Practices for Supporting and Confirming Decision-Making Involved in Kidney and Liver Donation by Related Living Donors in Japan: A Nationwide Survey.

This nationwide survey investigated the actual practices for supporting and confirming the decision-making involved in related living-organ donations in Japan, focusing on organ type and program size differences. Answers to a questionnaire survey were collected from 89 of the 126 (71%) kidney and 30 of the 35 (86%) liver transplantation programs in Japan that were involved in living-donor transplantations in 2013. In 70% of the kidney and 90% of the liver transplantation programs, all donors underwent "third-party" interviews to confirm their voluntariness. The most common third parties were psychiatrists (90% and 83%, respectively). Many programs engaged in practices to support decision-making by donor candidates, including guaranteeing the right to withdraw consent to donate (70% and 100%, respectively) and prescribing a set "cooling-off period" (88% and 100%, respectively). Most donors were offered care by mental health specialists (86% and 93%, respectively). Third parties were designated by more of the larger kidney transplant programs compared with the smaller programs. In conclusion, the actual practices supporting and confirming the decision to donate a living organ varied depending on the organ concerned and the number of patients in the program.

[Occurrence of BOOP outside radiation field after radiation therapy for small cell lung cancer].

We report a case of bronchiolitis obliterans organizing pneumonia (BOOP) that occurred outside the radiation field after radiation therapy for small cell lung cancer. A 74-year-old woman received chemotherapy and a total of 60 Gy of radiation therapy to the right hilum and mediastinum for small cell carcinoma of the suprahilar area of the right lung. Radiation pneumonitis developed within the radiation port 3 months after the completion of radiation therapy. She complained of cough and was admitted 7 months after completion of the radiation therapy. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field on the side contralateral to that receiving the radiation therapy. Bronchoalveolar lavage showed that the total cell count was increased, with a markedly increased percentage of lymphocytes. Transbronchial lung biopsy revealed a histologic pattern consistent with BOOP. Treatment with corticosteroids resulted in rapid improvement of the symptoms and complete resolution of the radiographic abnormalities of the left lung. Although some cases of BOOP following radiation therapy for breast cancer have been reported, none of BOOP after radiation therapy for lung cancer have appeared in the literature.

Thin-section CT features of intrapulmonary lymph nodes.

PURPOSE: The objective of this study was to evaluate CT findings of pathologically proven intrapulmonary lymph nodes (IPLNs) and discuss the utility of thin-section CT and contrast-enhanced CT. METHOD: CT findings of 18 nodules in 14 patients with pathologically proven IPLNs were reviewed. CT scanning of the whole lung was performed contiguously with slice thickness of 10 mm. In addition, a helical scan with slice thickness of 2 mm was performed in nine patients, focusing on the nodule. Contrast-enhanced helical CT was performed in four patients, and the utility of thin section CT and contrast-enhanced CT was investigated. RESULTS: One patient had three nodules, 2 patients had two nodules, and the remaining 11 patients had a solitary nodule. All nodules were located below the level of the carina and within 15 mm of the pleura. In one case, conventional CT revealed the nodule 20 mm away from the pleura; however, the nodule attached to the major fissure was clearly revealed on thin-section CT. The size of the nodules was < or =15 mm, and the shape was round (n = 8), oval (n = 9), or lobulated (n = 1) with sharp border. One nodule demonstrated a spiculated border due to a surrounding pulmonary fibrosis on conventional CT; however, thin-section CT showed precisely a sharp border. The lobulated shape of one case histopathologically reflected a hilus of lymph node. On contrast-enhanced helical CT, all four nodules were enhanced and the degree enhancement was 36-85 HU (median 66.6 HU). CONCLUSION: In current times, IPLNs are not uncommon lesions. We should consider IPLN in the differential diagnosis of solitary or multiple pulmonary nodules in the peripheral field and below the level of the carina. Thin-section CT showed precisely the border or relation between IPLNs and the surrounding structure. It was difficult to distinguish between IPLNs and malignant nodules from the degree of enhancement on contrast-enhanced CT. On thin-section and contrast-enhanced CT, the findings of IPLNs are not necessarily specific. Therefore, strict observation on CT is necessary; in certain cases that are increasing in size, video-assisted thoracic surgery should be considered because of their location.

[Occurrence of BOOP outside radiation field after tangential radiation therapy for breast carcinoma].

We report three cases of bronchiolitis obliterans organizing pneumonia (BOOP) that occurred outside the radiation field after radiation therapy using tangential fields for breast carcinoma. All patients complained of a cough between 14 and 20 weeks after completion of radiation therapy. Fever also developed in two of the three. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field on the same side as the radiation therapy. Laboratory data showed an increased level of C-reactive protein and an increased erythrocyte sedimentation rate. Bronchoalveolar lavage showed an elevated total cell count with a very high percentage of lymphocytes. Transbronchial lung biopsy revealed a histologic pattern consistent with BOOP. Treatment with corticosteroids resulted in rapid clinical improvement and complete resolution of the radiographic abnormalities. This pulmonary disorder appears to be induced by radiation, especially when a tangential field is employed for breast carcinoma, though the etiology has not been fully investigated. It is important to be aware of this type of pulmonary complication in patients given radiotherapy for breast carcinoma.

Acute disseminated encephalomyelitis associated with poliomyelitis vaccine.

A 6-year-old female patient with acute disseminated encephalomyelitis associated with poliomyelitis vaccine virus is reported. She had a history of high fever, headache, and gait disturbance. Neurologic examination confirmed spastic triparesis, urinary incontinence, diminution of tactile sensation, and vision deterioration. Hemography, serum laboratory findings, and urinalysis were normal. The cerebrospinal fluid was clear, with normal pressure, 9 leukocytes/mm(3), and 27 mg/dL protein, but the myelin basic protein was elevated to 10.7 ng/mL. T(2)-weighted magnetic resonance imaging disclosed multifocal high-intensity lesions of the spinal cord. The serum polio virus type 2 antibody titer was raised in the acute phase, and polio vaccine virus type 2 was detected in viral cultures of the cerebrospinal fluid and pharynx swab and had undergone an A-G neurovirulence mutation at nucleotide 481. Finally, she had human leukocyte antigen (HLA)-Cw3 and HLA-DR2, to which multiple sclerosis is related in Japan. Thus the cause of ADEM may have been related to her HLA type.

Zonisamide - induced urinary lithiasis in patients with intractable epilepsy.

We report here three patients with intractable epilepsy who developed urinary lithiasis during zonisamide (ZNS) treatment. Abdominal pain due to left-sided hydronephrosis was the initial symptom in the first patient, and it was resolved after the excretion of a stone. The second patient, who had no specific symptoms, was found to have a thick sludge of calcium phosphate in the bladder when he suffered from aspiration pneumonia and dehydration. The third patient, who had a history of recurrent urinary obstruction, was also found to have a thick sludge of calcium oxalate in the bladder. The urinalysis of the three patients revealed alkaline urine and hypercalciuria. Although their urinary lithiasis was resolved by discontinuation of ZNS and supportive therapy, routine examination of urine parameters such as pH and sediments, and daily urine-output checks are thought to be necessary during treatment with ZNS, especially for patients who are bedridden for a long time and receive multiple antiepileptic drugs.

[Myositis and rhabdomyolysis with influenza infection].

Myositis and rhabdomyolysis with influenza are rare, but sometimes serious complications. Patients with myositis more commonly have influenza B infection than influenza A. On the other hand, rhabdomyolysis are more frequently recognized in patients with influenza A infection than those with influenza B. Upper respiratory symptoms usually precede myositis, while rhabdomyolysis occurs simultaneously or shortly after the respiratory symptoms. Creatine kinase levels are elevated in myositis mildly and in rhabdomyolysis markedly. Influenza myositis improve spontaneously within 6 weeks, but influenza rhabdomyolysis sometimes induce renal failure with fatal outcome. Although the true incidence of myositis and rhabdomyolysis in the influenza infection remains unknown, careful medical care is necessary when patients have muscle pain and weakness.

CT findings of BALTOMA.

OBJECTIVE: To review the CT findings of BALTOMA, a low-grade malignant lymphoma originating from bronchus-associated lymphoid tissue (BALT). METHODS: The CT findings, symptoms, and clinical courses of BALTOMA in five patients were reviewed. The specimens obtained at operation were investigated, and the pathological findings were compared with the CT findings. RESULTS: There were no symptoms in four patients and normal laboratory data in all patients. One patient who complained of general malaise underwent surgery under suspicion of lung carcinoma. Four patients were observed from 4 months to 7 years and 1 month under the diagnosis of organizing pneumonia or chronic inflammatory processes. On CT images a localized lesion was seen in four cases, while multiple lesions were seen in one case. Attenuation of the lesions was between 39.15 and 60 HU on nonenhanced CT. Lesions were homogeneously enhanced by contrast material. The margins of the lesion were clearly demarcated by interlobular septa in one portion and were unclear in the other portion in all cases. Air bronchograms were seen in four cases. CT angiogram signs were seen in three of four cases in which contrast study was performed. There was no lymphadenopathy, pleural changes, or invasion to other organs. The pathological investigation revealed small lymphocytes that showed monoclonality in all cases. CONCLUSIONS: Awareness of the CT findings of BALTOMA can help to avoid misinterpreting BALTOMA as chronic inflammation and/or lung carcinoma. When a slowly progressive chronic pneumonia is being followed up, transbronchial lung biopsy and immunoglobulin staining of lymphocytes should be recommended for the correct diagnosis.

[Successful removal of a left ventricular fibroma in a 10-year-old patient].

A 10-year-old girl with negative T wave in leads I, II, III, aVF, and V2-6 in the ECG was examined. The two-dimensional echocardiogram and the MRI revealed that she had a tumor in the free wall near the apex of the left ventricle. We removed the intramural fibroma (50 x 35 x 30 mm) of the left ventricle under cardiopulmonary bypass very carefully not to perforate the left ventricular cavity. After the removal, the defect was repaired by the sutures of the myocardial layers so that the volume inside the left ventricle could be kept and its shape could be maintained. She has been doing well without any trouble for 5 months after the operation.

[A case of Pryce type I intrapulmonary sequestration].

A twenty-year-old asymptomatic man hospitalized because of a vascular murmur and abnormal shadow in the left lower lung on X-ray film. An aortogram revealed an abnormal artery arising from the descending thoracic aorta and supplying the left basal segment, which had no other pulmonary arteries. Although lung ventilation scintigraphy demonstrated reduced ventilation to the left lower lobe, bronchogram showed an almost normal bronchial tree except that peripheral branches were slightly thin. A clinical diagnosis of Pryce type I intrapulmonary sequestration was made, and left lower lobectomy was performed successfully. We have analyzed 31 cases of Pryce type I intrapulmonary sequestration in Japan. A vascular murmur is often heard, and a chest X-ray usually shows either a mass shadow or increased vascular markings. In most of those cases, an abnormal artery arises from the descending thoracic aorta and it supplies the left basal segment. Because this type of sequestration causes hemoptysis and infections, surgical intervention is indicated.

Autonomic nervous system activity in essential hypertension: a comparison between dippers and non-dippers.

The present study was undertaken to investigate the changes in autonomic nervous system activity in essential hypertension. Fourteen normotensive controls and 33 age-matched untreated hypertensive subjects, diagnosed by ambulatory blood pressure (ABP) measurement (24-h systolic ABP value over 140 mm Hg or 24-h diastolic ABP over 90 mm Hg, or both) were recruited. ABP and 24-h electrocardiogram were monitored simultaneously. Power spectral analysis of the R-R interval was performed by a fast Fourier transformation method and the powers of low frequency (LF; 0.04 to 0.15 Hz) and high frequency (HF; 0.15 to 0.4 Hz) components were obtained. Hypertensive subjects were divided into 'dippers', whose night-time systolic ABP fell by more than 10% of their daytime ABP, and 'non-dippers' in whom this phenomenon was absent. In hypertensive subjects, electrocardiogram monitoring and power spectral analysis were also performed for 5 min before and during 90 degrees tilt. There were no significant differences in the 24-h mean LF/HF power ratio, LF power or HF power between normotensive and hypertensive subjects. A significant negative correlation between the night-time systolic ABP level and the 24-h LF/HF power ratio was found (r= -0.36, P < 0.05) in the hypertensive subjects. A significant positive correlation was found between the 24-h LF/HF power ratio and the percentage nocturnal reduction of the daytime systolic ABP in hypertensive subjects (r = +0.40, P < 0.01). The 24-h LF/HF power ratio was significantly lower in non-dippers than in dippers (2.09 +/- 1.06 vs 3.24 +/- 0.97, P < 0.01). The mean daytime LF/HF power ratio was significantly lower in non-dippers than in dippers (2.50 +/- 1.43 vs 4.08 +/- 1.27, P < 0.01). The night-time LF/HF power ratio was not significantly different between the two groups. The LF/HF power ratio increased significantly in dippers (from 1.32 +/- 1.95 to 4.65 +/- 1.54, P < 0.001) during 90 degrees tilt, but there was no significant change in the LF/HF power ratio in non-dippers during tilt (from 1.13 +/- 0.28 to 1.36 +/- 0.78, NS). The 24-h LF/HF power ratio decreased according as the night-time systolic BP elevated in hypertensive subjects. During ambulatory monitoring, the non-dippers showed a significantly lower LF/HF power ratio than the dippers. The LF/HF power ratio increased significantly in dippers, but not in non-dippers during tilting. These results suggest that impaired cardiovascular reflexes might contribute to the decreased sympathovagal balance in non-dipper type hypertension.

A Japanese boy with Young-Simpson syndrome.

In 1987 Young and Simpson reported a child with hypothyroidism, a congenital heart disease, severe mental retardation and striking facial dysmorphism, including microcephaly, blepharophimosis, bulbous nose, thin lip, low-set ears and micrognathia. This study presents an 8-month-old boy with virtually identical features to those in Young and Simpson's original case. The patient is a sporadic case and his parents are unrelated and phenotypically normal, hence the family data corresponds to any mode of inheritance. This is the first male case reported in the world and the first in Orientals.

Pulmonary involvement in polymyositis and dermatomyositis: sequential evaluation with CT.

OBJECTIVE: The characteristic findings of pulmonary involvement in polymyositis (PM) or dermatomyositis (DM) and the change in findings before and after treatment were evaluated with sequential high-resolution CT studies. MATERIALS AND METHODS: CT images of pulmonary involvement in 19 patients with PM or DM were reviewed. During a period of 2-61 months, 17 of these patients underwent sequential CT before and after treatment with corticosteroids, immunosuppressants, or both. RESULTS: Findings of the initial CT studies included pleural irregularities and prominent interlobular septa (n = 19), ground-glass attenuation (n = 19), patchy consolidation (n = 19), parenchymal bands (n = 15), irregular peribronchovascular thickening (n = 15), and subpleural lines (n = 7). Honeycombing was not detected on any CT images. These findings were more remarkable in the lower portion and the subpleural area of the lungs. In 16 of the 17 patients who underwent sequential CT conditions such as patchy consolidation, parenchymal bands, and irregular peribronchovascular thickening improved, becoming pleural irregularities and prominent interlobular septa, ground-glass attenuation, and subpleural lines on follow-up CT scans. CONCLUSION: Consolidation with patchy and subpleural distribution, parenchymal bands, and irregular peribronchovascular thickening were characteristic and reversible CT findings in patients with PM or DM.

Clinical role for a superantigen in Yersinia pseudotuberculosis infection.

Yersinia pseudotuberculosis is an enteric pathogen that causes a variety of clinical symptoms in the human. Recently, we reported the production of a superantigen (Y. pseudotuberculosis-derived mitogen, YPM) by this organism and characterized the gene structure of ypm. To further study the potential pathogenic role of YPM in Y. pseudotuberculosis infection, we assayed IgG anti-YPM antibodies and T cell antigen receptor-Vbeta expression of the T cells in peripheral blood and in mesenteric lymph node in patients acutely infected with Y. pseudotuberculosis. 20 out of 33 patients (61%) had an elevated antibody titer compared with healthy controls (P = 0.0001). Patients with systemic symptoms such as lymphadenopathy, transient renal dysfunction, and arthritis had significantly higher titers of anti-YPM than patients with gastrointestinal tract symptoms alone. T cells bearing the Vbeta3 gene segment were significantly increased (P = 0.009) among acute phase patients compared with healthy children. During the convalescence phase of the illness, there was a reduction in the abnormal level of Vbeta3 T cells. Moreover, in the mesenteric lymph node, an elevated level of Vbeta3 T cells compared with peripheral blood and a sequence diversity in the junctional region of the T cell antigen receptor beta-chain containing Vbeta3 element was observed in one patient. Together, these findings suggest that YPM was produced in vivo and played an important role in the pathogenesis of Y. pseudotuberculosis infection.

Systemic arterial supply to normal basilar segments of the left lower lobe: role of continuous thin sliced CT.

A rare congenital anomaly of the left lower pulmonary artery is presented. A 39-year-old woman was admitted to our hospital for evaluation of a splenic mass. Abdominal CT disclosed abnormal vessels in the left lower lobe. Angiography revealed a large systemic artery from the descending aorta supplying the basilar segments of the left lower lobe. Continuous thin sliced CT revealed the anatomical details of this anomaly and showed that the tracheobronchial tree had a normal connection with the lung parenchyma. Although the volume of the left lower lobe was reduced, there were no symptoms related to this lesion. Since the splenic lesion was malignant lymphoma limited to the spleen, only splenectomy was performed. In spite of intensive systemic chemotherapy following the operation, there were no pulmonary complications. Although surgery may be necessary in the future, observation alone has been carried out for more than 3 years because of the lack of symptoms and normal pulmonary function. Continuous thin sliced CT was useful in evaluating this anomaly.

Lack of potentiation with felbinac patch on the convulsive toxicity of enoxacin in rats.

We investigated the possible potentiation of the convulsive toxicity of enoxacin (ENX) by the concomitant topical application of a felbinac (FLB) patch in rats. A felbinac patch (Seltouch; 0.5%, 3 cm x 4 cm) was attached on the back of rats where their hair has been removed. ENX was infused from the left jugular vein at 8 h after the application of FLB patch under an unanesthetized and unstrained condition. Blood, CSF and brain samples were collected at the occurrence of convulsion, and ENX concentrations of each part were determined. As a result, no significant potentiation by FLB patch was found in the onset time of convulsion or in the ENX concentration of each part. Moreover, based on the assumption that there are no inter-species differences in ENX concentration in the brain at the occurrence of a convulsion (Cbr), the predicted plasma ENX concentration required to elicit convulsions in humans, which was estimated from the Cbr and Kp value of ENX in the brain of rats, was 20 times higher than the therapeutic plasma level.

[Initial outcome of coronary intervention in elderly patients].

The effect of age on the early results of coronary intervention was examined retrospectively using the initial success rate of coronary angioplasty in 60 patients older than 70 years. Patients were selected from those who underwent coronary angioplasty at the Saiseikai Utsunomiya Hospital from January 1992 to December 1994. There were 267 patients with 350 lesions, 223 men and 44 women, aged from 31 to 79 years (mean age 61.4 +/- 9.8 years). The elderly group consisted of 60 patients (mean age 73.5 +/- 3.0 years) and the control group was 207 patients less than 70 years (mean age 57.9 +/- 8.2 years). Successful coronary dilatation was defined as > 20% reduction of stenosis with residual stenosis < 50%. Body mass index, presence of hypertension or diabetes mellitus and the ratio of smokers were not significantly different between the two groups. The elderly group included more women and patients with hyperlipidemia. Both groups had similar baseline extent of coronary artery disease, distribution of coronary artery stenosis type and left ventricular ejection fraction. The initial success rate for all patients was 93.4%. There was no significant difference in the initial success rate between the elderly and control groups (98.8% and 91.9%, respectively). There was no significant difference in major complication rate between the two groups (6.3% and 11.5%). Multivariate logistic regression analysis showed that only the type of coronary artery stenosis was significantly associated with initial success rate (p < 0.01). These results suggest that coronary intervention can be successfully performed with a low incidence of major complication in elderly patients.

Carmofur-induced leukoencephalopathy: MRI.

Carmofur, a derivative of 5-fluorouracil, has recently been noted to have an infrequent but serious association with leukoencephalopathy. To our knowledge, there has been no report of early MRI findings in this leukoencephalopathy. We describe a case in which diffuse high signal intensity of the entire cerebral white matter, including the corpus callosum, was seen on T2-weighted magnetic resonance images. Although similar findings can be seen in many other diseases, carmofur-induced leukoencephalopathy should be suspected in a patient treated with carmofur. It is important to know the clinical and MRI characteristics of this condition, for early diagnosis and better prognosis.