POS0197 SARS-CoV-2 INFECTION CAUSED THROMBOSIS IN THE LUPUS MODEL WITH ANTIPHOSPHOLIPID ANTIBODY, WHEREAS COVID-19 ASSOCIATED THROMBOSIS WAS IRRELEVANT IN PATIENTS WITH POSITIVE ANTIPHOSPHOLIPID ANTIBODY

Background

Thrombosis is a unique complication in coronavirus disease 2019 (COVID-19). We have reported that elevated ferritin and D-dimer on admission were the risk factors of thromboses by analyzing the patients sequentially admitted to our hospital due to COVID-19 (1). However, we have not analyzed thrombotic complications in the view of the antiphospholipid antibodies (aPLs), which are frequently detected in the COVID-19 patients.

Objectives

To elucidate the thrombogenic effects of aPLs in COVID-19, we analyzed the development of thrombosis in three lupus models after SARS-CoV-2 infection. Additionally, we evaluated the association of thrombotic events and the serum profile of aPLs in Japanese patients with COVID-19.

Methods

Three animal models of lupus (MRL-lpr/lpr, NZBxNZW F1 and NZW×BXSB F1) were evaluated in this study. NZW×BXSB F1 was also considered as a model of antiphospholipid syndrome (APS) since aPLs were detected with a high titer (2). Experimental SARS-CoV-2 infection was induced using mouse-passaged virus strain (3). The incidence of thromboses in the lungs and kidneys were identified by evaluating H&E staining and PTAH staining of paraffin-embedded sections. We have experienced 44 thrombotic events in 34 out of 594 patients admitted to our institute. As a non-thrombotic COVID-19, 68 patients were selected to make a 1 to 2 matched-pair based on the propensity score. In total 102 patients, seven types of aPLs (anti-cardiolipin (CL) IgG/IgM, anti-β2GP1 IgG/IgA/IgM, and anti-phosphatidyl serine/prothrombin complex (PS/PT) IgG/IgM) were measured using specific ELISA kits. The patients’ clinical characteristics and serological profile of aPLs were further evaluated.

Results

We identified the development of thromboses in the lungs or kidneys in 6 out of 12 (50%) NZW×BXSB F1 mice after the SARS-CoV-2 infection, whereas no thrombosis was observed in non-infected mice. Further, there was no thrombosis in the other lupus models (0%) after the infection. These findings might suggest the pathogenic role of aPLs under the SARS-CoV-2 infection.

Among our COVID-19 patients, 39 out of 102 (38%) were tested positive for one or more aPLs. The positive ratios of any aPLs were statistically indifferent between the patients with or without thrombosis; anti-CL IgG (8.8% vs 5.9%)/IgM (0% vs 5.9%), anti-β2GP1 IgG (21% vs 12%)/IgA (8.8% vs 15%)/IgM (0% vs 1.5%), and anti-PS/PT IgG (0% vs 2.9%)/IgM (12% vs 13%), respectively. In addition, their titers were relatively lower than those observed in APS patients. The patients’ characteristics and the prognosis of COVID-19 were comparable regardless of the detection of any aPLs. These findings suggested that COVID-19 associated aPLs were irrelevant to thrombotic complications.

Conclusion

Thromboses were induced after the infection of SARS-CoV-2 only in the APS model. However, aPLs detected in COVID-19 patients have little impact on the development of thrombosis. SARS-CoV-2 infection might have a high risk of thrombosis, especially in APS patients, as shown in the case report (4). The discrepancy of its thrombogenic effects of aPLs might be explained by the low titer of the antibody or the diversity of antibody epitope. Further analyses are required to clarify the mechanisms of aPLs production and the development of thrombosis in COVID-19.

References

[1]Oba S, et al. Arterial and Venous Thrombosis Complicated in COVID-19: A Retrospective Single-Center Analysis in Japan. Front Cardiovasc Med. 2021 Nov 19;8:767074.

[2]Hashimoto Y, et al. Anticardiolipin antibodies in NZW x BXSB F1 mice. A model of antiphospholipid syndrome. J Immunol. 1992 Aug 1;149(3):1063-8.

[3]Iwata-Yoshikawa N, et al. A lethal mouse model for evaluating vaccine-associated enhanced respiratory disease during SARS-CoV-2 infection. Sci Adv. 2022 Jan 7;8(1):eabh3827.

[4]Chidharla A, et al. A Case Report of COVID-Associated Catastrophic Antiphospholipid Syndrome Successfully Treated with Eculizumab. J Blood Med. 2021 Oct 30;12:929-933.

Disclosure of Interests

Seiya Oba: None declared, Tadashi Hosoya Speakers bureau: Janssen Pharmaceutical K.K.

Daiichi Sankyo Company, limited

Asahi Kasei Corporation

Ono pharmaceuticals

Eisai

Eli Lilly, Daisuke Kawata: None declared, Wenshi Lee: None declared, Mari Kamiya: None declared, Yoji Komiya: None declared, Hideyuki Iwai: None declared, Yuko Nukui: None declared, Shuji Tohda: None declared, Shinsuke Yasuda Speakers bureau: Abbvie,

Asahi Kasei Pharma,

Chugai Pharmaceutical,

Eisai, Eli Lilly,

GlaxoSmithKline,

Mitsubishi Tanabe Pharma,

Ono pharmaceutical,

Pfizer., Consultant of: ImmunoForge, Grant/research support from: Abbvie,

Asahi Kasei Pharma,

Chugai Pharmaceutical,

CSL Behring,

Eisai,

ImmunoForge,

Mitsubishi Tanabe Pharma,

Ono pharmaceutical

Current status of narrow-band imaging magnifying colonoscopy for colorectal neoplasia in Japan

The narrow-band imaging system can be used to examine the microvascular architecture and surface pattern on the mucosal surface with high sensitivity. The clinical significance of NBI observation is summarized as follows: (1) differential diagnosis of hyperplasia, adenoma, and carcinoma; (2) diagnosis according to the presence of a surface pattern as an alternative to magnifying endoscopic observation with dye spraying, and (3) determination of the invasion depth of an early colorectal carcinoma. However, at present, many NBI magnifying observation classifications for colorectal tumor exist in Japan. To internationally standardize the NBI observation criteria, a simple classification system is required. On the basis of these backgrounds, an international cooperative group (Colon Tumor NBI Interest Group - CTNIG) has developed a simple category classification (NICE classification: NBI International Colorectal Endoscopic Classification) which classifies NBI findings into types 1-3.

Comparison between low flow sevoflurane anesthesia and total intravenous anesthesia during intermediate-duration surgery: effects on renal and hepatic toxicity

BACKGROUND

Renal and hepatic dysfunction or injury might be involved by ether based anesthetic and intravenous anesthetic drug or surgical stress. The purpose of this study is to compare the effect of moderate duration low-flow sevoflurane versus total intravenous anesthesia on renal and hepatic functions.

PATIENTS AND METHODS

Eighty (80) patients between the ages of 25-70 scheduled for elective lumbar disc herniotomy, with an expected operation time of 120-240 min, were enrolled in the study. Anesthesia was induced using remifentanil, propofol and atracurium. Patients were randomly divided into two groups. After intubation, Group S (n=40) received sevoflurane and Group T (n=40) received total intravenous anesthesia with propofol in oxygen and air with a fresh gas flow of 5 L min(?1). Ten minutes after induction the fresh gas flow was decreased to 1L min(?1) in both groups. Serum BUN, creatinine, ALT, AST, LDH and 24 hours excretion of glucose, protein, and creatinine in urine were measured preoperatively and the first three postoperative days.

RESULTS

Serum BUN at 48 hours, creatinine at 24, 48. hours, and urine glucose at 24, and 48 hours were significantly higher from the preoperative values in Group S (p<0.05). However, serum BUN and creatinin, urine glucose were within the normal range. There were no significant differences in the renal and hepatic function tests between the groups.

CONCLUSIONS

These results show that the renal and hepatic effect of moderate duration low-flow sevoflurane and total intravenous anesthesia is similar.

Effects of sedation during upper gastrointestinal endoscopy on endocrine response and cardiorespiratory function

Upper gastrointestinal endoscopy is often accompanied by tachycardia which is known to be an important pathogenic factor in the development of myocardial ischemia. The pathogenesis of tachycardia is unknown but the condition is thought to be due to the endocrine response to endoscopy. The purpose of the present study was to investigate the effects of sedation on the endocrine response and cardiorespiratory function. Forty patients scheduled for diagnostic upper gastrointestinal endoscopy were randomized into 2 groups. While the patients in the first group did not receive sedation during upper gastrointestinal endoscopy, the patients in the second group were sedated with intravenous midazolam at the dose of 5 mg for those under 65 years or 2.5 mg for those aged 65 years or more. Midazolam was administered by slow infusion. In both groups, blood pressure, ECG tracing, heart rate, and peripheral oxygen saturation (SpO2) were monitored during endoscopy. In addition, blood samples for the determination of cortisol, glucose and C-reactive protein levels were obtained from patients in both groups prior to and following endoscopy. Heart rate and systolic arterial pressure changes were within normal limits in both groups. Comparison of the two groups regarding the values of these two parameters did not reveal a significant difference, while a statistically significant reduction in SpO2 was found in the sedation group. No significant differences in serum cortisol, glucose or C-reactive protein levels were observed between the sedated and non-sedated group. Sedation with midazolam did not reduce the endocrine response and the tachycardia developing during upper gastrointestinal endoscopy, but increased the reduction in SpO2.

Novel risk stratification of patients with neuroblastoma by genomic signature, which is independent of molecular signature

Human neuroblastoma remains enigmatic because it often shows spontaneous regression and aggressive growth. The prognosis of advanced stage of sporadic neuroblastomas is still poor. Here, we investigated whether genomic and molecular signatures could categorize new therapeutic risk groups in primary neuroblastomas. We conducted microarray-based comparative genomic hybridization (array-CGH) with a DNA chip carrying 2464 BAC clones to examine genomic aberrations of 236 neuroblastomas and used in-house cDNA microarrays for gene-expression profiling. Array-CGH demonstrated three major genomic groups of chromosomal aberrations: silent (GGS), partial gains and/or losses (GGP) and whole gains and/or losses (GGW), which well corresponded with the patterns of chromosome 17 abnormalities. They were further classified into subgroups with different outcomes. In 112 sporadic neuroblastomas, MYCN amplification was frequent in GGS (22%) and GGP (53%) and caused serious outcomes in patients. Sporadic tumors with a single copy of MYCN showed the 5-year cumulative survival rates of 89% in GGS, 53% in GGP and 85% in GGW. Molecular signatures also segregated patients into the favorable and unfavorable prognosis groups (P=0.001). Both univariate and multivariate analyses revealed that genomic and molecular signatures were mutually independent, powerful prognostic indicators. Thus, combined genomic and molecular signatures may categorize novel risk groups and confer new clues for allowing tailored or even individualized medicine to patients with neuroblastoma.

Functional lower lip reconstruction with a forearm flap combined with a free gracilis muscle transfer

We applied a forearm flap combined with a gracilis muscle flap for total reconstruction of the lower lip. The motor nerve of the gracilis muscle was repaired to the buccal branch in the cheek. The patient obtained good sphincter function for eating and speaking, and he could inflate a balloon without air leakage.

Reconstruction of knee ligaments with a free tensor fascia lata myocutaneous flap transfer

A 26-year-old woman suffered a grinding injury of the thigh and knee, resulting in the loss of a large amount of soft tissue and some of the femur. A contralateral tensor fascia lata myocutaneous free flap was used to reconstruct the soft tissues and the lateral ligament compartment around the knee. Later, a ceramic artificial bone was implanted. The patient was able to walk, and a stress radiograph showed that the implanted artificial bone and the knee joint were stable. There was no donor-site morbidity. The functional and cosmetic results were satisfactory.

Cranial-bone defects with depression deformity treated with ceramic implants and free-flap transfers

Hydroxyapatite ceramic has many advantages in the treatment of cranial-bone defects. However, for large skull defects with severe depression deformities, it may be risky to use ceramic implants because an extradural dead space will be left and the overlying scalp will have to be closed under tension. In these cases microvascular free-flap transfers are a good solution. We have treated three patients for large skull defects with severe depression deformities after repeated local infections and several operations or irradiation. A latissimus dorsi myocutaneous flap was combined with a serratus anterior muscle flap to fill the extradural space under the ceramic implant in the first patient. A latissimus dorsi muscle flap was inserted under the ceramic implant in an irradiated site and a combined small serratus anterior muscle flap was used as a monitor in the second patient. A latissimus dorsi myocutaneous flap was used to cover the ceramic implant and fill the scalp defect in the third patient. The follow-up periods varied from 12 to 35 months (mean: 20.7 months). The clinical courses of all three patients were uneventful and no flap was lost. The extradural space can be reduced to some extent by making the ceramic implant slightly flatter or thicker, but in patients with severe depression deformities, whose brain expansion cannot be expected, a muscle flap should be transferred into the space.

Cochlear receptor (microphonic and summating potentials, otoacoustic emissions) and auditory pathway (auditory brain stem potentials) activity in auditory neuropathy

OBJECTIVE

To define both auditory nerve and cochlear receptor functions in subjects with auditory neuropathy (AN).

DESIGN

We tested 33 AN subjects (66 ears) and compared them with 21 healthy subjects (28 ears). In AN subjects, the average pure-tone (1, 2, and 4 kHz) threshold loss was 57 dB HL. Click stimuli were used to elicit transient evoked otoacoustic emissions (TEOAEs), cochlear microphonics (CMs), and auditory brain stem responses (ABRs). Both cochlear and ABR potentials were recorded from surface electrodes (vertex-ipsilateral mastoid) using averaging procedures. The amplitudes and latencies of CMs and ABRs and the amplitude of the TEOAEs were analyzed.

RESULTS

CM amplitudes recorded from normal ears decreased as a function of subject age. CMs recorded from AN subjects fell within the normal age-adjusted range in 60% of the subjects and were >2 SEEs (standard error of estimate) above the age-adjusted normal regression in 40% of the subjects. TEOAEs were absent in 19 (30%) AN ears (bilaterally in eight, and unilaterally in three subjects) and were present in 44 ears. In AN subjects, correlations among CM amplitude, TEOAE amplitude, and pure-tone average thresholds were not significantly related. CM amplitudes were not significantly different whether TEOAEs or ABRs were present or absent. The ABR was present in 21% of AN subjects and consisted of a low-amplitude Wave V without a preceding Wave I. Measures of CM amplitude and PTA hearing loss were not significantly different in those AN ears with a preserved ABR compared with ears with absent ABRs. Summating potentials to transient click stimuli were of small amplitude (<0.1 microV) and detectable in approximately 50% of the AN and healthy control subjects limiting formal analysis of summating potentials.

CONCLUSIONS

In a significant proportion of AN subjects, we found abnormalities of cochlear receptor function, including elevated CM amplitudes and absence of TEOAEs. These two abnormalities occurred independently of each other. A low amplitude Wave V of the ABR was found in approximately one-fifth of AN subjects, evidence that neural synchrony can be partially preserved in some subjects with this disorder.

Mandibular contour reconstruction with three-dimensional computer-assisted models

Facial contours are thought to depend on the appropriate balance of hard and soft tissue. To obtain aesthetically good results in head and neck reconstruction, surgeons should know the exact three-dimensional shape and volume of both hard and soft tissue to be reconstructed. The authors used computer-assisted three-dimensional solid models of the mandible in 7 patients (4 women and 3 men) who underwent mandibular contour reconstruction. Scapular osteocutaneous flaps were used in all 7 patients. The follow-up periods ranged from 7 to 57 months (mean follow-up, 29 months). No flap was lost. One patient died of metastatic cancer. In 2 patients the aesthetic results were excellent and in 4 patients they were good. Computer-assisted three-dimensional models for mandibular contour reconstruction in head and neck reconstruction are quite useful.

Temporal and speech processing deficits in auditory neuropathy

Auditory neuropathy affects the normal synchronous activity in the auditory nerve, without affecting the amplification function in the inner ear. Patients with auditory neuropathy often complain that they can hear sounds, but cannot understand speech. Here we report psychophysical tests indicating that these patients' poor speech recognition is due to a severe impairment in their temporal processing abilities. We also simulate this temporal processing impairment in normally hearing listeners and produce similar speech recognition deficits. This study demonstrates the importance of neural synchrony for auditory perceptions including speech recognition in humans. The results should contribute to better diagnosis and treatment of auditory neuropathy.

Keloids have continuous high metabolic activity

The adenosine triphosphate (ATP) content of keloids and scars resected from patients was demonstrated by high-performance liquid chromatography. The surface color of hypertrophic scars was red or pink and that of atrophic scars was white. The ATP content of red scars was (in mmol/g protein) 1.06 +/- 0.14, of pink scars 0.12 +/- 0.02, of white atrophic scars 0.19 +/- 0.06, and of keloids 1.06 +/- 0.19. The longer the elapsed time after the trauma, the lower the level of ATP in scar tissues (correlation coefficient = -0.506; p = 0.005 by Spearman's rank correlation). However, ATP levels in keloids were still high 10 years after the injury. Fibroblasts and fibrocytes in keloids and scars were counted in histologic preparations stained with hematoxylin and eosin. The average number of fibroblasts in a definite area (56 x 10(-4) mm at a magnification of x400) was 4.8 in keloids, 5.1 in red scars, 2.4 in pink scars, and 1.3 in white atrophic scars. The number of fibrocytes in the same area was 0.4 in keloids, 0.4 in red scars, 2.3 in pink scars, and 1.3 in white atrophic scars. These results indicate that keloids and red hypertrophic scars have higher ATP levels and contain more fibroblasts than pink or white scars, and they also suggest that the levels of ATP and the number of fibroblasts decrease when red hypertrophic scars change into atrophic scars. In keloids, ATP and fibroblasts seem to remain at high levels for a long time.

Relevance of periglomerular myofibroblasts in progression of human glomerulonephritis

To clarify the pathological and clinical significance of periglomerular alpha-smooth muscle actin (alpha-SMA)-positive cells, we examined 51 needle-biopsy specimens from patients with human glomerulonephritis. Immunoelectron microscopy confirmed these cells were myofibroblasts showing characteristic features with abundant alpha-SMA-positive thin myofilaments. Nonsclerotic glomeruli with periglomerular myofibroblasts were larger in the Bowman's capsular planar area than nonsclerotic glomeruli without periglomerular myofibroblasts (24.7 +/- 6.0 x 10(3) microm2 v 19.9 +/- 8.5 x 10(3) microm2; P < 0.01). We studied the correlation between the clinical prognosis and the extent of periglomerular myofibroblasts in 24 patients with IgA nephropathy. Patients were divided into two groups; those with plasma creatinine levels within normal range at biopsy and significantly elevated at follow-up were designated group 1 (poor prognosis), and patients with plasma creatinine levels within normal range at biopsy and not significantly elevated at follow-up were designated group 2 (fair prognosis). In the kidneys of group 1 patients, periglomerular alpha-SMA was expressed more intensively than it was in the kidneys of group 2 patients (alpha-SMA expression score, 1.0 +/- 0.48 v 0.52 +/- 0.54; P < 0.05). These findings indicate that periglomerular myofibroblasts appeared surrounding the nonsclerotic hypertrophic glomeruli, which may lead finally to glomerulosclerosis. This report suggests that interaction between the glomerular cells and the periglomerular myofibroblasts may have a role in the progression of glomerular diseases.

Downregulation of the Klotho gene in the kidney under sustained circulatory stress in rats

We recently reported the isolation of the klotho gene, which in predominantly expressed in the kidney and involved in human aging phenotypes. In our previous studies, we demonstrated that the Klotho protein or its metabolites may possibly function as humoral factor(s) and protect against endothelial dysfunction because acetylcholine-mediated NO production in arteries was impaired in heterozygous klotho deficient mice (kl/+). However, the pathophysiological significance of the Klotho protein has not been clarified yet. In the present study, we examined expression of the klotho gene in the kidney of the following rat models for human diseases: (1) spontaneously hypertensive rat, (2) deoxycorticosterone acetate-salt hypertensive rat, (3) 5/6 nephrectomized rat, (4) non-insulin-dependent diabetes mellitus rat (the Otsuka Long-Evans Tokushima Fatty rat), and (5) rat with acute myocardial infarction. The expression levels of klotho mRNA in the kidney in these models were significantly lower than controls except for MI rats. This is the first report showing the expression of the klotho gene in the kidney is regulated under sustained circulatory stress such as long-term hypertension, diabetes mellitus, and chronic renal failure.

Transient deafness due to temperature-sensitive auditory neuropathy

OBJECTIVE

To define mechanisms accounting for transient deafness in three children (two siblings, ages 3 and 6, and an unrelated child, age 15) when they become febrile.

DESIGN

Audiometric tests (pure-tone audiometry, speech and sentence comprehension), tympanometry, middle ear muscle reflex thresholds, otoacoustic emissions (OAEs), and electrophysiological methods (auditory brain stem responses [ABRs], sensory evoked potentials, peripheral nerve conduction velocities) were used to test the children when they were afebrile and febrile.

RESULTS

ABRs, when afebrile, were abnormal with a profound delay of the IV-V and absence of waves I-III. The ABR in one of the children, tested when febrile, showed no ABR components. Measures of cochlear receptor function using OAEs were normal in both febrile and afebrile states. Cochlear microphonic potentials were present in the three children, and a summating potential was likely present in two. When afebrile, there was a mild threshold elevation for all frequencies in the 15-yr-old and a mild elevation of thresholds for just low frequencies in the two siblings. Speech comprehension in quiet was normal but impaired in noise. One of the siblings tested when febrile had a profound elevation (>80 dB) of pure-tone thresholds and speech comprehension was absent. Acoustic reflexes subserving middle ear muscles and olivocochlear bundle were absent when febrile and when afebrile. No other peripheral or cranial nerve abnormalities were found in any of the children. Sensory nerve action potentials from median nerve in one of the children showed no abnormalities on warming of the hand to 39 degrees C.

CONCLUSION

These children have an auditory neuropathy manifested by a disorder of auditory nerve function in the presence of normal cochlear outer hair cell functions. They develop a conduction block of the auditory nerves when their core body temperature rises due, most likely, to a demyelinating disorder of the auditory nerve. The auditory neuropathy in the two affected siblings is likely to be inherited as a recessive disorder.

Location and action of angiotensin II type 1 receptor in the renal microcirculation

To localize angiotensin II type 1a (AT-1a) receptor and to reveal the physiological roles of angiotensin II in the renal microcirculation, we investigated the AT-1a gene deficient mice, generated by a targeted replacement of the AT-1a receptor loci by the lacZ gene (Sugaya et al, J Biol Chem 270: 18719, 1995). Immunohistochemical localization of beta-galactosidase was performed in the heterozygous mutant mice to reveal the expression sites of AT-1a. The AT-1a receptor (that is, beta-galactosidase) was expressed both in the afferent and efferent arteriolar smooth muscles and also in the mesangial cells. The effect of angiotensin II on glomerular arterioles was directly observed using the hydronephrotic mice. Angiotensin II similarly constricted both the afferent and efferent arterioles in the wild-type and heterozygous mutant mice in a dose-dependent manner. This constriction was completely abolished by an AT-1 antagonist, CV-11974. In the homozygous null mutant mice, however, angiotensin II did not affect the arterioles at all. Electron microscopic studies revealed that the mesangial cells made contact with the glomerular basement membrane (GBM) at the capillary neck and also with each other in the wild-type mice. However, in the homozygous null mutant mice, the mesangial cells lost the contact either with GBM or with each other and thus the capillary neck became remarkably wider. The mesangial matrix area appeared loose and enlarged, suggesting impaired mesangial matrix formation. In conclusion, via the AT-1a receptor, angiotensin II equally constricts both the afferent and efferent arterioles and plays an essential role in maintaining the normal glomerular function and structure.

A flap to monitor a temporoparietal fascial flap. Case report

The temporoparietal fascial flap is useful in reconstructions of the hands and feet as tendon gliding material, but it is difficult to monitor its viability postoperatively. We have monitored such flaps by attaching a small preauricular skin flap 2 x 1 cm in size to the vascular pedicle. This preauricular island flap can be used as a "monitoring" flap.

Novel DNA probes capable of discriminating indica and japonica rice cultivars

We obtained two DNA clones, G93 (1.6kb) and G318 (1.7kb) from indica rice (Oryza sativa L.) cultivar Culture 340. Southern hybridization analysis indicated that both DNA probes hybridized with DNA of indica cultivars but not with japonica cultivars. Some javanica cultivars DNAs did not hybridize with these probes. Nucleotide sequence (400bp) of a part of G93 showed a 65.8% G + C content. These novel DNA probes can be used for the study of evolutional fingerprinting of rice cultivars.

Which vessel is more important in the supercharged flap--artery, vein, or both? An experimental study

The supercharged flap is one which is expected to attain better survival, by anastomosing the distal vessels of the flap to the recipient vessels. An experimental study is reported to determine whether the vessel to be anastomosed should be an artery, a vein, or both. The authors advise anastomosing an artery and a vein, but they believe that arterial inflow is more important than venous drainage.

Microarterial anastomosis with a distal tapering technique

In microsurgical arterial anastomoses, there are some occasions in which the diameter of the distal artery is much larger than that of the proximal one. A fish-mouth incision technique is useful when there is considerable size discrepancy. However, this method cannot be used when the distal artery is much larger than the proximal artery because turbulent flow and thrombus formation occur, due to the sudden increase of luminal diameter. The distal tapering technique is recommended to prevent turbulent flow. A wedge resection is performed in the distal surplus vessel wall, and there is no sudden change in luminal diameter. Two clinical cases are presented in which this technique was used effectively.

Omentum as gliding material after extensive forearm tenolysis

Tendon adhesion occurring after major replantation can be severe and extensive due to the nature of the trauma, ischaemia, prolonged oedema and/or infection. Therefore there is a high possibility of re-adhesion after tenolysis. In two cases of tenolysis after forearm replantation omentum was used as gliding material and good results were obtained.

[A study on drinking and problem drinking in tuberculosis patients]

Drinking and problem drinking were studied in 43 tuberculosis patients with the following results. The results of the KAST (Kurihama Alcoholism Screening Test) revealed that 10% of the patients were severe problem drinkers (diagnosed as alcohol dependent syndrome), 7% of the patients had drinking problems and 17% were potential problem drinkers. These percentages are higher than those of the general adult population. In the cases having higher KAST scores, the time between the onset of subjective symptoms and the first medical examination were long, but the time between the first medical examination and diagnosed tuberculosis was short. Severe tuberculosis patients showed higher KAST scores. It was assumed that tuberculosis patients who drink too heavily or are problem drinkers, were apt to put off consulting a physician, and as a result, the condition of tuberculosis would be more severe when they finally did see a physician. In the field of tuberculosis prevention and medical treatment, professionals should pay more attention to drinking and alcoholism. The need to stay sober is important in both preventing relapses and supporting recovery from tuberculosis.

An experimental study of delay of flow-through venous flaps

A delayed procedure was performed in flow-through venous flaps made in rabbits' ears. Compared with undelayed venous flaps, the delayed flaps at 7, 14 and 21 days after delay showed a distinct increase of survival area. This effect increased with the delay period.

Dura and cranial base reconstruction by external oblique fascia and rectus abdominis muscle flap

The rectus abdominis muscle flap, combined with the external oblique fascia, were utilized in cranial-base reconstruction. In a wide defect caused by resection of a giant meningioma, the dura was reconstructed with the external oblique fascia and anterior sheath, and the cranial-base defect was reconstructed with the rectus abdominis muscle flap.

[Optimal dose of cyclosporin in living related kidney transplantation]

We performed in total 528 kidney transplantations from Feb. 1983 to Dec. 1988 in Kidney Center of Tokyo Women's Medical College. Of the 528 kidney transplantations, 450 were living related kidney transplantations. The living related renal transplant recipients treated with CYA were divided into 3 groups: high dose CYA double drug therapy group (group 1), high dose CYA triple drug therapy group (group 2) and low dose CYA triple drug therapy group (group 3). Group 1 (n = 263) was treated with CYA (initial dose 12 mg/kg) and methylprednisolone (MP). Group 2 (n = 106) was treated with CYA (initial dose 10 mg/kg), MP and azathioprine (AZ) (1 mg/kg). Immunosuppression of group 3 (n = 81) consisted of CYA (initial dose 6 mg/kg), MP and AZ (2 mg/kg) (or mizoribine (MZ) (3-5 mg/kg). CYA serum trough level (polyclonal) was lowered according to the initial dose of CYA, and in particular trough level in group 3 was controlled at a low level (50-150 ng/ml in induction phase) to reduce CYA nephrotoxicity. However, even if strict control of serum trough level was accomplished, we could not get improvement of renal function in Group 3. Group 3 had more frequent and severe accelerated acute rejections (AAR) than the other groups. These data showed that inadequate immunosuppression in group 3 caused more frequent and severe rejection episodes. Also, renal biopsy revealed CYA nephrotoxicity even in group 3 and this nephrotoxicity may have been caused by ischemic damage by severe rejections.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mutual supplementation in treatment of renal failure by blood purification and kidney transplantation]

More than 100,000 uremic patients have been maintained by various blood purification modalities in Japan. However, their quality of life is far from satisfaction not only in terms of physical problems related to the complications specific to long-term dialysis treatment, but also the restriction in social activities by spending much time for hospital dialysis. A graft functioning rate in kidney transplantation has been remarkably improving after introduction of Cyclosporine A as an immunosuppressant and is presently approximately 90% one year after transplantation. As long as the transplanted kidneys function, further extensive social activities and highly-graded quality of life is warranted compared to artificial kidney treatment. On the other hand, patients in end-stage renal diseases and with rejected transplants are expected to undergo safe kidney transplantations as being maintained by dialysis therapy. Furthermore, recent development in blood purification technology has made the specific kidney transplantations successful in recipients with the preformed antibody (-ies) and the incompatible ABO blood type antibody (-ies). Nowadays, relation between blood purification and kidney transplantation is not competitive, but mutually supplementary as a matter of realism.

[Clinical studies of bacteriuria in renal transplantation recipients. Correlation with pyuria and symptomatic genitourinary tract infection]

The clinical state of bacteriuria and its correlation with pyuria and symptomatic genitourinary tract infection (GUTI) were studied in 42 renal transplantation recipients who were followed up in the Kidney Center of Tokyo Women's Medical College over 6 months and who showed bacteriuria more than 3 times between January and December in 1987. The results were as follows. 1) Of the 42 recipients, bacteriuria was found less than 5 times in 19 patients, 6 to 10 times in 18 patients and more than 11 times in 5 patients. There was a tendency for the same bacteria to be isolated several times from the same patient. The most commonly isolated bacterias were Enterobacter, Enterococcus, Serratia and E. coli. 2) Bacteriuria was accompanied by pyuria in 33 patients (79%) and by symptomatic GUTI in 12 patients (29%). Bacteriuria without pyuria was shown in 9 patients (21%) without symptomatic GUTI and it was suggested that bacteriuria did not result in graft hypofunction after two years. 3) Of 16 patients with bacteriuria accompanied by pyuria, symptomatic GUTI occurred in 9 patients (56%). Of these, one patient was found to have VUR of the transplanted kidney, another was found to have VUR of the native kidney, and a third patient died due to interstitial pneumonitis presumably as a result of overimmunosuppression. Transplantation recipients with bacteriuria accompanied by pyuria develop symptomatic GUTIs frequently and should be treated with proper antibacterial agents. When bacteriuria continues, further examination should be performed for an organic disease of the urinary tract or an overimmunosuppressed state. When a patient shows bacteriuria without pyuria, chemotherapy is not needed and it is sufficient to observe the course carefully.

[Postoperative pyuria after TUR-P: the study of postoperative pyuria by using NFLX]

The postoperative duration of pyuria was studied in 35 patients who underwent transurethral resection of the prostate (TUR-P). The average postoperative duration of pyuria was 58.0 +/- 23.6 days. The age over 70 years, preoperative indwelling of urethral catheter and the preoperative urinary tract infection did not make the duration of pyuria longer. The volume of resected prostatic tissue over 20 g and the existence of diabetes mellitus make it significantly longer. It is effective and safe to use a low-dose antibacterial agent such as NFLX which has a broad spectrum and hardly develops bacterial resistance after TUR-P. It is suggested unnecessary to change the anti-bacterial agent even when pyuria continues.

[A case of jugular foramen meningioma in a child]

The common tumors originating in the jugular foramen are chemodectoma and schwannoma. Jugular foramen meningioma is extremely rare. Review of the literature revealed only seven reported cases of this tumor. The authors present a child case of jugular foramen meningioma with intra and extracranial extension. A 9-year-old boy was admitted to the Department of Neurosurgery, Hiroshima University School of Medicine on March 20, 1985. Since the age of 3, the patient had hoarseness and was found to tilt his neck when he shouted. Since the age of 6, he was found to nod when he swallowed. At the age of 8, he developed swallowing difficulties. On admission, his general condition was unremarkable except for his lean build (126 cm in height and 23 kg in weight). An elastic hard and immobile mass was palpable in the left upper neck deep in the atrophic sternocleidomastoid muscle. Neurological examination revealed involvement of the ninth, tenth, eleventh, and twelfth cranial nerves. A plain skull roentgenogram and laminogram revealed hyperostosis around the left jugular foramen, and narrowing of the canal. CT with contrast enhancement revealed a high density mass in the left cerebellopontine angle extending through the jugular foramen to the left parapharyngeal space. Cerebral angiography did not show any abnormal findings except for complete blockage of the left sigmoid sinus. On April 4, 1985, subtotal removal of the intracranial tumor was performed using suboccipital craniotomy. Then, on July 3, 1985, the left parapharyngeal tumor was excised through a cervicofacial incision. Finally the residual tumor in the jugular foramen was excised using suboccipital approach on August 18, 1986.(ABSTRACT TRUNCATED AT 250 WORDS)