonae group was a contaminant in the tap-water for diluting concentrated chlorhexidine, the organism happened to be isolated with the mucous membranes of the 6 patients' colons that were picked up while using the washed fiber-scope. These findings suggest that M. fortuitum and M. chelonae groups, in spite of the fact that they rarely cause infection, have a significant risk of infecting aged patients in general hospitals with various underlying diseases attributable to infections. As only a few colonies were isolated from patients' specimens in the majority of cases, it took time to carry out these clinical examinations, and to improve this "laboratory's delay", it is needed to make faster report to clinicians.

[Clinical effects of transabdominal simple hysterectomy on micturition function].

We prospectively investigated micturition function in 68 women who were operated on by transabdominal simple hysterectomy for uterine myoma. Twelve parameters including stress urinary incontinence, obstructive symptoms, irritative symptoms, uroflow curves and amount of residue were subjectively or objectively evaluated before surgery and a mean of 4.4 months post-operatively. Though 55 patients (81%) had had one or more symptoms of micturition disorders prior to operation, surgery significantly reduced this number to 32 (47%) (p < 0.01). Hysterectomy significantly decreased the number of patients suffering from stress urinary incontinence, weak urinary stream, straining micturition, interrupted stream, urgency and frequency in the daytime. The relationship between the weight of the uterus removed and pre-operative symptoms of micturition disorders was assessed. Interrupted stream was present significantly more in the patients with a uterus weighing less than 400 grams and urgency in the patients with a uterus weighing more than 401 grams. We conclude that transabdominal simple hysterectomy is of use to improve micturition disorders pre-operatively recognized.

[Clinical evaluation of usefulness of cefixime (200 mg administered once daily) in the treatment of acute uncomplicated cystitis].

A comparative study of cefixime (CFIX), a new oral cephem antibiotic, was carried out at the Department of Urology, Nagoya University Hospital and its four affiliated hospitals to evaluate the clinical efficacy and safety of two dosage regimens of CFIX, given either in twice daily doses (BID group) or once daily dose (UID group), in the treatment of acute uncomplicated cystitis. Forty six female patients (BID group) were administered the daily dose of 200 mg in two divided doses for 3 days, 30 female patients (UID group) were administered 200 mg once daily for 3 days. The clinical efficacy was evaluated in 33 cases from the BID group and in 22 cases from the UID group, respectively, according to the criteria recommended by the Japan UTI Committee. In the BID group, the clinical efficacy was evaluated as excellent in 18 cases, moderate in 13 and poor in 2, with an overall clinical effectiveness rate of 94%. In the UID group, it was evaluated as excellent in 9 cases, moderate in 12 and poor in 1, with an overall clinical effectiveness rate of 96%. Safety was monitored in 71 patients, and only one case of stomatitis was seen in the UID group. This findings suggest that 200 mg once daily dosing regimen of cefixime is as effective as 100 mg twice daily dosing regimen in treatment of acute uncomplicated cystitis, and is well tolerated in terms of safety.

[Antibiotic prophylaxis for transurethral resection of the prostate--comparison of oral administration therapy with intravenous administration therapy].

To compare the prophylactic effect of oral and intravenous antibiotics against postoperative fever and urinary tract infection (UTI) after transurethral resection of the prostate (TUR-P), we conducted a multi-center prospective randomized study. The incidence of pyrexia over 38 degrees C was defined as the primary endpoint. One hundred and fifty patients with sterile urine before TUR-P were entered into this study. The patients were allocated randomly into the two arms; arm A cefotiam 4 g a day for 7 days, arm B tosufloxacin 300 mg a day for 7 days, based on the stratification into the 4 groups determined with/without preoperative indwelling catheters and with/without the history of preoperative UTI. Of these patients, 143 were eligible. We divided 124 patients without preoperative UTI and without indwelling catheters as the "low risk group", and the other 19 patients with preoperative UTI and/or with indwelling catheters as the "high risk group". In the low risk group, 9 patients out of 63 (14.3%) in arm A and 6 out of 61 (9.8%) in arm B had pyrexia during 7 postoperative days. The incidence of fever in arm B was 4.4% less than that in arm A and the 95% confidence limit was from -7% to 16%. In the high risk group, 4 out of 11 (36.4%) patients in arm A and none of 8 in arm B had fever but the difference was not significant. The incidence of post operative UTI in the low risk group on the 4 to 5, 9 to 12, 23 to 26 and 37 to 40 postoperative days was 8.3, 16.4, 25.0 and 23.9% in arm A and 6.7, 16.7, 29.6 and 36.7% in arm B, respectively. The prophylactic effect of oral administration of tosufloxacin is equivalent to that of the intravenous administration of cefotiam. The use of oral antibiotics is beneficial to reducing the cost of medication.

[Needle suspension of the bladder neck for stress urinary incontinence: surgical results of 394 patients operated on with quantitative procedures].

We have investigated surgical results of quantitative suspension of the bladder neck for stress urinary incontinence. Three hundred ninety-four female patients suffering from stress incontinence have been operated on with Stamey's or Gittes' procedures during the past 8 years. While the bladder neck was elevated by quantifying tension of nylon threads in 84 patients, 310 patients subsequently were operated on by quantifying both tension and length of nylon loops. A follow-up period averaged 51 months for a group of the Stamey's and 19 months for a group of Gittes' procedures. Postoperative continence rate was defined by patients' subjective evaluation. Those whose nylon loops were quantified as from 130 to 149 mm attained the highest continence rate, which was not related to age or severity of incontinence. Postoperative difficulty in urination was less in those who had nylon loops of 130 to 149 mm, and was more in those over 60 years of age. Eighty-eight percent of the patients stated very much satisfied or satisfied with the surgery they had undergone. Continence rate was 78% for those operated on with the Stamey's (51 months later) and 69% with the Gittes' procedures (19 months later). The 7-year continence rate was 77% for the former and the 3-year continence rate was 38% for the latter, indicating that the Stamey's procedure was significantly more useful than the Gittes' procedure. Postoperative complications were encountered with 17% of the patients. We conclude that quantitative suspension of the bladder neck is of value to obtain the high success rate of the needle suspension procedure.

[Vesicoureteral reflux and urinary incontinence in myelodysplastic patients: a comparison between those who had anti-reflux surgery alone and those who were treated by anti-reflux surgery combined with bladder augmentation with or without sling operation].

BACKGROUND: Vesicoureteral reflux and urinary incontinence are frequently observed among myelodysplastic patients. Since the conservative therapy is not always effective to improve these pathologies, surgical intervention is necessary for some of the patients. METHODS: Thirty-eight myelodysplastic patients were divided into 2 groups: Group A comprised 17 patients who had been operated by anti-reflux surgery (crossover method) alone and Group B 21 patients who had undergone anti-reflux surgery (Orikasa's method) and augmentation enterocystoplasty with or without sling operation. Cessation rate of reflux, bladder capacity, bladder compliance and operative complications were analyzed in the 2 groups. A questionnaire was sent to the patient asking to answer frequency of clean intermittent catheterization (CIC), severity of urinary incontinence, satisfaction rate for operation and so on. Mean followed-up periods were 11.7 (5.3-13.6) years for Group A and 3.7 (0.6-6.9) years for Group B, respectively. RESULTS: Reflux was successfully eradicated in 19 of 24 ureters (79%) of Group A and in 25 of 29 ureters (86%) of Group B, which was not significantly different. In Group A, bladder capacity and compliance slightly improved. The latter, however, remained less than 10 ml/cmH2 O. Bladder capacity and compliance of Group B increased more than twice the original value with statistical significance. Operative complication in Group A was ureteral obstruction in 1 patient, which eventually necessitated peritoneal dialysis. In Group B revision of ventriculoperitoneal shunt was necessary in 4 patients, incomplete ileus was conservatively treated in 3, and a bladder stone was formed in 1. The patients assessed that frequency of pyelonephritis was less in Group B compared to Group A. Other subjective parameters, however, such as frequency of CIC, severity of urinary incontinence, postoperative changes in the amount of urinary incontinence, and satisfaction rate for operation, were not different between the 2 groups. COMMENTS: Though operation-related complications occurred more frequently in those of Group B, these patients enjoyed significant improvement in bladder capacity and bladder compliance. We conclude when the conservative therapy fails to cure and improve vesicoureteral reflux and urinary incontinence, surgical interventions including anti-reflux surgery and augmentation cystoplasty with or without sling operation are recommended as a treatment option.

[Clinical study of a modified Stamey's endoscopic bladder neck suspension procedure for one hundred female patients with stress incontinence].

One hundred female patients with stress incontinence have been operated on by means of modified stamey's endoscopic bladder neck suspension procedure, i.e. quantifying the thread tension for bladder neck suspension. Twelve patients had 1,000 grams in the nylon loop, 5,800 grams, 9,700 grams, 25,600 grams and 49,400 grams. A follow-up period varied from 10 to 32 months (mean: 20.5 months). A 60-min pad-weighing test revealed urinary loss of 1.0 to 196.0 grams/hour (mean: 36.0) prior to operation. 1. The modified Stamey's procedure was successful in 95 patients (95%). The appropriate thread tension for bladder neck suspension was 400 grams. 2. Various complications were encountered: removal of unilateral nylon suture was necessitated in 2 patients, bleeding from operative wound in 2, bladder tamponade in 2, and clean intermittent catheterization for more than one month in 4. 3. Micturition parameters, i.e. maximum and average flow rates, temporarily got worse post-operatively. Maximum urethral closure pressure decreased and functional profile length elongated which were significantly different from those of pre-operative values. 4. Questionnaire sent to the patients revealed that 89 percent of them were satisfied with the operative results but 11 percent were not. 5. The modified Stamey's procedure is simple to perform and prevents over-tightness of nylon loops. We conclude that this operative method is the treatment of choice for correction of stress incontinence.

[The efficacy of Turbuhaler dry powder inhaler in Japanese asthma--measurement of peak inspiratory flow when using Turbuhaler].

Inhaled antiasthmatic agents can be effective, but their efficacy depends on the delivery system and on inhalation technique. The dry powder inhaler Turbuhaler is being evaluated clinically, and correct inhalation technique with this device has been shown to be easy to teach. To find out whether this device could be useful in Japan, we studied inspiratory flow and inhalation technique with the Turbuhaler in Japanese patients with asthma. Of the 105 patients studied, 80 patients (76.2%) used the Turbuhaler correctly after only one practice session; 58 patients (55%) found it easy or very easy to use, and 19 patients (18%) found it difficult to use. The mean peak inspiratory flow for all patients was 61 L/min. Peak inspiratory flow was less than 30 L/ min in only two patients, both of whom were women over 65 years old. Peak inspiratory flow did not correlate with other indices of pulmonary function. In summary, inspiratory flow in Japanese patients with asthma was sufficient for the Turbuhaler to be effective, and these patients soon learned to use the device even though they had no previous experience with a dry powder inhaler. Therefore, the Turbuhaler should be clinically useful in Japan.