Non-peptide inhibitors of HCV serine proteinase.

We screened a chemical library of 2000 compounds for inhibitors of hepatitis C virus (HCV) serine proteinase using an in vitro screening method measuring the hydrolysis of the peptide substrate. Three compounds were found to be the most potent inhibitors (IC50 < 10(-5) M). Two of them had a similar structure, that of halogenated benzanilide, and were not inhibitory for common serine proteinases. They inhibited the enzyme non-competitively with the substrate. Together with the result of the analogous compounds in the chemical library, the presumed structural requirements of the inhibition are pointed out.

Subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery.

A 48-year-old male presented with a rare subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery. The aneurysm was resected and replaced with a Gore Tex artificial graft. Computed tomography, angiography and cerebral blood flow findings suggest that defect of the right internal carotid artery occurred in the developmental stage. There was no past history of trauma, nor histological evidence of inflammatory or sclerotic changes in the aneurysmal wall. The two vascular lesions may have been influenced by a synchronous causative factor in his developmental stage.

Changes in the molecular sieve of the glomerular basement membrane of rats with chronic serum sickness.

In order to explore the pathogenic mechanism of proteinuria in glomerulonephritis, ultrastructural changes of the glomerular basement membrane were investigated in rats with chronic serum sickness induced by repeated intravenous injections of bovine serum albumin (experimental rats). Rats injected with saline served as controls. The animals were sacrificed and examined 13 weeks after treatment, when the mean urinary protein of experimental animals reached 206 mg/24h/100g body weight. Enhanced transcapillary passage of anionic ferritin was observed in experimental rats. Purified glomerular basement membranes of control and experimental rats were examined by electron microscopy after negative staining. The glomerular basement membrane of experimental rats had enlarged pores. The results suggest that an increase in the radius of glomerular pores may be responsible for proteinuria in glomerulonephritis.

Leukocytes in the glomerular capillary lumen in Masugi nephritis. A scanning electron microscopic study of freeze-cracked specimens.

Masugi nephritis was induced in rats by a single intravenous injection of rabbit anti-rat kidney serum, and studied with a scanning electron microscope. A characteristic finding was the presence of white cells, probably polymorphonuclear leukocytes, with many microspikes which penetrated through degenerated glomerular endothelial cells to be in direct contact with the glomerular basement membrane. This finding confirms the pathogenic role of leukocytes in glomerulonephritis induced by anti-glomerular basement membrane antibody.

Aortic valve stenosis with left ventricular outflow tract pressure gradient.

A 61-year-old man was diagnosed with severe aortic valve stenosis with left ventricular outflow tract pressure gradient due to systolic anterior movement of the mitral valve and a large poststenotic dilation of the ascending aorta. He underwent successful aortic root replacement and concomitant septal myectomy.

[A case report of bilateral multiple pulmonary arteriovenous fistulas treated surgically at one-stage procedure by median sternotomy].

A 40-year-old female was admitted because of abnormal chest shadows. Chest CT and pulmonary angiography revealed bilateral multiple arteriovenous fistulas in the right S5a, S5b and left S5, S9. Fistula excision and bilateral partial resection of lung were performed through median sternotomy in one stage. This surgical options allows entire removal of the fistulas as well as preservation of lung function.

[Mediastinal non seminomatous germ cell tumor successfully treated with chemotherapy and curative surgery; report of a case].

A 20-year-old male was clinically diagnosed as having a mediastinal non seminomatous germ cell tumor because of the elevation of the serum AFP and a large mass lesion in the anterior mediastinal and right thoracic cavity. After 3 courses of chemotherapy with cisplatin (CDDP) and etoposide (VP-16), the serum level decreased to normal range. But, the mediastinal mass enlarged after chemotherapy due to hemorrhage. The tumor was completely removed with sternotomy and right thoracotomy. Postoperative course was uneventful, and he has been free of recurrence for 2 years.

[Surgically repaired bilateral giant bullae after long-time follow-up; report of a case].

A 44-year-old male was admitted to our hospital owing to severe dyspnea of sudden onset. Chest X-ray disclosed bilateral giant bullae. His pulmonary function was severely depressed. VC (%) was 2.61 l (66.3%) and FEV1% (%) was 1.47 l (64.5%). Indication of surgical repair of giant bullae are; space occupying lesion more than 25-50% in 1 thorax, progressive dyspnea, enlargement over time irrespective of symptoms, and expectation that re-expand the normal lung. He was conducted two-staged bullectomy using video-assisted thoracoscopic surgery (VATS) with small incisions. First operation was performed to left lung. Pulmonary function improved. VC (%) increased 3.02 l (76.8%) and FEV1% (%) 2.36 l (76.6%). After second operation, which was performed to right lung, VC (%) was 2.40 l (60.5%) and FEV1% (%) was 2.21 l (92.1%). Hugh-Jones grade improved class IV to class I. Postoperative course was uneventful and he was discharged 15 days after second operation. Two-staged bullectomy was appropriate in this case, because he might have suffered from re-expansion pulmonary edema after first surgery. The extent of recovery of pulmonary function was unpredictable. And performing right lung bullectomy just after the left bullectomy may be dangerous, because the patient have to receive anesthesia with his resected left lung. There is some possibility that patient who has bilateral giant bullae shows severe dyspnea during the progress, care should be taken to conduct operation as soon as possible.

[A case of catamenial pneumothorax associated with diaphragmatic endometriosis].

A case of catamenial pneumothorax associated with diaphragmatic endometriosis was reported. A 43-year-old woman had 4 times-recurrent pneumothorax on right side for recent 5 months. Each onset was related to the beginning of menses. Right thoracotomy revealed the presence of multiple darkly-pigmented spots and several pinhole like perforations in the central tendon of diaphragm. The area showing these lesions were considered to be the focal region, and this part of diaphragm was excised. Histology showed the stromal endometriosis surrounded by hemosiderin pigment deposits. The patient has been asymptomatic for 4 years after operation. Our case may give support to Maurer's hypothesis. Surgeons should be aware of the importance of carefully inspecting the diaphragm during operation.

[A case of complete mediastinal goiter located in the retrotracheal region: review on reported cases from 1986 to 1997 in Japan].

A 66-year-old man was admitted to our hospital as a result of an abnormal shadow which was observed on his chest X-ray. A chest CT scan and chest MRI revealed an upper mediastinal tumor. The tumor was located in the retrotracheal region and resected completely following a thoracotomy. Histological examination of the tumor revealed follicular adenoma of the thyroid gland. Complete mediastinal goiter is a relatively rare lesion, with only 59 cases (including our case) in Japan prior to 1997. Only two cases were reviewed, in which the tumors were located in the retrotracheal region, out of the 59 cases in Japan.

[Ruptured dissecting aneurysm of the transverse arch after replacement of the descending and ascending aorta].

A 28-year-old Marfan's syndrome woman was referred to our hospital because of sudden chest and back pain. She had received replacement of the descending and ascending aorta for acute aortic dissection previously in other two institutions. CT scan revealed the massive mediastinal hematoma and hemothorax which suggested ruptured dissecting aneurysm of the transverse arch. Emergent total arch replacement, re-ascending replacement and aortic root plasty successfully weve performed. She recovered uneventfully although she had residual thoracoabdominal dissecting aneurysm. It was suggested that total arch replacement should be performed for Stanford A type dissection in Marfan's syndrome.

[A case report of total cavopulmonary connection following total cavopulmonary shunt].

A 20-year-old man underwent total cavopulmonary shunt for univentricular heart type A (A.L.L.) with hemiazygos connection six years ago. Four years later, his condition deteriorated with easy fatigue and cyanosis. Cardiac catheterization showed recanalization of ligated SVC. Chest CT showed tight adhesion between the chest wall and the ascending aorta. We approached the heart through left anterolateral thoracotomy in order to avoid injury of the aorta and the ventricle during redo median sternotomy. Total cavopulmonary connection with intraatrial conduit was performed under circulatory arrest and retrograde cardioplegia without aortic cross clamp. His postoperative course was satisfactory. Left thoracotomy was useful for total cavopulmonary connection following total cavopulmonary shunt associated with postoperative adhesion.

A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm, with associated bronchial artery aneurysms: report of a case.

A 57-year-old woman who went into shock following an acute left hemothorax was operated on after stabilization under the diagnosis of a ruptured aortic aneurysm. A left fifth intercostal thoracotomy was done which revealed approximately 500 ml of bloody effusion in the extrapleural space and 2,000 g of clotted blood in the pleural cavity. While the aneurysm was initially thought to have originated in the isthmic or descending aorta, intraoperative findings revealed a swollen hematomatous thymus adherent to the aorta. A ruptured thymic branch aneurysm, 3 cm in diameter, was subsequently found in the resected hematomatous thymus. Histological examination also revealed several small aneurysms in the tortured bronchial arteries. Postoperative angiography showed a saccular aneurysm, 1.5 cm in diameter, and several smaller aneurysms in the bronchial artery of the left lung. The aneurysm was successfully treated by a transcatheter arterial embolization, and the patient has had no further symptoms since then. To our knowledge, there has been no other case of a ruptured thymic artery aneurysm reported in the literature, and only a few cases of bronchial artery aneurysms have been documented.

[A case of yolk sac tumor of the anterior mediastinum].

A 26-year-old male was clinically diagnosed as having a anterior mediastinal yolk sac tumor because of the elevation of the serum AFP (26,765 ng/ml) and a large mass lesion (13 x 12 x 8 cm) in the anterior mediastinum and right thoracic cavity. After three courses of chemotherapy with CDDP and VP-16, the mediastinal mass reduced in size significantly but the serum AFP level did not reach within normal range. We suspected that the tumor took a resistance to drugs, accordingly the operation was performed. The tumor was completely removed and there were small viable foci of the tumor in part of the tumor. The histological examination revealed the findings of yolk sac tumor. After the operation, the serum AFP level decreased within normal range. He is alive without evidence of recurrence during 18 months after operation. It was noticed that the serum AFP is a useful indicator for determining the chance of operation after chemotherapy.

[Surgical management of coarctation of the aorta in early infants].

Thirteen infants under three months old were repaired aortic coarctation between 1980 and 1988. The mean age at operation was 2 +/- 0.8 months, the mean weight was 3.7 +/- 0.6 kg. Patients were simple coarctation in 1, coarctation with VSD in 7, and coarctation with complex heart disease in 5. As the operative method, the prosthetic patch plasty was done in 11 patients, end to end anastomosis in 1 patient and remaining one was primary VSD closure and secondary coarctation repair (patch plasty). Three patients died perioperatively, the overall early mortality rate was 23%. Since the introduction of PGE1 therapy in 1985, operative mortality rate of the operation (patch aortoplasty) was improved dramatically. Two of 10 patients died from LOS after the secondary operation (one was TGA and another was congenital MS with VSD). Eight patients are alive and clinical course after operation had been good. The measurement of arm-leg pressure difference didn't reveal significant residual gradient. Postoperative isthmus index was 90 +/- 13% in follow up measurement. Recoarctation has not been occurred in patients undergoing operations with patch plasty. Postoperative hypoplastic arch index was 93 +/- 19% in 1 to 2 years after operation compared with 70 +/- 16% of the preoperation. Therefore, it is concluded that prosthetic patch aortoplasty and end to end anastomosis of the aorta are both available as reasonable and/or adequate operation for the early infants with coarctation.

Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair.

PURPOSE: The purpose of this study was to compare the midline retroperitoneal approach with the midline transperitoneal approach for abdominal aortic aneurysm (AAA) repair with respect to operative details, gastrointestinal complications, and wound complications. METHODS: From January 1990 through January 1998, 128 patients underwent elective aortic reconstruction for infrarenal AAA. Of these, 64 patients (the transperitoneal group) underwent conventional transperitoneal midline aortic exposure, whereas the remaining 64 patients (the retroperitoneal group) underwent retroperitoneal midline exposure of the aneurysm. RESULTS: Preclamp time, that is, the time from skin incision to aortic clamping, was significantly shorter in the transperitoneal group than in the retroperitoneal group (P <.001). However, the midline retroperitoneal approach was associated with decreased incidence of ileus (P <.01), earlier resumption of oral intake (P <.01), and decreased wound pain (P <.01), in comparison with the transperitoneal approach. Furthermore, there was no incidence of wound complications such as abdominal bulge or wound pain in any of the patients in the postoperative period or over the long term. CONCLUSIONS: The midline retroperitoneal approach for AAA was associated with fewer postoperative gastrointestinal and wound complications than the midline transperitoneal approach. Over the long term, there was no wound complication such as abdominal bulge and wound pain in any of the patients.

Failure of exclusion of internal iliac artery aneurysms.

PURPOSE: We investigated in detail the state of internal iliac artery (IIA) aneurysms over the midterm after the exclusion procedure. METHODS: From January 1990 to December 1998, 29 patients underwent the exclusion procedure for IIA aneurysms. The medical records of 27 survivors were retrospectively reviewed, and 30 excluded aneurysms of these patients were followed up with computed tomography scanning over the midterm. RESULTS: In the immediate postoperative period, 26 aneurysms were completely thrombosed, and four were incompletely thrombosed. In the midterm, 24 aneurysms were completely thrombosed (complete group), and six were incompletely thrombosed (incomplete group). No aneurysms expanded or ruptured during the follow-up period from 6 to 98 months (mean, 26 months). The size of the excluded aneurysm decreased in 22 of 24 aneurysms in the complete group, but no change in size was noted in the six aneurysms in the incomplete group. The preoperative size of the IIA aneurysm in the incomplete group was significantly larger than that in the complete group (P =.0047). The size of two aneurysms in the incomplete group was smaller than 3.0 cm. The aneurysms in the incomplete group extended significantly deep into the pelvis as compared with those in the complete group (P =.0008). CONCLUSIONS: The exclusion of IIA aneurysm did not reliably result in thrombosis of the aneurysm. For IIA aneurysms extending deeply into the pelvis, even if the size of the aneurysm is smaller than 3.0 cm, the exclusion procedure should not be performed.

Successful utilization of the median sternotomy approach in the management of descending necrotizing mediastinitis: report of a case.

We describe herein the case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM). Although most reports describe cervical or thoracotomy approaches, our experience strongly suggests that median sternotomy is a satisfactory alternative approach for treatment of this disease.