Autologous blood transfusion is an endorsed blood conservation strategy that has become widely practiced in elective surgical procedures. Wereview ten years' experience in this arena, along with emerging strategies designed to continue to minimize allogeneic blood exposure but reduce the costs associated with autologous blood procurement. Weconclude that point-of-care autologous blood procurement (acute normovolemic hemodilution and intraoperative autologous blood salvage) can replace the predonation of autologous blood in surgical patients when transfusion medicine specialists, anesthesiologists, and surgeons develop a prospective, comprehensive approach to blood conservation.
(Internal Medicine 37: 238-245, 1998)

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Thyroid functions were analyzed before, during and after interferon (IFN) therapy in patients with chronic hepatitis C. According to the results of routine thyroid function tests and measurements of the levels of anti-thyroid autoantibody prior to the therapy, patients were divided into 2 groups; Group A (19 patients) had at least one abnormal finding related to the thyroid, and Group B (40 patients) did not show any abnormality. Five patients (26% ) in Group A and 4 (10%) in Group B showed thyroid dysfunctions which were very clearly reflected by thyrotropin (TSH) measurements. Interestingly, the time of peak TSH elevation in Group A (mean±SD, 4.3±0.8 months) was significantly earlier than that in Group B (6.8±0.8). Most patients in Group B were diagnosed as having destructive thyroiditis. These findings may suggest that the pathogenesis of IFN-induced thyroid dysfunction consists not only of exacerbation of pre-existing thyroid autoimmunity but also of de novo destructive changes even in the intact thyroid before IFN therapy.
(Internal Medicine 37: 246-252, 1998)

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Interleukin-8 (IL-8) is a peptide which induces not only chemotaxis of neutrophils but also the release of reactive oxygen metabolites from the neutrophils. There are few reports which clarify the relationships between IL-8 and mucosal infiltration of neutrophils or reactive oxygen metabolites produced by neutrophils in the colonic mucosa of ulcerative colitis (UC). Biopsy specimens of colonic mucosa obtained from 26 patients with active UC and 21 patients with inactive UC were studied in order to clarify the relationships among the inflammation factors in UC. Levels of IL-8 and myeloperoxidase in organ culture media of the biopsy specimens from active UC (measured by ELISA and EIA) were significantly higher than those from inactive UC and controls. Reactive oxygen metabolites of biopsy specimens in active UC (measured by luminol-dependent chemiluminescence) were also markedly increased compared to those in inactive UC and controls. The levels of IL-8 were closely correlated to luminol-dependent chemiluminescence or myeloperoxidase levels. However, the levels of IL-8 and myeloperoxidase did not correlate with the grades of activity on colonoendoscopic findings. These findings suggest that IL-8 may play a role in the pathophysiology of UC but it does not define the endoscopic activity grades of UC.
(Internal Medicine 37: 253-258, 1998)

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We examined the usefulness of color-coded Doppler echography for evaluating hemodynamics in patients with subclavian steal syndrome. Eighteen patients with subclavian steal syndrome, aged 54 to 77 years, were investigated. The diagnosis was confirmed by conventional angiography and pulsed-wave Doppler sonography. Using color-coded Doppler echography, the common, internal and external carotid and vertebral arteries and the subclavian artery on the affected side were visualized. In all patients, color-coded images of the antegrade common carotid arterial flow and the retrograde vertebral arterial flow on the affected side were obtained. Rapid flow through stenotic lesions and reflux from vertebral to subclavian arteries at the vertebral arterial ostia were observed. Color-coded Doppler echography is superior to duplex echography without the colorcoded mode, because the flow through the affected vertebral and subclavian arteries can be easily traced in detail and the images are persuasive. This method is beneficial for diagnosing subclavian steal syndrome.
(Internal Medicine 37: 259-264, 1998)

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It has been shown that an adenine (A) to guanine (G) transition at position 3243 of the mitochondrial transfer RNA(tRNA)^leu(UUR) gene is associated with a subgroup of diabetes mellitus. Therefore, we screened for this transition in 86 patients with non-insulin-dependent diabetes mellitus (NIDDM) in which two or three generations were affected with diabetes, in 14 patients with insulin-dependent diabetes mellitus, and in 9 families with diabetes mellitus and/or associated disorders suggesting mitochondrial gene abnormalities. We failed to identify the mutation in 100 diabetic patients, 86 NIDDM and 14 insulin-dependent diabetes mellitus (IDDM). Out of the latter 9 families, we identified an A to G transition in 14 individuals in 5 families. Diabetes mellitus was shown to be maternally inherited in one family. In 9 of 14 patients with the mutation, insulin was required to treat diabetes mellitus, indicating impaired insulin secretion. A hyperglycemic clamp test performed in one subject revealed significant impairment of insulin secretion, whereas euglycemic clamp test showed normal insulin sensitivity in this patient. The heteroplasmy of the mutant mitochondrial DNA (mtDNA) in leukocytes does not appear to correlate with the severity of diabetes in terms of the insulin therapy required. Body mass index of the affected individuals was less than 23.3. In one family, in addition to diabetes mellitus and hearing loss, hypoparathyroidism was associated with the mutation, suggesting that hypoparathyroidism is caused by the impaired processing and/or secretion of proparathyroid hormone due to the mutation. In addition, the affected subjects presented with proteinuria at the time of diagnosis of diabetes mellitus which appeared not to be related with diabetic nephropathy.
(Internal Medicine 37: 265-272, 1998)

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We evaluated the influence of the levels of glycosylated hemoglobin (HbA1C) and fasting plasma glucose on the variation in low density lipoprotein (LDL) peak particle size in 210 subjects who were undergoing an annual check-up. Univariate analysis showed that LDL particle size was significantly and positively correlated with high density lipoprotein (HDL) cholesterol levels, and was inversely correlated with the levels of total plasma cholesterol, triglycerides, fasting glucose, fasting insulin, HbA_1C, and body mass index (BMI). Stepwise regression analysis selected four independent contributing variables that could affect LDL particle size; triglyceride levels, HDL cholesterol levels, LDL cholesterol levels, and HbA_1C levels. Similar regression analysis performed for men and for normotensive subjects showedthat HbA_1C levels also independently influenced LDL particle size. The results indicate that HbA_1C levels have a significant effect on LDL particle size. This suggests that small LDL particles would be present in subjects with non-insulin-dependent diabetes mellitus regardless of plasma lipid concentrations.
(Internal Medicine 37: 273-279, 1998)

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We evaluated arterial and mixed venous oxygen desaturation during symptom-limited exercise in patients with chronic pulmonary disease. Patients were divided into five groups according to disease: [chronic pulmonary emphysema (CPE), chronic bronchitis (CB), pulmonary tuberculosis sequalae (TB-seq), fibrosing lung disease (FLD), and pulmonary vascular disease (PVD)]. There were no significant difference in the values of arterial (PaO₂) and mixed venous (P ?? O₂) oxygen tension before and at the end of exercise among the five groups, whereas absolute decreases in P ?? O₂ were significantly larger in PVD and FLD. The changes in P ?? O₂ were similar to the changes in the coefficient of oxygen delivery (COD)which is equal to oxygen transport divided by oxygen consumption. These results suggest that the relative decrease in oxygen transport during exercise due to the high ratio of oxygen extraction by tissues is an important factor to determine decreases in P ?? O₂ in pulmonary hypertensive disease and fibrosing lung disease.
(Internal Medicine 37: 280-285, 1998)

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Hickman catheters are useful for vascular access after bone marrow transportation because they can handle large volume and allow for easy transfusions and blood drawing through wide double lumens making it easier to case for patients under sterile conditions in a clean room. However, the safety of Hickman catheters as compared to Silastic catheters in marrow transplants has never been discussed. We therefore retrospectively reviewed the complications of two catheters in 71 allogeneic bone marrow transplant recipients between September 1986 and August 1994. The complication and infection rates of Hickman catheters were 0.21 and 0.09 per 100 device-life days, and rate of temperature >38° during leukocytopenia (<1, 000 white blood cells) was 0.18. These rates were not different from those of Silastic catheters suggesting that Hickman catheters are safe and acceptable in marrow transplantation. The benefits and drawbacks of Hickman catheters revalent to catheter choice were also discussed.
(Internal Medicine 37: 286-291, 1998)

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We report a rare case of multiple pulmonary metastases with cavitation from gallbladder cancer. A 77-year-old woman was admitted to our hospital complaining of productive cough and exertional dyspnea. Chest X-ray film showed multiple nodular shadows with some cavitation. Computed tomography showed multiple cavities, up to 2 cm in diameter, as well as nodules, in bilateral lung fields. Under a survey of primary focus, the ultrasonographic test of the abdomen revealed a hypoechoic mass in the hepatic hilum. The patient died of respiratory failure. Autopsy findings revealed that that multiple lung tumors had metastasized from papillary adenocarcinoma of the gallbladder and that cavitation of the lung was formed by bronchioloectasis.
(Internal Medicine 37: 292-294, 1998)

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We describe a 42-year-old man with von Hippel-Lindau disease and islet cell tumor of the pancreas. He had retinal and cerebellar hemangioblastomas. His sister had pheochromocytoma. A pancreatic tumor was detected by ultrasonography at his periodical medical checkup. Contrast enhanced computed tomography and abdominal angiography revealed a hypervascular tumor in the pancreatic head. Histological examination of the resected tumor revealed characteristics of islet cell tumor of the pancreas, which was positive for chromogranin-A, S-100 protein, and pancreatic polypeptide, but was negative for insulin, gastrin, glucagon, somatostatin, vasoactive intestinal peptide, serotonin, and adrenocorticotropic hormone.
(Internal Medicine 37: 295-299, 1998)

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The cause and course of isolated thyrotropin (TSH) deficiency are not well understood. We report a 65-year-old man with a transient, probable isolated TSH deficiency associated with cavernous sinus syndrome secondary to tympanitis. On his admission, serum TSH and triiodothyronine levels were very low. No TSH response to thyrotropin releasing hormone (TRH) was observed. However, 6 years later, TSH response to TRH was restored. The present case showed that inflammation in the cavernous sinus could be one of the causes of TSH deficiency. Further, it demonstrated that TSH deficiency is not always permanent and the reevaluation of pituitary function is necessary.
(Internal Medicine 37: 300-303, 1998)

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A 77-year-old woman was admitted to our hospital because of a mass lesion in the left lung. The tumor was pulmonary carcinoid associated with sarcoid reactions in the regional lymph nodes and scattered in the resected lung parenchyma. Pulmonary carcinoid with sarcoid reactions is extremely rare. This appears to be the first case report in which tumor-related sarcoid reactions were studded within the tumor-existing lung parenchyma and confirmed not to be within the uninvolved right lung.
(Internal Medicine 37: 304-306, 1998)

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KL-6, a serum marker for interstitial pneumonitis, was evaluated in patients with Pneumocystis carinii pneumonia (PCP). Patient 1 was a 56-year-old woman with rheumatoid arthritis treated with immunosuppressive drugs and corticosteroids. Patient 2 was a 59-year-old man with a glioblastoma who received anti-cancer drugs and corticosteroids. In both patients, serum KL-6 showed an abnormally high level due to the complication of PCP, and it decreased following successful treatment. These results indicate that PCP is one of the diseases in which serum KL-6 increases.
(Internal Medicine 37: 307-310, 1998)

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We describe here two cases of diffuse large cell type non-Hodgkin's lymphoma affecting the bilateral breasts. The contralateral tumor in one case appeared 17 months after the first mastectomy, whereas the bilateral tumors occurred concurrently in the other patient who was pregnant and showed widespread dissemination at initial presentation. Lymphomacells from both cases showed the mature B-cell immunophenotype and had rearrangements of the BCL6 gene. Both patients developed progressive disease despite chemo-radiotherapy and died of leukemic manifestations. There were no apparent pathological features of lyniphomas of mucosa-associated lymphoid tissue origin.
(Internal Medicine 37: 311-315, 1998)

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Pyoderma gangrenosum (PG) is a neutrophilic dermatosis, which may be associated with systemic conditions such as hematologic disorders. We present a patient who had been diagnosed as having myelodysplastic syndrome associated with PG at onset, in whom a febrile ulcerative skin lesion developed following cytosine arabinoside, aclarubicin and granulocyte colony-stimulating factor (G-CSF) combination chemotherapy in the course of the disease. Skin biopsy revealed dense neutrophilic infiltrate in the dermis with central epidermal ulceration, consistent with the diagnosis of PG. Oral prednisolone was effective for the skin lesion. In this case, G-CSF application may participate in the recurrence of PG.
(Internal Medicine 37: 316-319, 1998)

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We present a case report of a 55-year-old male patient with hypoplastic myelodysplastic syndrome (MDS, refractory anemia) in which a good response to recombinant human erythropoietin (rhEPO) has been maintained for more than 60 months. There is with no evidence of progression to high risk MDS or acute leukemia, although he was predicted to be a low-responder to rhEPO therapy because of very high serum EPO levels (5, 260 mU/ml), a history of multiple transfusions, chromosomal abnormalities (47, XY, +8) and severe thrombocytopenia. Since he received rhEPO with no adverse effects, it may be valuable to try rhEPO treatment at least one time for low-risk MDS patients, depending on red cell transfusion requirements.
(Internal Medicine 37: 320-323, 1998)

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An 18-year old male was admitted to our hospital complaining of back pain. His chest computed tomography showed a tumor in the posterior mediastinum. Open biopsy was performed, and a diagnosis of peripheral neuroepithelioma was made. No genetic abnormalities were detected in the DNA obtained from the biopsy specimen. He received chemotherapy and radiation several times. These treatment regimens were effective, but he relapsed 14 months later and died of respiratory failure due to tumor growth. Autopsy examination revealed a large tumor which occupied almost the entire right thoracic cavity, but there was no evidence of metastasis to other organs. Chromosomal translocation t(14;17) (q24;p12.2) and point mutation of exon 5 of the p53 gene were detected.
(Internal Medicine 37: 324-329, 1998)

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A 55-year-old man had rhabdomyolysis and myocardial damage induced by palytoxin. Weakness and myalgia of four extremities occurred five hours after eating a fish. Rhabdomyolysis developed and the serum creatine phosphokinase (CK) was elevated to 40, 000 IU/ι on the 3rd day. Gastric lavage with activated charcoal and forced mannitol-alkaline diuresis therapy were performed. The patient recovered with no complication such as renal failure. In this case, palytoxin was suggested to induce myocardial damage which was demonstrated by an elevation of the myosin light chain level and a change in electrocardiogram.
(Internal Medicine 37: 330-333, 1998)

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A persistent trigeminal artery (PTA) represents an embryonic vascular anastomosis connecting the carotid and basilar arterial systems. Little is known about its protective role in cases of basilar artery occlusion. We followed up a 63-year-old man who had suffered a brain stem infarction due to basilar artery stenosis and was found to have a PTA. Although a second brain stem infarction due to basilar artery occlusion developed, the circulation to the brain stem was well maintained via collateral flow from the PTA, and the patient demonstrated good recovery. A PTA may function as an anastomosis between the carotid and basilar systems, thus preventing a more serious infarction.
(Internal Medicine 37: 334-337, 1998)

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Diffuse panbronchiolitis (DPB) is a distinct clinicopathologic entity, which is characterized by chronic recurrent sinopulmonary infection and inflammation. We describe 3 patients with rheumatoid arthritis (RA) associated with DPB and consider that DPB is one of the bronchopulmonary manifestations associated with RA.
(Internal Medicine 37: 338-341, 1998)

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Non-bacterial thrombotic endocarditis (NBTE) commonly occurs in patients with wasting disease (e.g. malignancy) or with valves damaged following trauma due to intra-cardiac foreign body, scarring or marked turbulence. Although disseminated intravascular coagulation (DIC) is well documented following viperine bite and the underlying mechanism of NBTE is thought to be DIC, there is no report of NBTE in humans following snake bite. We report a young male who following viperine bite developed local swelling, superficial gangrene of tissues at the site of bite, and oliguria and died following multiple cerebral infarcts and acute renal failure. The post-mortem examination showed NBTE of the aortic valve, multiple embolic infarcts of brain, spleen and kidneys, acute tubular necrosis and features of DIC in the brain in the form of fibrin thrombi in the capillaries, perivascular hemorrhages and necrosis.
(Internal Medicine 37: 342-344, 1998)

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