[Off-pump coronary artery bypass grafting supported by intra-aortic balloon pumping in a patient with moyamoya disease].

A 48-year-old woman was admitted to the hospital for coronary artery bypass grafting (CABG) of ischemic coronary disease, including left main trunk disease. She had a history of moyamoya disease with bilateral internal carotid artery occlusion. Her cerebral blood flow and cerebral vascular reactivity were evaluated by single photon emission computed tomography. Her collateral blood flow and cerebral vascular reserve were the lower limit of normal. We performed off-pump CABG supported by intra-aortic ballon pumping to maintain appropriate cerebral blood flow intraoperatively. Moreover, during operation, systolic blood pressure and blood Paco2 level were constantly maintained above 100 mmHg and 40 mmHg. Her postoperative course was uneventful without transient ischemic attacks or stroke.

[Aortic valve replacement and repeat coronary artery bypass grafting in a patient with a patent internal thoracic artery bypass graft; report of a case].

We report a case of aortic valve replacement and repeat coronary artery bypass grafting in a patient with a patent internal thoracic artery bypass graft. A 77-year-old man, who underwent coronary artery bypass grafting (CABG) 10 years ago, was admitted to the hospital for aortic stenosis and angina pectoris. Transthoracic echocardiography demonstrated severe aortic calcification with an 86 mmHg gradient across the aortic valve. Coronary angiography demonstrated the patency of all grafts and 90% stenosis of the left circumflex coronary artery. At surgery, a full median sternotomy was performed. The adhesions around the heart and great vessels were severe and the left internal thoracic artery (LITA) was found adherent to the heart and sternum. The LITA and saphenous vein graft (SVG) graft were dissected carefully. Retrograde coronary sinus (CS) perfusion was performed with antegrade myocardial protection for cardiac arrest. We performed aortic valve replacement (AVR) with a 17 mm St. Jude Medical Regent Valve and CABG to the circumflex artery with the saphenous vein under cardiopulmonary bypass. His postoperative course was uneventful. He was discharged from our hospital without major complications.

[Recurrent cardiac myxoma that developed rapidly in a short period].

A 55-year-old woman, who had undergone extirpation of left atrial myxoma 3-years before, was admitted to our hospital with dyspnea. Chest computed tomography revealed a low density mass in the left atrium (LA) with a diameter of 54 mm. Transthoracic echocardiography showed that the mass was attached to the left atrial septal wall and had a pendulum-like movement. We urgently performed an operation for recurrent left atrial myxoma. Through atrial transseptal approach, a huge myxomatus tumor was observed in the LA. The stalk was on the endocardium at the cranial side of the previous autologous pericardial patch. The tumor was completely excised along with the patch. We repaired the disrupted endocardium and performed Dacron patch repair of the atrial septal defect. The patient recovered uneventfully and was discharged 14 days after surgery. The excised tumor was found to be myxoma on pathological examination similar to the previous tumor. We report a case of recurrent left atrial myxoma with rapid growth in a short time period.

[Extracardiac rupture of aneurysm of the noncoronary sinus of valsalva: report of a case].

A 78-year-old female was admitted to our hospital because of sudden onset of chest pain and general fatigue. A chest X-ray showed marked cardiomegaly and computed tomography (CT) revealed pericardial effusion with left pleural effusion. Upon admission to CCU, she suddenly lost consciousness and was intubated. Echocardiography confirmed increase in the amount of the pericardial effusion, which was drained at CCU. By an emergent operation, ruptured aneurysm of the noncoronary sinus of Valsalva to the pericardial space was confirmed upon opening the chest and patch plasty of the sinus of Valsalva was performed. The postoperative course was uneventful, and she was discharged on the 24th postoperative day. Extracardiac rupture of aneurysm of the sinus of Valsalva is extremely rare, and the emergent operation is indispensable.

Invasive Aspergillus stomatitis in patients with acute leukemia: report of 12 cases.

An 8-year retrospective analysis of invasive Aspergillus stomatitis in neutropenic patients with acute leukemia was performed to characterize the epidemiology and clinical features of the infection. Twelve cases of invasive Aspergillus stomatitis were identified with both clinicohistological and microbiological evidence, and the majority of cases were caused by Aspergillus flavus (10 [83%] of 12 patients). The infection was strongly suspected when a neutropenic patient developed persistent fever without a known source, symptoms of gingival pain and facial swelling, and a solitary ulcerating lesion of mucogingiva covered with a gray necrotic pseudomembrane. Aspergillus stomatitis was diagnosed a median 23 days after admission. In all 12 patients, the diagnosis was made during the period of neutropenia. Ten patients (83%) were treated with amphotericin B and surgery and survived with recovery of neutrophils. Two patients died, and disseminated aspergillosis was identified in 1 patient.

Molecular identification of a clinical isolate of non-pigmented and asporogenic Aspergillus fumigatus strain which cannot be identified by traditional morphological methods.

A non-pigmented and asporogenic fungal strain without taxonomically useful characteristics was isolated from sputum of a patient with chronic bronchitis. Although the taxonomic position could not be determined based on traditional morphological criteria, the fungus was identified as an Aspergillus fumigatus mutant strain by molecular techniques including ITS sequence analysis and PCR identification system using a PCR primer pair specific for A. fumigatus. Usefulness of these molecular techniques for the identification of non-classifiable fungal strains in a clinical laboratory is discussed.

[Valve replacement with cryopreserved allograft].

Allograft valves have several advantages such as 1) the absence of thromboembolic complications without anticoagulation, 2) superior durability to bioprosthetic valves, 3) good resistance to infection, 4) excellent hemodynamic performance especially in small sizes. Surgeons in western countries, therefore often use these valves and have reported good long-term results. In Japan, there have been only a small number of case reports on such valve replacement. We experienced five cases of valve replacement with cryopreserved allografts, four men and one woman. Four of them had formerly received AVR or Cabrol operation, and the prosthetic valve (graft) infection or aortitis syndrome was the main reason of reoperation. One 15 year-old woman suffering from congenital aortic stenosis underwent Ross operation with pulmonary allograft. Although one case with PVE received re-re-AVR 2 years and 4 months after the allograft replacement because of the recurrence of infection, the other four cases are in good condition long after the surgery. We hope that the use of allograft valves will become common in Japan.

Difference between PA700-like proteasome activator complex and the regulatory complex dissociated from the 26S proteasome implies the involvement of modulating factors in the 26S proteasome assembly.

The PA700-like proteasome activator complex was highly purified from porcine erythrocytes, and its properties were compared with those of the regulatory complex disassembled from the purified 26S proteasome. The molecular mass of the PA700-like complex, which comprises 25-110-kDa subunits, was estimated to be 800 kDa by Superose 6 gel filtration. This complex showed neither ATPase activity nor peptidase activity toward Suc-Leu-Leu-Val-Tyr-MCA. Nevertheless, it was possible to make a high molecular mass complex from the purified PA700-like complex by incubating with the 20S proteasome in the presence of ATP. In contrast, the regulatory complex dissociated from the 26S proteasome did not reconstitute a larger complex under the same conditions. The subunit composition of the PA700-like complex was similar but not identical to that of the regulator complex dissociated from the 26S proteasome: the former complex had a 25-kDa subunit which is absent in the latter, whereas the latter had two or three 43-kDa subunits lacking in the former. These results indicate that the purified PA700-like proteasome activator complex is structurally and functionally distinct from the regulatory complex dissociated from the 26S proteasome, implying the involvement of modulating factors in the 26S proteasome assembly.

Partial splenic embolization for Felty's syndrome: a 10-year followup.

Partial splenic embolization was performed in a case of Felty's syndrome in 1980. The granulocyte count has since remained normal without serious infections for the 10 years after the procedure. This is the first report of partial splenic embolization in this syndrome. This treatment may have an advantage over splenectomy because the defense mechanisms of the spleen are preserved and overwhelming infections may occur less frequently.

[A case of Legionnaires' disease associated with rhabdomyolysis].

Legionnaires' disease is primarily a respiratory disorder, but recently several cases with extrapulmonary manifestations are reported. We report a case of Legionnaires' disease associated with pneumonia, diarrhea, central nerve disorders and rhabdomyolysis. The pathogenesis of rhabdomyolysis in Legionnaires' disease remains speculative. Endotoxin isolated from Legionella pneumophila may play a role in the pathogenesis of the myonecrosis. An additional factor that might contribute to rhabdomyolysis in this case is severe dehydration induced by diarrhea. Pneumonia with elevated CPK levels and myoglobinuria may suggest Legionnaires' disease.

Ofloxacin in respiratory tract infection. A review of the results of clinical trials in Japan.

An open clinical study of ofloxacin in respiratory tract infections was conducted with patients receiving daily doses of ofloxacin 300 mg, 400 mg or 600 mg. The duration of treatment was 6 to 14 days for 70% of the patients. Ofloxacin was effective in 668 of 828 patients analysed (80.7%). Of 293 patients with upper respiratory infections, the efficacy rate was 85.3%. In 535 cases with lower respiratory infections, ofloxacin was effective in 78.1%. It is noteworthy that a 70% efficacy rate was obtained in 80 cases with intractable chronic diffuse panbronchiolitis primarily associated with Pseudomonas aeruginosa. There was no difference in the efficacy rate among various daily doses or severity of infections. In lower respiratory infections the bacterial eradication rate was 80.9% for Gram-positive aerobes (including 80% for Staphylococcus aureus and 76.5% for Streptococcus pneumoniae) and 72.1% for Gram-negative aerobes (including 92.6% for Klebsiella pneumoniae, 32.3% for P. aeruginosa and 97.1% for Haemophilus influenzae). Although there were no serious cases, adverse reactions were noted in 46 of 843 patients (5.5%): 38 cases (4.5%) of gastrointestinal tract reactions (nausea, vomiting, heartburn, etc.), 4 cases (0.5%) of hypersensitivity (e.g. eruption) and 19 (2.3%) of central nervous system effects (e.g. dizziness). Abnormal changes in laboratory findings included elevations of AST (1.2%) and ALT (1.5%) and an increase in the eosinophil count (1.7%).