[Aortic dissection and annulo-aortic ectasia complicating systemic lupus erythematousus; report of a case].

A 31-year-old man with systemic lupus erythematosus had received long term steroid therapy. He had no compliant, but magnetic resonance imaging showed aortic dissection and annulo-aortic ectasia. Echocardiogram showed severe aortic regurgitation. Therefore aortic root replacement was performed. A histological study of the aortic wall demonstrated myxomatous degeneration in the media. He recovered uneventfully, except for receiving continious hemodia filtration during 4 days after the operation

[Infective endocarditis with the fistula from sinus Valsalva to right atrium and ventricle; report of a case].

A 77-year-old man complained general fatigue and fever. Preoperative echocardiography revealed vegetation of aortic valve, abnormal shunt flow from the sinus of Valsalva was detected in the right atrium and ventricle without perivalvular abscess cavity or aneurysm of the sinus of Valsalva. He diagnosed aortic valve endocarditis with aorto-right atrium and ventricle fistula. He received aortic valve replacement and patch closure at the sinus of Valsalva using the pericardium. Residural aortic-right atrium and ventricle shunt was not detected after the operation, the post operative course was uneventful without congestive heart failure nor signs of infection.

[Large coronary aneurysm after coronary intervention for acute myocardial infarction; report of a case].

A 59-year-old man was admitted to our hospital because of angina pectoris and a large right coronary aneurysm. Two years previously, he underwent percutaneous coronary balloon angioplasty for a stenotic lesion in right coronary artery (RCA) #3. Angiography and computed tomography showed a large right coronary aneurysm. On-pump coronary artery bypass grafting (CABG), ligation of RCA proximal and distal to the aneurysm, resection of the aneurysm was performed successfully. Postoperative course was uneventful with satisfactory angiographic results.

[Perforation due to new myocardial infarction long time; report of a case].

A 65-year-old man was admitted to the hospital because of effort chest pain, 8 years after he received coronary artery bypass grafting [CABG: left internal thoracic artery (LITA) to left anterior descending artery (LAD), saphenous vein graft (SVG) to first diagonal branch (D1) and SVG to postero-lateral branch (PL)]. Emergent coronary angiography revealed right coronary artery occlusion with well patent bypass grafts. Percutaneus coronary intervention (PCI) was performed successfully, but 9 hours later, ventricular septal perforation (VSP) was occurred. Swan-Ganz catheter revealed that pulmonary to systemic blood flow ratio (Qp/Qs) was 2.6. In spite of intensive medical care, his hemodynamics was gradually exacerbated. Subsequent intracavitary repair with equine pericardial patch, sutured using interrupted mattress sutures with felt pledgets, was performed. He had an uneventful recovery thereafter, extubated and weaned from an intra-aortic balloon pumping at the 1st day. He was discharged from hospital on the 27th postoperative day.

[Endovascular stent-grafting for mycotic thoracic aortic aneurysm].

We report 3 cases of endovascular stent-grafting (ESG) for mycotic thoracic aortic aneurysm. The case 1 was a rupture of pseudoaneurysm of the descending aorta caused by mediastinitis due to perforation of esophageal ulcer. The patient underwent emergent ESG for temporary control of the rupture. He underwent esophagus reconstruction 5 month after ESG. The case 2 was admitted due to inflammatory reaction. She was diagnosed with mycotic descending aortic aneurysm and underwent elective ESG because of her old age. Her postoperative course was uneventful and no infection recurred. The case 3 underwent ESG for a ruptured mycotic descending aortic aneurysm. But 113 days after ESG, he underwent ESG again for a ruptured endoleak of the stentgraft. His blood culture demonstrated methillin-resistant Staphylococcus aureus (MRSA). He died of rupture to bronchus and esophagus at 18th day after ESG. We believe that ESG is useful in high risk patients for temporary management of the rupture.

[Successful consecutive seven time's surgical repair of Marfan syndrome].

We report a patient with Marfan syndrome who received successful 7 consecutive operations during 11 years. She underwent descending aortic replacement for chronic type B dissection at the age of 24. Mitral valve replacement (MVR) was performed for mitral regurgitation (MR) at the age of 30, and abdominal aortic replacement was done for persistent dissection at the age of 31, aortic root and arch replacement was done at the age of 34. The 9 months later, she received re-MVR for dysfunction of bioprosthesis and tricuspid valve anuloplasty (TAP) for tricuspid regurgitation (TR). But severe paravalvuler leakage of mitral valve necessitated direct closure of detachment. Thoracoabdominal replacement was performed for rupture of persistent dissection at the age of 35. She was discharged on the 54th day after the 7th surgery.

[Management of quadruple valves for severe infective endocarditis; report of a case].

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.

Young's syndrome associated with situs inversus totalis.

Primary ciliary dysfunction causes recurrent sino-pulmonary infections and shares the pathophysiology of the reproductive tract. A 34-year old man with bronchectasis and situs inversus totalis was investigated because of azoospermia. Endocrinological evaluations were all normal and scrotal exploration revealed the distended caput, but atrophic body to tail, of the epididymis. Light microscopy of testicular biopsy showed normal spermatogensis and motile sperms were easily obtained by testicular sperm extraction. Electron microscopy demonstrated normal sperm structure, whereas 65% of nasal cilias showed defect of central microtubules. This case, which bears a resemblance of Kartagener's syndrome (situs inversus totalis), is considered a unique variant of Young's syndrome.

Indication of varicocelectomy in the era of assisted reproductive technology: prediction of treatment outcome by noninvasive diagnostic methods.

Of 103 patients who underwent varicocelectomies, 87 underwent all the diagnostic methods: color Doppler ultrasonography (DOP), scrotal deep body temperature (DBT), and scrotal scintigraphy (SSG). Total motile sperm (TM) was calculated. The positivities of DOP, DBT, and SSG were 67, 51, and 90%, respectively. In the patients <30 years old, TM increased in the DBT-positive group. In older patients, positive for DBT indicated poor improvement of TM, whereas positive for DOP indicated better response in the group. Patients older than 30 years and positive for DBT, but not DOP, should be counseled directly to receive intrauterine insemination or in vitro fertilization/intracytoplasmic sperm injection.

Quantitative analysis of testicular interstitial fibrosis after vasectomy in humans.

PURPOSE: Germ cell differentiation, DNA synthesis, and apoptosis can be evaluated quantitatively. On the other hand, an interstitial lesion is difficult to examine. We have focused on the quantitative analysis of testicular interstitial fibrosis after vasectomy. MATERIALS AND METHODS: Forty testicular biopsy specimens from twenty consecutive men were obtained at vasovasostomy. Johnsen's mean score was calculated from testicular biopsy specimens. Percent of interstitial fibrosis was determined quantitatively by the NIH-Image after Masson-trichrome staining. RESULTS: A significant increase in interstitial fibrosis was observed along with the obstructive interval (p < 0.001). Johnsen's mean score count did not associate with the obstructive interval. CONCLUSION: Interstitial lesions of testicular physiology and pathophysiology can be evaluated using the NIH-Image. Interstitial fibrosis, but not the intraseminiferous status, reflects the irreversible damage of vasectomized testes.

Internal spermatic vein diameter and age at operation reflect the response to varicocelectomy.

It was evaluated whether the diameter of internal spermatic veins (measured directly during operation) correlates with the clinical grade and treatment outcome following varicocelectomy. Fifty-seven consecutive men undergoing left varicocelectomy were included in the study, and spermatic vein diameter was compared with the response to the operation. The diameter appeared larger with increasing clinical grade (subclinical: 3.40 +/- 1.64 mm; grade 1 : 2.74 +/- 0.84 mm; grade 2 : 3.70 +/- 1.09 mm; grade 3 : 4.38 +/- 1.30 mm). In patients 30 years or older, spermatic vein diameter in men whose post-operative semen parameters were unchanged or worsened was statistically larger than that of patients whose post-operative semen parameters were improved, in terms of both sperm concentration (3.90 +/- 1.24 mm versus 2.84 +/- 0.94 mm; P < 0.05) and sperm motility (3.98 +/- 1.24 mm versus 2.67 +/- 0.67 mm, P < 0.01). Although the diameter of internal spermatic veins measured directly during operation correlated well with clinical grade, it is the diameter and patient's age at operation, but not clinical grade, that determine the reversibility of testicular injury following varicocelectomy.

Idiopathic clitoral hypertrophy.

We report a case of clitoral hypertrophy of unknown origin. A 3-year-old girl showed clitoral hypertrophy at birth. Biochemical analysis of peripheral blood and endocrinological examinations were normal. Other virilizing symptoms were not recognized. Clitoroplasty was carried out, and the clitoris has not enlarged 20 months after the operation. Her mother was administered cefotiam and terbutaline (beta-stimulant) during pregnancy because of threatened abortion. No virilizing agents such as progesterone were used during pregnancy.

The treatment of obstructive azoospermia in male infertility--past, present, and future.

Until recently, the primary treatment option for infertile men with obstructive azoospermia was the reconstruction of the male seminal tract when the causes of obstruction were reconstructable. For unreconstructable causes, such as congenital absence of the vas deferens, the primary treatment option involved implantation of an alloplastic artificial spermatocele for subsequent percutaneous retrieval of sperm. Retrieved sperm was then used for intrauterine insemination. The introduction of in vitro fertilization (IVF), performed together with microsurgical epididymal sperm aspiration (MESA), provided new frontiers for the treatment of unreconstructable obstructive azoospermic infertility in men. Against this background, the author reviewed the past and present status of the treatment of obstructive male infertility for the purpose of seeking a future course for the treatment of obstructive azoospermia. At the Andrology Clinic, 246 (26%) of 963 infertile males revealed azoospermia and 72 (29%) of these 246 patients showed obstruction at the seminal tract, showing that 7.5% of male infertility cases were caused by ductal obstruction. Microsurgical reconstruction of the seminal tract was performed, including vasovasostomy (29 cases), epididymovasostomy (18 cases), and artificial spermatocele implantation (20 cases). Vasovasostomy resulted in an 81.3% patency rate and a 37.5% fertility rate. Epididymovasostomy showed a 71% patency rate and a 29% fertility rate. In contrast, artificial spermatocele implantation resulted in positive sperm present in the aspirated fluid in 33.3% of the patients; however, no pregnancy was achieved by artificial insemination using aspirated sperm. MESA together with assisted reproductive technology (ART) in 14 patients showed 79% ovum fertilization rates and a 35.7% clinical pregnancy rate. Thus, this new technique could open new frontiers for the future treatment of obstruction of the male seminal tract which cannot be reconstructed by vasovasostomy or vasoepididymostomy.

Pathophysiology of clinical varicoceles in infertile men.

In infertile men, clinical varicoceles most often occur bilaterally. In our experience with these patients, both testicles are smaller than normal. We find more than 25% to 35% immature and tapered sperm in in the ejaculum of these men, and the motility of the sperm is usually low. We have found serotonin in the plasma of the varicoceles, and believe this biogenic amine is responsible for the poor sperm motility. We now agree that a subset of neuroendocrine cells in the prostate secrete serotonin. Bilateral varicocele surgery can improve the patient's fertility potential, and we advocate surgical treatment.

Juberg-Marsidi syndrome: report of an additional case.

We report on a 2-year-old boy with Juberg-Marsidi syndrome. He has mental retardation, short stature, micropenis, cryptorchidism, and minor facial abnormalities. His Leydig cells responded to the administration of human chorionic gonadotropin and there were positive responses of LH and FSH to the administration of LH-RH. He showed normal weight gain and head circumference which have not been described previously. The association of Juberg-Marsidi syndrome with HbH disease was ruled out in the propositus.

Quantitative analysis of spermatogenic DNA synthesis in the rat using a monoclonal anti-5-bromodeoxyuridine antibody.

The utility of the 5-bromodeoxyuridine (BrdUrd) labelling technique for the quantitative analysis of spermatogenic deoxyribonucleic acid (DNA) synthesis was investigated in the rat. Rat testicles were labelled by a single intraperitoneal injection of 100 mg kg-1 of BrdUrd. The testicles were removed 1 h after injection, fixed in Bouin's fluid and embedded in paraffin. BrdUrd-labelled cells were detected by immunohistochemical staining using a monoclonal anti-BrdUrd antibody. The number of BrdUrd-labelled tubules per total number of tubules (percent L.T.), the number of BrdUrd-labelled cells per total number of tubules (tubular ratio) and the number of BrdUrd-labelled cells per number of Sertoli cells (Sertoli cell ratio in BrdUrd-labelled cells) were calculated as indices of spermatogenic DNA synthesis during each stage of the seminiferous epithelial wave. BrdUrd labelling was found exclusively in the nuclei of spermatogonia and in preleptotene spermatocytes in the seminiferous epithelium. The percent L.T. was generally greater than 50%, except in stages VI, VII and XIV, and the tubular as well as Sertoli cell ratios in BrdUrd-labelled cells was greater than 2.0 and 0.15, respectively, in stages I, II-III, V, VIII, X, and XII. The tubular ratio and Sertoli cell ratio in BrdUrd-labelled cells along the seminiferous epithelial wave had two distinct peaks. The distribution of the tubular ratio using the BrdUrd-labelling technique correlated well with the distribution previously established by measuring tritiated thymidine uptake per tubule. Thus, the BrdUrd labelling technique, which is more efficient than the tritiated thymidine labelling technique, can be used to quantitatively evaluate spermatogenic DNA synthesis.

[Effect of E. coli endotoxin and D-galactosamine on pathophysiology in rat lungs].

The effects of repeated intravenous injection of E. coli endotoxin (ETX) and intraperitoneal injection of D-galactosamine (GAL), which decreases the circulating level of alpha 1-antitrypsin, on the pathophysiology of chronic lung injury was studied in rats. Four groups were prepared as follows for 8 weeks. Group 1 (control): Intravenous injection of saline. Group 2: Intravenous injection of ETX (2 mg/kg) once a week. Group 3: Intraperitoneal injection of GAL (200 mg/kg), 2 times daily on 3 consecutive days each week. Group 4: Injection of both ETX and GAL, at the same dosages as used in groups 2 and 3. Total lung capacity and static lung compliance divided by weight were high in the ETX group and the ETX + GAL group, comparative when compared with those in the control and GAL groups, even though weight gain rates in the ETX + GAL group was less than in other groups. Mean linear intercept of rats in the ETX + GAL group was significantly greater than in other groups. These results suggest that ETX + GAL-treated rats have more emphysematous changes in pulmonary function and structure.

Syosaiko-to and saiboku-to (Chinese-Japanese herbal medicine) suppress the release of arachidonic acid metabolites from cultured porcine pulmonary artery endothelial cells.

The influences of Syosaiko-to and Saiboku-to, traditional Chinese-Japanese medicines, on the arachidonic acid metabolism of porcine pulmonary artery endothelial cells (PPAEC) in culture were investigated. 6-keto-PGF1 alpha, a stable end product of prostacyclin, released by PPAEC during a 48 h incubation period with 1000 micrograms/ml of Syosaiko-to or Saiboku-to was significantly decreased. Analysis of the eicosanoid profile by high performance liquid chromatography revealed that both cyclooxygenase and lipoxygenase derivatives were released in smaller than usual proportions from PPAEC during 24 h incubation periods with 500 micrograms/ml of Syosaiko-to or Saiboku-to. Clinically, Syosaiko-to is used for chronic hepatitis and Saiboku-to is prescribed for bronchial asthma. The experimental findings could explain the anti-inflammatory effect of Syosaiko-to and Saiboku-to from the perspective of their influences on arachidonic acid metabolic activity associated with PPAEC.

[Effects of liposome-entrapped E. coli endotoxin on lung pathophysiology in rats].

The effects of repeated intravenous injections of E. coli endotoxin (ETX)-containing liposomes (LP) on the development of emphysematous change in rats were examined. Male Wistar rats, weighting 150-200 g, were divided into 3 groups. Group 1; rats treated with phosphate buffered saline (PBS), Group 2; rats treated with liposome-entrapped PBS, Group 3; rats treated with liposome-entrapped ETX (10 mg/ml). In each group, 0.5 ml was injected intravenously once a week for 8 consecutive weeks. After 8 weeks, functional and morphometrical analyses of lungs were performed. Functional residual capacity (FRC), total lung capacity (TLC), and static compliance (Cst.) were measured using a pressure plethysmograph for small animals. Mean linear intercept (MLI) and internal surface area (ISA) were also determined. TLC did not differ among the 3 groups. In rats treated with liposome-entrapped ETX, Cst. corrected by body weight (Cst./body weight) was significantly increased compared with that in liposome-entrapped PBS-treated rats. Further more, MLI was larger than that of the other 2 groups and ISA was less than that of the liposome-entrapped PBS-treated rats. These results suggest that liposome-entrapped ETX induces emphysematous changes in rats.

[Endopyelotomy for ureteropelvic junction obstruction: results and complications].

We treated eleven cases of primary ureteropelvic junction obstruction with percutaneous endopyeltomy. Endopyelotomy was successful in nine of the eleven cases. Complications during and after endopyelotomy occurred in three cases, two of which had pyelonephritis and the other severe postoperative hemorrhage requiring blood transfusion due to incision of a posterior crossing vessel. In this last case, the kidney was supplied by three arteries. The lower segmental artery passed behind the ureter. We emphasized that angiography should be performed to rule out the presence of a posterior crossing vessel before endopyelotomy, when it is doubtful if an extrinsic cause of ureteropelvic junction obstruction is present.