Unusual atrial pacing induced by type II far-field p-wave sensing in a patient with complete atrioventricular block

An 88-year-old Japanese woman underwent DDD pacemaker (MicroPort KORA 250 DR, V lead: VEGA R52) implantation for complete atrioventricular block. A 12-lead electrocardiogram for a routine examination showed atrial pacing within the intrinsic P wave, followed by inhibition of ventricular pacing. Pacemaker interrogation revealed no abnormalities in the basic parameters; however, ventricular pacing was inhibited by far-field sensing of intrinsic atrial waves before atrial events; type II far-field P-wave sensing. As a result, unusual atrial pacing occurred due to the pause suppression algorithm, which is the one of the functions that prevent atrial fibrillation development.

Influence of the right ventricular septum/free-wall boundary (hinge) on differentiation of the ventricular lead implantation site

BACKGROUND

The prognosis associated with right ventricular (RV) free-wall pacing is worse than that of septal pacing. Identification of the pacing site using a 12‑lead electrocardiogram (ECG) is controversial and may be influenced by ECG changes within the same septal or free-wall area. The relationship between the diagnostic capabilities of ECG and pacing sites has previously been qualitatively evaluated. However, in this study, this relationship was analyzed quantitatively, and accurate evaluation of the pacing site was determined using computed tomography (CT).

METHODS

Of 779 consecutive outpatients, 65 who underwent pacemaker implantation and thoracic CT were prospectively included and classified into the following groups according to the lead tip position: free-wall, septal, or septum/free-wall boundary (hinge) group. The hinge was used as an anatomical marker, and the distance from the hinge to the lead tip was measured. Under RV pacing, a 12‑lead ECG was obtained. ECG findings were evaluated using three criteria (including lead I, II, and aV_L and precordial leads V₅ and V₆) previously reported to be useful in differentiating pacing sites.

RESULTS

The lead tips were anchored at the free-wall in 10 patients, the septal wall in 19 patients, and the hinge in 32 patients. Paced QRS duration correlated with the distance from the hinge to the lead tip for the free-wall and septum (r = 0.47 and - 0.68, respectively). Estimation of the lead tip implantation site using the ECG algorithm was useful; however, the algorithm's accuracy decreased around the hinge.

CONCLUSIONS

ECG is useful in differentiating pacing sites but is less accurate around the hinge, which may be the reason that the identification of the RV pacing site using ECG remains controversial.

Relationship between device displacement distance toward the caudal side during standing and pocket position laterality

BACKGROUND

The displacement of cardiac implantable electronic devices (CIEDs) toward the caudal side during standing after CIED implantation could cause lead dislodgement. This study investigated the relationship between supine pocket position and standing CIEDs' displacement distance after the implantation.

METHODS

After CIED surgeries performed at 2 hospitals between 2012 and 2020, 134 patients underwent postoperative chest x-rays in the supine and standing positions during hospitalization. To measure the displacement distance of CIEDs from the supine to the standing position, we identified the first thoracic vertebrae (Th1) in the supine position using the first rib as an index, drew a horizontal line at the lower edge of the Th1, and calculated the distance from that point to the upper edge of the CIED. The difference between measures for the two positions was compared. At the position of the pocket in the thorax in the supine position, the ratio of the distance between the thorax and the device is defined as the device thorax ratio (DTR). We examined the relationship between DTR and CIED displacement distance.

RESULTS

In this study, we included 134 patients (53% men; median age, 79 years, body mass index, 22.3 ± 3.4; pacemaker 93%, left implantation 96%). We found that the more lateral the position of the CIED pocket, the more the CIED fell when standing (confidence interval = 0.34-0.60, P < 0.001).

CONCLUSIONS

The farther the CIED was implanted outside the thorax in the supine position, the more significantly the CIED was displaced in the standing position. This article is protected by copyright. All rights reserved.

Incidence of out-of-hospital cardiac arrests and survival rates after 1 month among the Japanese working population: a cohort study

OBJECTIVES

The prevention and improvement of the prognosis of out-of-hospital cardiac arrests (OHCAs) are important issues especially with respect to their social and economic significance in working populations. The age distribution of the working population in Japan is expected to change continually due to its ageing society and extension of retirement; however, few reports have examined the long-term condition of OHCA in the working population, defined by age. The aim of this study was to determine the incidence of OHCAs and the survival rates after 1 month, among the Japanese working population, defined by age, considering the changing age distribution.

DESIGN AND SETTING

We analysed the All-Japan Utstein registry, a prospective, nationwide, population-based, observational registry (2005-2016).

PARTICIPANTS

From the registry, 212 961 patients with OHCA from the Japanese working population (defined aged 20-69 years), with only cardiogenic aetiology participated in this study. These patients were further divided into four groups according to the type of citizen bystander (family, friends, work-colleagues and passers-by).

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were 1-month survival with favourable neurological outcomes.

RESULTS

The incidence of OHCAs, in any age group, was almost constant during the 12-year period. The work-colleagues had the best prognosis despite having significantly longer times to initial defibrillations compared with the passers-by (13 vs 12 min, respectively, p<0.001) that was associated independently with 1-month survival with favourable neurological outcomes (adjusted OR: 0.94 (1 min increments), p<0.001).

CONCLUSIONS

In the 12-year period, the incidence of OHCAs in any age group remained almost constant, whereas the prognosis improved each year. Reducing the time to initial defibrillation may further improve the prognosis of OHCAs with a work-colleague bystander.

Large discrepancy in optimal atrioventricular delay between sensed and paced atrial events in a pacemaker patient

A 74-year-old man experienced complete atrioventricular (AV) block 2 days after catheter ablation for right atrial (RA) macroreentrant tachycardia. We performed DDD pacemaker implantation with atrial septal pacing because other sites of pacing threshold were not acceptable. The maximum left ventricular outflow tract velocity time integral was 15.8 cm with sensed AV delay (40 ms) and 15.0 cm with paced AV delay (220 ms); however, this exceeded the pacemaker's maximum difference of 100 ms. We herein report the case of a large discrepancy in optimal AV delay intervals between sensed and paced atrial events, requiring consideration of proper pacemaker settings.

Accessory pathway ablation during atrial fibrillation in Ebstein anomaly

An 84-year-old woman with type B Wolff-Parkinson-White (WPW) with Ebstein anomaly was admitted with heart failure. She had rapid wide QRS tachycardia due to accessory pathway (AP) conduction associated with atrial fibrillation (AF). Since transesophageal echocardiography before catheter ablation showed a left atrial thrombus, ablation was performed using a 3D mapping system under AF. After marking the functional tricuspid anulus with intra-cardiac echocardiography, 3D intra-cardiac electrogram visualization (ripple map) during AF enabled clear identification of location of the AP. After ablation, there was no complication of cerebral infarction, and the heart failure improved.

Adenosine revives catheter-induced mechanical blocks in radiofrequency ablation

Adenosine can hyperpolarize the atrial action potential, which helps rapidly re-establish the membrane potential in ablated sites and unmask "dormant conduction." It has been reported that pharmacological agents, including adenosine, were unable to revive traumatized tissues. We present the first case of the catheter-induced mechanical block ("bump" phenomenon) that was unmasked with adenosine administration in the working myocardium of the superior vena cava. This result may be because, unlike before, we could determine the force of contact between the tip of the ablation catheter and the myocardial tissue. This case suggests the clinical usefulness of adenosine for unmasking bumped sites.

RR interval variability in the evaluation of ventricular tachycardia and effects of implantable cardioverter defibrillator therapy

BACKGROUND

An implantable cardioverter defibrillator (ICD) is the most reliable therapeutic device for preventing sudden cardiac death in patients with sustained ventricular tachycardia (VT). Regarding its effectiveness, targeted VT is defined based on the tachyarrhythmia cycle length. However, variations in RR interval variability of VTs may occur. Few studies have reported on VT characteristics and effects of ICD therapy according to the RR interval variability. We aimed to identify the clinical characteristics of VTs and ICD therapy effects according to the RR interval variability.

METHODS

We analyzed 821 VT episodes in 69 patients with ICDs or cardiac resynchronization therapy defibrillators. VTs were classified as irregular when the difference between two successive beats was >20 ms in at least one of 10 RR intervals; otherwise, they were classified as regular. We evaluated successful termination using anti-tachycardia pacing (ATP)/shock therapy, spontaneous termination, and acceleration between regular and irregular VTs. The RR interval variability reproducibility rates were evaluated.

RESULTS

Regular VT was significantly more successfully terminated than irregular VT by ATP. No significant difference was found in shock therapy or VT acceleration between the regular and irregular VTs. Spontaneous termination occurred significantly more often in irregular than in regular VT cases. The reproducibility rates of RR interval variability in each episode and in all episodes were 89% and 73%, respectively.

CONCLUSIONS

ATP therapy showed greater effectiveness for regular than for irregular VT. Spontaneous termination was more common in irregular than in regular VT. RR interval variability of VTs seems to be reproducible.

The features and trends of out-of-hospital cardiac arrests in Japanese working generation: long-term aspects of a prospective, nationwide, population-based registry

Background

Despite sudden cardiac death (SCD) in working generation is a crucial issue in terms of public health, social and economic significance, the long-term SCD condition in working generation is unclear.

Purpose

This study aimed to clarify the features and long-term trends of SCD in working generation from 2005 through 2016 in Japan, using a prospective, nationwide, population based out-of-hospital cardiac arrest (OHCA) registry.

Methods

We performed data analysis of the nation-wide registry in Japan who experienced OHCA during the 12 years. Working generation was defined as 20 to 69 years and we analyzed only definitive cardiogenic OHCA as an approximation of SCD.

Results

The number of definitive cardiogenic OHCA of working generation during the period was 66,214 and 31% of the events in whole population was working generation. Definitive cardiogenic OHCA in working generation in terms of both number and percentage of the population had been decreased from 6522 (0.07‰) in 2005 to 4910 (0.06‰) in 2016, bystander cardiopulmonary resuscitation (CPR) and usage of automated external defibrillator (AED) ratio increased from 32.7% in 2005 to 49.6% in 2016, and 0.3% in 2005 to 14.7% in 2016 respectively, and the survival rate after one-month improved year by year, from 12.8% in 2005 to 34.0% in 2016 (picture below). Among non-medical bystanders, CPR was most often performed by colleagues in this generation, while AED use rate by colleague was smaller, and the time from witness to initial defibrillation was significantly longer than by passerby. Good prognosis was observed in terms of one-month survival ratio and neurological outcome for those undergoing CPR by colleague and passerby compared with other bystanders. For 12 years, although the degree varies, all non-medical bystander had same tendency; bystander CPR and usage of AED ratio increased, and the survival rate after one-month and neurological outcome improved year by year.

Conclusions

Not only the number but the incidence of cardiogenic OHCA in working generation has been decreased in Japan. The positive prognosis of this generation may be related to CPR by colleagues.

Figure 1. OHCA number & 1-month survival rate

Funding Acknowledgement

Type of funding source: None

Rate-dependent pacing failure after pacemaker implantation: Novel insights into the mechanism of using adenosine

An 82-year-old woman received pacemaker implantation for sick sinus syndrome. Two days after the implantation, electrocardiography showed 2:1 atrial pacing failure, followed by a bradycardia-dependent increase in the atrial pacing threshold during a pacemaker examination. However, transient 1:1 atrial pacing capture recovered by adenosine triphosphate (ATP) administration, which was performed to evaluate the bradycardia-dependent pacing failure mechanism. We considered this phenomenon to be caused by Phase 4 depolarization and avoided replacing this atrial lead. Three weeks later, the atrial pacing threshold had improved. We report the potential role of Phase 4 depolarization in a bradycardia-dependent increase in pacing threshold by using ATP.

Prevention of serious air embolism during cryoballoon ablation; risk assessment of air intrusion into the sheath by catheter selection and change in intrathoracic pressure: An ex vivo study

INTRODUCTION

One cause of cerebral infarction during cryoballoon ablation is the entry of air into a sheath due to the use of inappropriate catheters. It is known that the left atrial pressure of patients with obstructive sleep apnea syndrome can be negative. However, the effects of catheter selection and negative pressure changes in the sheath on air intrusion are not yet well understood. The aim of this study was to evaluate how catheter selection and negative pressure changes affect air intrusion and to perform countermeasures for air intrusion.

METHODS AND RESULTS

This experiment used siphon principle to create negative pressure in the sheath. Noncryoablation catheters (not designed exclusively for cryoballoon ablation) and cryoballoon catheters were investigated. Catheters were inserted into the sheath and then removed. Thereafter, the amount of air in the sheath was measured. For catheters producing significantly larger amounts of air intrusion, the catheters were inserted via a long sheath in the sheath (sheath-in-sheath technique) and the same procedures were repeated. We found that the amount of air intrusion through most of the noncryoablation catheters was significantly larger than that through cryoablation catheters. An increase in the magnitude of negative pressure in the sheath resulted in a proportional increase in air intrusion, but the sheath-in-sheath technique significantly reduced air intrusion.

CONCLUSION

The amount of air intrusion increased when using catheters with complicated tip shapes and thin outer diameters and when the magnitude of negative pressure in the sheath increased. The sheath-in-sheath technique may be an effective countermeasure.

Outcomes of single- or dual-chamber implantable cardioverter defibrillator systems in Japanese patients

Background

There are no criteria for selecting single- or dual-chamber implantable cardioverter defibrillators (ICDs) in patients without a pacing indication. Recent reports showed no benefit of the dual-chamber system despite its preference in the United States. As data on ICD selection and respective outcomes in Japanese patients are scarce, we investigated trends regarding single- and dual-chamber ICD usage in Japan.

Methods

Data from a total of 205 ICD recipients with structural heart disease (median age, 63 years) in two Japanese university hospitals were reviewed. Patients with bradycardia with a pacing indication and permanent atrial fibrillation at implantation were excluded.

Results

Single- and dual-chamber ICDs were implanted in 36 (18%) and 169 (82%) patients, respectively. Non-ischemic cardiomyopathy dominated both groups. Seventeen dual-chamber patients developed atrial pacing-dependency over 4.5 years, and it developed immediately after implantation in 14. Although preoperative testing showed no sign of bradycardia in these patients, their pacing rate was set higher than it was in patients who were pacing-independent (61 vs. 46 paces per min, p<0.01). Two single-chamber patients (5%) underwent atrial lead insertion.

While inappropriate shock equally occurred in both groups (7 vs. 21 patients, single- vs. dual-chamber, P=0.285), device-related infection occurred only in dual-chamber patients (0 vs. 9 patients, P=0.155). No differences in death or heart failure hospitalization were observed between groups.

Conclusions

Dual-chamber ICDs were four-fold more common in Japanese patients without a pacing indication. No benefit over single-chamber ICD was observed. Newly developed atrial pacing-dependency seemed to be limited and could have been overestimated due to higher pacing rate settings in dual-chamber patients.

Different characteristics of heart failure due to pump failure and bradyarrhythmia

Background

Heart failure (HF) can be caused by left ventricular (LV) pump failure as well as by bradyarrhythmias. Hemodynamic differences between HF by LV pump failure and that by bradyarrhythmia have not been fully investigated. We hypothesized that HF by LV pump failure could be associated with both reduced cardiac output (CO) and increased LV filling pressure due to associated LV diastolic dysfunction, whereas HF by bradyarrhythmia could be associated with reduced CO but only modestly increased LV filling pressure due to the absence of LV diastolic dysfunction.

Methods

In 39 patients with HF by LV pump failure (LV ejection fraction <35 %), 24 with HF by bradyarrhythmia, and 22 normal controls, LV volume, ejection fraction, stroke volume, left atrial volume, and early diastolic mitral valve flow to tissue annular velocity ratio (E/E′) were measured by echocardiography.

Results

Compared to patients with HF by LV pump failure, those with HF by bradyarrhythmia had significantly lower heart rates, less LV dilatation, preserved LV ejection fraction, preserved stroke volume, similarly reduced cardiac index (1.8 ± 0.4 vs. 1.6 ± 0.4 L/min/m², n.s.), preserved LV diastolic function (E′) (4.4 ± 2.1 vs. 7.1 ± 2.9 cm/s, p < 0.001), less dilated end-systolic LA volume, and preserved E/E′ (24 ± 10 vs. 13 ± 7, p < 0.001).

Conclusions

HF by LV pump failure is characterized by both significantly reduced CO and increased LV filling pressure, whereas HF by bradyarrhythmia is characterized by a similar reduction in CO but only modestly increased LV filling pressure.

Pacing and sensing interference by air bubble surrounding the non-extended helix of intact active fixation lead

BACKGROUND

Active fixation pacing leads with silicon cylinder tips have been used for their safety and flexibility. Measurement of baseline sensing/pacing characteristics before fixation of helix helps to identify the optimal pacing site, but we encountered difficulties in making these measurements despite multiple attempts with the model LPA 1200M lead. To identify the cause and overcome this complication, we compared 4 different retractable active fixation lead models, which enabled baseline sensing/pacing measurements before extension of helix. METHODS AND RESULTS: We immersed 4 different lead tips and rings in a 0.18% saline solution, and measured the lead impedance before and after flushing of air bubble visible inside the lead tip. Before evacuation of the air bubble, the impedance of the model LPA 1200M lead was >4,000 Ω in 8 out of 10 measurements, although that of the other leads was within the measurable range. After evacuation of the air bubble, the lead impedance returned to within the measurable range. There was no prominent change in the impedance of the metal cylinder tip lead.

CONCLUSIONS

Air bubbles may interfere with the measurement of baseline sensing/pacing characteristics before active fixation of pacing leads with cylindrical silicon tips. In the case of high impedance beyond the measurable range before extension of helix, the measurement should be repeated after fixation into the myocardium before suspecting lead dysfunction.

Atrial pacing site and atrioventricular conduction in patients paced for sinus node disease

BACKGROUND

Unnecessary ventricular pacing in sinus node disease (SND) must be avoided. To test the hypothesis that in SND, with or without 1st degree atrioventricular (AV) block, cumulative percent ventricular pacing (cum%VP) can be limited by low right atrial septal (LRAS) instead of right atrial appendage (RAA) pacing.

METHODS

We studied 102 dual-chamber pacemaker recipients with SND. The PQ interval on 12-lead electrocardiogram and the atrial paced to ventricular sensed interval (Ap-Vs) during LRAS and RAA pacing were measured and compared at implantation, 3 months and 1 year of follow-up. Group 1 included 62 patients with baseline PQ interval <200 milliseconds during LRAS (n = 28) versus RAA (n = 34) pacing. Group 2 included 40 patients with baseline PQ ≥200 milliseconds during LRAS (n = 20) versus RAA (n = 20) pacing. cum%VP were measured at 3 months and 1 year.

RESULTS

The characteristics and AV conduction properties were similar and the Ap-Vs interval was significantly shorter in the LRAS than in the RAA pacing group up to 1 year (193 ± 32 milliseconds vs. 220 ± 27 milliseconds in Group 1; P = 0.003, 222 ± 41 milliseconds vs. 281 ± 30 milliseconds in Group 2; P < 0.001). While cumulative percent atrial pacing was consistently similar, cum%VP was significantly smaller during LRAS than RAA pacing (1 ± 1% vs. 8 ± 18% in Group 1; P = 0.03, 7 ± 10% vs. 48 ± 38% in Group 2; P < 0.001). Similar observations were made with or without left atrial (LA) enlargement.

CONCLUSION

Compared with RAA, LRAS pacing showed shorter AV interval in SND patients with or without 1st degree AV block and LA enlargement. This beneficial effect persisted through 1-year follow-up, and decreased cum%VP significantly.

Diffusion-weighted magnetic resonance imaging in infants with periventricular leukomalacia

OBJECTIVE

We examined diffusion-weighted magnetic resonance imaging (DWI) findings in periventricular leukomalacia (PVL) and then evaluated the relationship between the mean apparent diffusion coefficient (ADC) values and the region and severity of PVL.

METHODS

Between April 2006 and July 2007, 98 infants at gestational ages between 27 and 33 weeks were enrolled in the study. DWI was performed during the first week of life when electroencephalography indicated PVL. The mean ADC values were evaluated using regions of interest drawn manually in the periventricular white matter, posterior limbs of internal capsules (PLICs), and various regions of the brain.

RESULTS

DWI was performed in three of four infants with PVL indicated on electroencephalography. All had decreased diffusivity in the anterior to posterior white matter despite a predominance in the posterior white matter. DWI abnormalities were also observed in the corpus callosum and PLICs and were more broadly distributed in the brain than those detected by later conventional MRI. In the PLICs, the changes in the ADC values were correlated with the severity of the PVL.

CONCLUSION

The DWI findings provided additional information regarding PVL. Among the findings, the association of the presence of decreased diffusivity in the corticospinal tract with later motor impairment was the most interesting.

[The historic study on the health drink-especially on the origin of health drink and the formation of its market-]

The health drink is oral liquids which are classified as elixirs or limonades and so on, which are peculiar to Japan and differ from other liquids to glass a dose of drug. It has mainly been divided into two classes by glassed volume (dosage) in the bottle. One class is the drink tonic which is the capacity of 100 ml and another is the mini-drink tonic which is 50 ml and less. In addition, oral liquid glassed with an ampule is called the ampule tonic. Such drugs were thought to appear after World War II and have been widely known since 1960. However, tonics which had consisted of recipies like the present health drink were shown to exist before World War II. Thus, it was considerable that such prescription formulas were also applied to the ampule tonic and drink tonic. On the other hand, one of the important problems with health drugs was how to make their taking easy in its development. Further, it was necessary to add to acid antiseptic and high content of sugar etc., because the liquids generally had been putrescible. It might be one of the reason for their appearances that it was allowed to produced a liquid which was stabler and made its taking easier to be released from the above limit by the introduction of a dose-glassed liquid. In 1960, the ampule tonic quickly became popular and the drink tonic followed. It was probably caused by changes on the standard and style of living involved the enhancements of the labor time, purchasing power and sense on the health and active propaganda of the manufacturers. In this way, the market has satisfactorily expanded. However, because such medicines liked beverages appeared, it was difficult to distinguish their differences since 1965. Therefore, the Ministry of Health and Welfare has performed some administrative guidances. In 1978, it regulated new approval of the production of 100 ml drink tonics, which led to the appearance of the mini-drink tonic. Its market rapidly expanded since 1985. In 1991, its scale reached about 200 billion yen on both drink tonics and the sale volume was 20% at drug stores in Japan. The health drink is supporting the economic foundation of drug stores at present.

[The classification and therapeutical methods of cataract on Chinese medicine in the modern times]

We investigated cataract-related description on the medical literatures written at China in modern times. In those days, the cataract was classified by the shapes of clouds on the crystalline lens. In present Chinese medicine, it has been interpreted that the senilecataract was showed Eneinaisyo. Hyoei-naisyo, Katsuei-naisyo, Zyuei-naisyo, Sanei-naysyo, Fuei-naisyo, Tinei-naisyo, Ohei-naisyo, Engetsuei-naisyo, Soukaei-naisyo, Hakueiohsin-naisyo and Kokusuigyoei-naisyo; these words were old names for cataract. We separately rethought about their symptoms from the description in the original literatures; however, they showed some symptoms which generally were not found on the senilecataract. On the other hand, the therapeutic methods mainly existed pharmacotherapy, surgical methods and treatments with acupuncture and moxibustion and their applications were each different according to the shapes of the clouds.

Limitations of successive transradial approach in the same arm: the Japanese experience

The transradial approach (TRA) has been used for diagnostic and interventional cardiology. It has not previously been determined how many times the same radial artery can be cannulated without complications. A total of 812 patients (502 men and 310 women) underwent angiography or angioplasty via the TRA between 1997 and 1999 at our institution with a total of 1,438 procedures. Sheaths were 5 (55%) or 6 Fr (45%). Dropout rates of 3.5% and 7.9% were found at the second TRA attempt in the men and the women, respectively. Of the 62 TRA failures, 56 (90%) were due to narrowing or occlusion of the radial artery after the previous TRA procedure. A third TRA procedure was possible in 90% of the men and 80% of the women. A fifth TRA procedure was possible in 70% of the men and 50% of the women. The dropout rates for TRA increased as successive punctures were performed. This was primarily due to vessel narrowing and occlusion occurring as a function of multiple punctures.

Efficacy of a new hemostatic device, Adapty , after transradial coronary angiography and intervention

A novel hemostatic device, Adapty (Medikit, Tokyo, Japan), was developed to achieve effective and comfortable hemostasis following transradial procedures. The device consists of a pad fixed to a transparent plastic plate and a self-adhesive strap. The catheter sheath is removed from the radial artery after the pad has been positioned precisely over the puncture site, with the strap attached to the plate. Compression pressure then is adjusted with the self-adhesive strap, as is required with occlusive clamps. Patients do not need to maintain hyperextension of the wrist after the procedure. The wrist can be mobilized immediately after application. The efficacy of Adapty was evaluated in prospective observations of 200 patients. The device was successfully applied in all patients immediately after sheath removal. No patient required interruption of compression because of pain, congestion or ischemia. Complete hemostasis was obtained in 199 patients (99.5%), and the device caused no vascular complications. This study demonstrates that Adapty is highly effective for achieving hemostasis after transradial procedures.

Tumor necrosis factor-alpha (TNF-alpha)-induced and interleukin-1 beta (IL-1 beta)-induced shedding of TNF receptors from gingival fibroblasts

Tumor necrosis factor-alpha (TNF-alpha) exerts its functions by binding two different receptors (TNFR55 and TNFR75). Both TNFR55 and TNFR75 exist in cell-associated and soluble forms. Soluble TNF receptors (sTNFR), sTNFR55 and sTNFR75, are proteolytically shed upon inflammatory stimuli and then modulate various TNF-alpha bioactivities. As human gingival fibroblasts (HGF) can be potential targets for TNF-alpha in inflamed gingiva, we hypothesized that HGF partially modulate the cellular responses to TNF-alpha by regulating their own TNFR. In this study, the kinetics of expression of cell-associated and soluble forms of both receptors from cultured HGF in response to proinflammatory cytokines TNF-alpha and interleukin-1 beta (IL-1 beta) were investigated in vitro. Both TNF-alpha and IL-1 beta upregulated the gene expression of TNFR75 and did not affect that of TNFR55. TNF-alpha and IL-1 beta decreased binding of [(125)I]TNF-alpha to HGF. Moreover, TNF-alpha and IL-1 beta upregulated the release of sTNFR75 from HGF but not that of sTNFR55. These results suggest that HGF under inflammatory conditions may contribute to the inactivation of circulating TNF-alpha through the preferential induction and shedding of TNFR75.

A case in which stent insertion is considered to have triggered contrast medium-induced coronary vasospasm

A Gianturco-Roubin II (GR-II) stent was inserted in a 75-year-old man who developed restenosis of the right coronary artery (RCA) after percutaneous transluminal coronary angioplasty (PTCA). Although the vessel became partially occluded after 7 months, it was redilated by PTCA. Follow-up angiography of the RCA and left coronary artery (LCA) was performed 3 months later. Chest pain with bradycardia and hypotension occurred immediately after this examination, and ST elevation appeared in ECG leads II, III, and aVF. Repeat angiography of the RCA confirmed complete occlusion due to a spasm at a site proximal to the GR-II stent. The spasm was resolved by intracoronary infusion of isosorbide dinitrate (ISDN), and PTCA was carried out for extensive recurrent restenosis of the RCA; however, vascular dissection developed at the distal end of the GR-II stent. Therefore, a Palmaz-Schatz (P-S) stent was placed such that its proximal end overlapped the distal end of the GR-II stent. Follow-up angiography 3 months later showed no restenosis, but an episode of vasospasm similar to the previous one occurred immediately after left ventriculography. The RCA was completely occluded proximal to the GR-II stent because of spasm. Although this spasm was gradually relieved by intracoronary infusion of ISDN, marked spasm was also observed distal to the P-S stent; complete relief was achieved by infusion of additional ISDN.

Expression of truncated pro-opiomelanocortin gene transcript in human leukemia cell lines

Although previous studies have suggested that human peripheral blood mononuclear cells (PBMCs) may express pro-opiomelanocortin (POMC) mRNA and synthesize its related peptides, the patho-physiological role of POMC expressed in peripheral cells is not known. In this study, we investigated the POMC gene expression in various types of human leukemia cell lines by Northern blot analysis and the reverse transcribed-polymerase chain reaction (RT-PCR) method. The POMC mRNA was not detected by Northern blot analysis in all cell lines tested except the Jurkat cell line which is derived from T-lymphoblastic leukemia. The POMC mRNA expressed in the Jurkat cells was smaller than that in the human anterior pituitary gland. The RT-PCR method revealed that a truncated-POMC transcript could be detected not only in lymphoblastic leukemia cells but also in erythroid and myeloid cells. Interestingly, two cell lines of monocytic leukemia, J-111 and U937, did not express the truncated-POMC mRNA. Treatment with concanavalin-A stimulated truncated POMC mRNA expression and ACTH-like immunoreactivity in lymphoblastic leukemia cells with T-(Jurkat) and B-(BALL-1) lymphocyte phenotypes. These results confirm that human leukemia cells except for monocytic cells express a truncated-POMC mRNA as well as in the human normal PBMC.

Structural analysis of N-linked carbohydrate chains of funnel web spider (Agelenopsis aperta) venom peptide isomerase

The structure of the N-linked carbohydrate chains of peptide isomerase from the venom of the funnel web spider (Agelenopsis aperta) has been analyzed. Carbohydrates were released from peptide isomerase by hydrazinolysis and reductively aminated with 2-aminopyridine. The fluorescent derivatives were purified by phenol/chloroform extraction, followed by size-exclusion HPLC. The structure of the purified pyridylamino (PA-) carbohydrate chains were analyzed by a combination of two-dimensional HPLC mapping, sugar composition analysis, sequential exoglycosidase digestions, and mass spectrometry. The peptide isomerase contains six kinds of N-linked carbohydrate chains of truncated high-mannose type, with a fucose alpha 1-6 linked to the reducing N-acetylglucosamine in approximately 80% of them.

Species differences and mechanism of the epimerization of a new MAO-A inhibitor

1. (5R)-3-[2-((1S)-3-cyano-1-hydroxypropyl)benzothiazol-6-yl]-5-metho xymethyl-2-oxazolidinone (E2011) has two chiral centers in its structure. In vivo optical inversion of the hydroxy group at one of the chiral centers converts E2011 to a diastereoisomer (ER-20593). Pharmacokinetic parameters of E2011 and ER-20593 were determined after administration of E2011 to rat at 10 mg/kg, and the plasma concentration ratios of E2011 to ER-20593 were almost constant after Tmax of the plasma concentrations. 2. E2011 and ER-20593 were separately administered orally to six species in addition to rat, and the species differences in both directions of epimerization (i.e. from E2011 to ER-20593 and from ER-20593 to E2011) were studied by measuring the plasma concentrations of both compounds. In mouse, guinea pig, dog, and squirrel monkey, the epimerization of E2011 to ER-20593 did not occur, but the epimerization of ER-20593 to E2011 did. In rat, pig and rhesus monkey, the inversion of E2011 to ER-20593 occurred, but the ratios of this inversion were smaller than those for the inversion in the opposite direction. E2011 underwent about 15% inversion to ER-20593 in rat, which was the largest inversion in the seven species examined. 3. To study the mechanism of the epimerization, deuterium-labelled E2011 and ER-20593 (created by substituting the proton at the chiral center of the parent compounds for deuterium) were orally administered (separately) to rat and dog, and the concentration ratios and molecular weights of E2011 and ER-20593 in the plasma were determined by hplc and FAB(+)-mass spectrometry respectively. The results indicated that the major mechanism of the epimerization was oxidation to the carbonyl form followed by reduction to the original epimer and/or the other epimer. 4. The carbonyl form of E2011 (CO-E2011) was reduced to E2011 and ER-20593 (alcohol forms) by liver cytosol and microsomes from rat and dog in vitro with NADH or NADPH. The resultant epimeric ratios (E2011:ER-20593) were consistent with the in vivo results in rat and dog. 5. In conclusion, species differences in the epimerization of E2011 would result from product stereoselectivity of the reductase activity with the carbonyl intermediate.

[Repair of intrathoracic visceral damage using video-assisted thoracoscopic surgery for blunt chest trauma and rib fixation at the site of mini-thoracotomy]

We treated three patients with intrathoracic visceral damage caused by severely dislocated fractured ribs resulting from blunt trauma by using video-assisted thoracoscopic surgery (VATS) and rib fixation through a mini-thoracotomy. Under general anesthesia and unilateral respiration, the thoracic cavity was inspected with a thoracic video scope through the port inserted through the thoracic drainage opening which was made upon arrival at hospital. As the visceral damage seemed restorable under VATS, a mini-thoracotomy was positioned just above the rib fracture. Two thoracic ports were inserted through the site of rib fracture or through the intercostal space and then VATS was performed using three ports. After the restoration of intrathoracic visceral damage, the fractured rib was fixated using a bioabsorbable poly-L-lactide rib fixation pin or a marlex mesh. Lung injuries were sutured and ligated under VATS in two of our cases and a spur of the fractured rib was shaved in one case. Only severely dislocated ribs were fixated through the mini-thoracotomy in all cases. Air leakage stopped just after this procedure and there were no complications. The rib fixation and bone regeneration were excellent after this procedure. The advantages of this method are the visceral restoration under VATS through a mini-thoracotomy and the ability to perform rib fixation without injuries to the intercostal muscle, artery, vein or nerve. This operative procedure is recommended for intrathoracic visceral damage caused by severely dislocated rib fracture.

Portal-hepatic venous shunt through a portal aneurysm complicated by hepatic encephalopathy and pulmonary hypertension

We report a rare case of portal-hepatic venous shunt through an enormous portal aneurysm complicated by pulmonary hypertension. A 66-year-old woman was admitted to our hospital for hepatic encephalopathy. Chest roentgenography revealed pulmonary hypertension. Computed tomography and ultrasound examination demonstrated a shunt between the portal and hepatic veins through an enormous portal aneurysm. The diagnoses of portal-hepatic venous shunt and pulmonary hypertension were confirmed by hepatic venous catheterization and cardiac catheterization. Pulmonary hypertension might result from the effects of vasoconstrictive agents, which should be metabolized by the liver in normal subjects, passing through the intrahepatic shunt into the lung.

[Esophago-bronchial fistula which developed after the insertion of an expandable metallic stent for corrosive esophageal stenosis]

A 69-year-old man attempted suicide by abdominal penetrating injury and taking sulfonyl acid. After a laparotomic drainage operation, corrosive esophageal stenosis occurred. Esophageal bougienage was not effective. An expandable metallic stent (GIANTURCO-ROCHE Z stent, Cook Bloomington U.S.A.) was inserted aiming to achieve temporary oral diet and nutritional improvement. But diet did not improve sufficiently because of the awareness of the prosthesis, severe hiccup, uncontrolled regurgitation esophagitis and restenosis caused by intraluminal mucosal growth. After 4 months of insertion, an esophago-bronchial fistula was produced by the wire of EMS. An operation became necessary for this complication. No data exist on the long-term use of the EMS and it is not suitable for benign esophageal stenosis. Unavoidably if the palliative treatment of endoprosthesis is necessary for benign esophageal stenosis such as corrosive esophageal stenosis, a removable esophageal tube prosthesis is preferable.

GM-CSF- and IL-3-dependent CD34 expressing myeloid cell line (SAS-1) established from CD7 and CD34 expressing acute myeloblastic leukemic cells

A novel factor-dependent human myeloid leukemia cell line (SAS-1) was established from a 69-year-old Japanese male suffering from CD7 and CD34 expressing acute myeloblastic leukemia (AML M2 in FAB classification). Morphological and cytochemical staining showed that SAS-1 cells were round with basophilic cytoplasm which is positive for peroxidase. Analysis of surface markers revealed that SAS-1 cells were myeloblasts derived from an immature progenitor origin, which express CD34. The consensus karyotype of the cell line was 41 XY 5q-, -7, 11p-, 12p+, -13, -14, -16, -17, -19, -22, with two markers. The proliferation of SAS-1 cells was dependent on the presence of either granulocyte-macrophage colony-stimulating factor (GM-CSF) or interleukin-3 (IL-3), and GM-CSF- and IL-3-induced proliferation was dose dependent. Neither, stem cell factor (SCF) nor granulocyte colony-stimulating factor (G-CSF) alone supported the growth of SAS-1 cells, but supported their viability for more than 4 days and arrested them in the G0/G1 phase. SCF also enhanced GM-CSF- or IL-3-induced growth, but other cytokines did not have this synergistic effect. Clonogenic assays revealed that SAS-1 cells formed 36.0 +/- 5.7 or 41.5 +/- 0.7 colonies/1000 cells in the presence of GM-CSF or IL-3, respectively. SCF also increased the number of colonies formed by GM-CSF or IL-3 treatment, while SAS-1 cells did not form colonies in the presence of SCF alone. SAS-1 cells may prove to be a useful tool for studying the regulation of the cell cycle, myeloid proliferation, and differentiation.

[Administration method and recurrence-preventing effect of medroxyprogesterone acetate (MPA) as a postoperative adjuvant endocrine therapy for stage III breast cancer. Kitakyushu Collaborative Study Group for Breast Cancer]

By a collaborative study undertaken by 11 medical institutions in the Kita-Kyushu area, we evaluated the clinical efficacy of the combination of medroxyprogesterone acetate (MPA) and Tamoxifen (TAM) as a postoperative adjuvant endocrine therapy for Stage III breast cancer. First, 1 course of CAF therapy was administered; then, in combination with the basic therapy of 5-FU 200 mg/day p. o. for 3 years, ER (+) patients were treated with either 2-week sequential therapy of TAM (30 mg/day) and MPA (800 mg/day) or TAM (30 mg/day), and ER (-) patients received either MPA (800 mg/day) or 5-FU alone. Neither survival nor disease-free rates of the 92 analyzable patients were different between these treatment groups. Furthermore, the blood levels of MPA and cortisol had no correlation with survival and disease-free periods. We studied the effect of MPA on the natural inhibitors of blood coagulation, but found no difference from the result in healthy adults. It was, however, shown that MPA had a bone marrow-protecting effect.

Sarcoidosis after interferon therapy for chronic active hepatitis C

Sarcoidosis is characterized by multisystemic granulomatous lesions of unknown etiology. A 62-year-old woman developed sarcoidosis after treatment with alpha-2a interferon (IFN) for 24 weeks (total dose: 522 million units) for chronic hepatitis C. She developed complete atrioventricular block and multiple noncaseating granulomatous lesions in the lung. IFN therapy, which may disturb cellular immune activation in some patients, may have contributed to the onset and progression of sarcoidosis.

Cardiogenic shock following recombinant alpha-2b interferon therapy for chronic hepatitis C. A case report

A 57-year-old woman with chronic hepatitis C was treated with alpha-2b interferon (IFN). Forty-five days after the initiation of IFN therapy, she developed cardiogenic shock. Acute perimyocarditis as a cause of cardiogenic shock was clinically suspected by the findings of complete atrioventricular block, regional wall motion abnormality and pericardial effusion. Since IFN therapy may induce cardiogenic shock in some patients, it is important to carefully monitor patients under treatment with IFN for abnormal cardiac signs.

[Preoperative plasmapheresis for lung cancer with multiple myeloma]

A 66-old-male admitted to our hospital was diagnosed multiple myeloma (IgA kappa type, Durie & Salmon stage IIIA) and squamous cell lung cancer (c-T2N0M0 stage I). The function of platelets was within a normal range (11.7 x 10(4)/mm3 and the bleeding time of two minutes), but the function of coagulation was reduced (prothrombin time, 13.1 seconds; activating prothrombin time, 45.1 seconds; and antithrombin III, 65%). The hyperviscosity syndrome was anticipated because of high IgA M protein (6,551 mg/dl). Plasmapheresis with 800 ml of fresh frozen plasma was performed before the left lower pulmonary lobectomy and R1 lymph node dissection. Then the function of coagulation was improved (prothrombin time, 12.6 seconds; activating prothrombin time, 31.3 seconds; and antithrombin III, 75%). IgA M protein was also decreased to 4,696 mg/dl. Postoperative bleeding necessitated a second thoracotomy. The cause of postoperative bleeding was the ablasion of the pleural adhesion due to tuberculous pleuritis as well as bleeding tendency of multiple myeloma. The plasmapheresis performed in this case did not fully improve the bleeding tendency. Cases of cancer complicated with multiple myeloma have been increasing and if an operation is needed, plasmapheresis should be considered. The indication and the extent of hematologic restoration to be achieved should be further investigated.

PSA assay of dried blood samples from the ear lobe on a filter paper with special reference to prostatic mass screening

To eliminate complicated procedures for taking blood samples in the field work for prostatic mass screening, we developed a method for PSA testing using blood samples taken from the ear lobe and dried on a filter paper. The stability, the diagnostic efficacy, and the cost-benefit effect of the method were confirmed in hospitalized patients, as well as in subjects from our mass screening program.

Kinetic analysis of prostatic volume in patients with stage D prostatic cancer treated with LHRH analogues in relation to prognosis

OBJECTIVE

To evaluate the clinical usefulness of the kinetic analysis of prostatic volume in the prognosis of patients with Stage D prostatic cancer treated using luteinizing hormone-releasing hormone (LHRH) analogues.

PATIENTS AND METHODS

The reduction of prostatic volume was monitored in 12 patients with Stage D prostatic cancer using transrectal ultrasonography (TRUS) after treatment with LHRH analogues. Data obtained from the kinetic analysis of prostatic volume were compared with the prognosis.

RESULTS

All the patients having a reduction time, tau (derived from the kinetic analysis of prostatic volume change with time), of less than 41 days had neither clinical progression within 15 months nor death caused by prostatic cancer during the 5-year follow-up, while the disease-specific 5-year survival rate in patients having a tau of greater than 42 days was as low as 17%. The difference in both the progression and disease-specific survival between these groups was statistically significant (P < 0.05) despite the limited number of patients. In contrast, conventional prognostic parameters showed no significant predictability for prognosis with the exception of prostatic acid phosphatase, which correlated strongly with the occurrence of progression within 15 months.

CONCLUSION

The kinetic analysis of the change of prostatic volume using TRUS shows promise in the prognosis of the patients with Stage D prostatic cancer.

Direct determination of E2020 enantiomers in plasma by liquid chromatography-mass spectrometry and column-switching techniques

High-performance liquid chromatography with column switching and mass spectrometry (MS) was applied to the on-line determination and resolution of the enantiomers of E2020 (acetylcholinesterase inhibitor) in plasma. This system employs two avidin columns and fast atom bombardment (FAB)-MS. A plasma sample was injected directly into an avidin trapping column (10 mm x 4.0 mm I.D.). The plasma protein was washed out from the trapping column immediately while E2020 was retained. After the column-switching procedure, E2020 was separated enantioselectivity in an avidin analytical column. The separated E2020 enantiomers were specifically detected by FAB-MS without interference from metabolites of E2020 and plasma constituents. The limit of quantification for each enantiomer of E2020 in plasma was 1.0 ng/ml and the intra- and inter-assay relative standard deviations for the method were less than 5.2%. The assay was validated for enantioselective pharmacokinetic studies in the dog.

Clinical significance of prostate specific antigen for early stage prostate cancer detection

The characteristics of serum prostate specific antigen (PSA) in normal Japanese men were studied in 1480 subjects examined by mass screening (MS) for prostate cancer (Pca) in Gunma Prefecture in 1992. The serum PSA concentration was correlated with patient age. The average serum PSA level increased by 0.04 ng/ml/year. The upper normal limits (95 percentiles) of age specific PSA for normal men are 1.33 ng/ml for those aged 39-49 years, 3.65 ng/ml for those aged 50-59 years, 4.06 ng/ml for those aged 60-69 years, 5.09 ng/ml for those aged 70-79 years and 5.66 ng/ml for those aged 80-89 years. Among 227 normal men examined by our MS in 1991 and 1992, the PSA velocity (PSAV) was calculated to be 0.05 ng/ml/year. Among 10 Pca patients with normal PSA levels (< 6 ng/ml) detected previously by our MS, three had an abnormal PSAV. We demonstrated the possibility that PSA density could distinguish between Pca and benign prostate hypertrophy. The significance of PSA as a Pca screening modality should be evaluated across multiple age ranges and in combination with previous PSA data and/or prostate volume estimated by sonography.

[Time-resolved-fluoroimmunoassay for the determination of prostate-specific-antigen in capillary-blood spotted on filter paper and its clinical significance in prostate cancer patients]

Prostate-specific-antigen (PSA) has recently become widely recognized as an important tumor marker for prostate cancer. For relieving the examinee from pain and saving the time in blood collection, we developed a new method, based on time-resolved fluoroimmunoassay (TR-FIA), using a dried disc paper to collect capillary-blood. The standard curve ranged from 1.0 to 300 ng/ml, the intraassay (CV% was 4.09 to 6.36 (n = 10), while the interassay CV% was 3.45 to 8.87 (n = 2, k = 7). The diluted linearity and analytical recovery (91.5 to 98.2%) seemed to be satisfactory for routine use. All the samples from 30 healthy male adults had non-detectable serum PSA less than 1.0 ng/ml. When the cut-off value was set at 3.4 ng/ml (MEAN + SD of BPH), the positive rate in prostate cancer cases was 85.7% (12/14), in BPH cases was 20.0% (2/10) and in other benign urological disease was 0.0% (0/20). The clinical sensitivity was 85.7%, the specificity 93.3% and the efficacy 90.9%, accordingly. In conclusion, the newly developed TR-FIA method using dried disc paper to collect capillary-blood was quantitatively suitable as a routine test for prostate cancer, because of its simplicity in blood collection and less invasiveness to the examinee.

Kinetic analysis of focal hypoechoic lesion in the prostate treated by castration

Dynamic changes in the focal hypoehoic lesion (FHL) in the prostate, visualized by transrectal sonography (TRS), were determined in five patients with prostatic cancer (PC) after treatment by castration. In all cases, the volume of FHL, as well as the volume of the whole prostate, decreased exponentially after castration. In four out of five cases, the volume (not including the FHL, which might suggest the volume of the normal tissues) increased slightly in the early postoperative weeks, and decreased thereafter. In the remaining one case, it decreased consecutively. According to the formula established in our previous study, the reduction time (tau) of the volume of the whole prostate and of the volume of the FHL was calculated, indicating that the tau of the FHL was remarkably shorter than that of the volume not indicating the FHL. This evidence suggested that not only the cancerous tissues but also the normal prostatic tissues might reduce in volume after castration.

Percutaneous biopsy for adrenal tumors using ultrasonically guided puncture

Percutaneous biopsy for adrenal tumors was performed on 12 patients using ultrasonically guided puncture. Of the 12 tumors, 11 were detected incidentally by ultrasonography or computed tomography. In 11 cases, cytological or pathological diagnosis was obtained without any complication. Among these, surgical operation was carried out in 4 cases, in which biopsy findings were confirmed by the examination of the surgical specimens. The other 7 cases were being followed up without surgery. The rate of correct discrimination between benign and malignant adrenal tumors by biopsy was 91% (10/11 cases) in this series. It is accordingly considered that adrenal biopsy is the choice to confirm the diagnosis of nonfunctioning adrenal tumors because of its efficacy and ease of use.

Resolution of 4-(4-chlorobenzyl)-2-(hexahydro-1-methyl-1H-azepin-4yl)-1(2H)-phthalazi none enantiomers in plasma with frit-FAB LC-MS using a conalbumin column

A new column-switching method for analysis of drug enantiomers in plasma has been developed with liquid chromatography-frit fast atom bombardment mass spectrometry in combination with a chiral resolution column, which consists of conalbumin (egg-white glycoprotein) immobilized on silica gel and can be used in the reversed-phase separation mode. This method makes it possible to inject a large volume of deproteinized plasma and obtain resolution of drug enantiomers with high sensitivity. The optimum mobile phase, including a non-volatile buffer such as phosphate buffer, for separation of drugs from a large amount of endogenous compounds can be used, because of inclusion of a trapping column with a desalting function. This method is very simple and rapid, and should be very powerful in studies requiring high-sensitivity analysis with chiral separation of drugs from biological samples such as plasma.

Clinical and experimental studies on the role of platelet-activating factor (PAF) in the pathogenesis of septic DIC

Various toxic factors induced by endotoxin (Et) are thought to be deeply involved in the pathogenesis of severe infections. In this study, particular attention was paid to the role of the platelet-activating factor (PAF) in these conditions, and clinical and experimental studies were conducted on the relationship between PAF and the changes observed in the general parameters after surgical infections. In the clinical study, changes in the PAF concentration in the blood of seven patients with disseminated intravascular coagulation (DIC), five of whom were septic and two non-septic, were monitored by gas/mas spectrometry. The mean PAF level in the septic DIC group tended to be higher than that in the non-septic DIC group. Moreover, in the septic DIC group, the relationship between the increase in the PAF level and platelet count was analyzed with the lapse of time and we surmised a negative correlation between these parameters. Experimentally, we also investigated the role of PAF in Et shock and the effect of an anti-PAF agent and protease inhibitor. The Et-induced fall in blood pressure was similarly prevented by both the anti-PAF agent and protease inhibitor. However, the decrease in the platelet count was more significantly inhibited by the anti-PAF agent than by the protease inhibitor, whereas the parameters of the blood coagulation/fibrinolysis system were more affected by the protease inhibitor than by the anti-PAF agent.

Effect of LHRH analog on the seminal vesicles evaluated by transrectal sonography

The maximum horizontal area (MHA) of the seminal vesicles was measured in 20 prostatic cancer patients by means of transrectal sonography (TRS) after LHRH analog treatment. MHA of the seminal vesicles changed in parallel to the serum testosterone (T) level and decreased by 11-62%, compared with the baseline after LHRH analog treatment for 4 months. Two different patterns were observed for the change of MHA. In 9 cases, MHA of the seminal vesicles increased transiently and then decreased gradually, while in the other 11 cases, MHA decreased continuously from the beginning with no significant increase. Thus, the direct and dynamic response of the seminal vesicles to the change of serum T level was clarified.