This paper outlines how primary aldosteronism was discovered, how the diagnostic criteria for it changed, its classification and the localization of adrenal adenoma.
Emphasis is placed on the vascular complications and glucocorticoid remedial aldosteronism (DSH).
In the study of primary aldosteronism, the diagnosis, localization and treatment of aldosterone producing adenoma (PA) are now established, but the mechanism of the development of vascular complications is not clear. Contrary to general belief, prognosis is not always favorable: there are evidences that life-threatening vascular complications occurred in some relatively young patients. Thus early detection with appropriate treatment is important.
The pathology and etiology of idiopathic aldosteronism (IHA) and DSH are still largely obscure and their classifications are tentative, in spite of energetic analyses of diverse hormones and metabolic enzymes. Some authors postulated an unknown aldosterone secretion stimulating factor or steroid hormone. Whether these diseases are primary or secondary is also controversial.
Seven cases (PA 5, IHA 1, DSH 1) are presented to give a total profile of the disease. These cases illustrate the value of clinical study, which could translate the results obtained in laboratories into the clinical benefits.

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It has been reported that the gastric cancer with serosal infiltration causes the carcinomatous peritonitis and its' prognosis is poor. However, the detail is not known and the correct estimation on its prognostic value is not established. For this reason, cases of the invasive gastric cancer (Borrmann III, IV) with the diagnosis of prositive serosal infiltration were investigated. Of these cases, 20 cases with limited lymphatic metastasis (n (-) n1 (+)) were histologically examined by obtaining additional microscopic sections to reinvestigate the serosal exposure precisely.
Two patients with the serosal exposure and 6 patients with the several points of serosal infiltration of the gastric cancer died within 5 years after the diagnosis, and these cases were associated with the peritoneal recurrences. Eighty-six percent of the cases with the single point of serosal infiltration survived more than 5 years. Histologically, the cases of gastric cancer with serosal exposure was extremely rare. However this finding was always associated with the death of the patient. The cases of the several points of serosal infiltration were also associated with the death of the patient.

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We examined the usefulness of the two qualitative tests (ED002 and microbumin test) and one quantitative test for microalbuminuria using latex turbidimetric immunoassy (LA-Alb Eiken) in 89 outpatients with diabetes mellitus. Proteinuria was seen in 20 patients (22.5%) and 15 patients (16.9%) showed urinary protein (+/-). Proteinuria was not found in 54 patients (60.7%) . Urinary albumin concentrations greater than 30mg/l, measured by radioimmunoassay (RIA), was detected in 2 (3.7%) of the patients with urinary protein (-), and 13 (86.7%)of the patients with urinary protein (+/-). Fifty four (98.2%) of 55 patients with ED002 (-) had a urinary albumin concentrations less than 30mg/l, All of the patients with ED002 (+) showed urinary albumin concentrations greater than 30mg/l, However, 75% of the patients with microalbumin test (+) showed urinary albumin concentrations less than 30mg/l, A strong correlation existed between albumin concentrations measured by LA-Alb Eiken and those measured by RIA(P<0.01). There were 9 patients (16.4%) showing urinary albumin/creatinine ratio (mg/g. Cr) greater than 27 among the patients with ED002 (-). All of the urinary creatinine concentration of these patients with high albumin/creatinine ratio were less than 60mg/dl. From these results, ED002 test seems to be more useful for screening microalbminuria in diabetics, if urinary creatinine concentrations are measured simultaneously.

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In order to evaluate the pulmonary functional characteristic of steroid dependent bron-chial asthma (DEP), we compared the lung functional parameters with steroid independent bronchial asthma (IND) and bronchial asthma with chronic pulmonary emphysema (BA+CPE) in separate age. Of the 103 cases with bronchial asthma, 24 cases (23.3%) of DEP were recognized, and 6 of them were associated with both aspirin-induced asthma and nasal polyp.
The overinf lation of lung as shown in the significant high ratio of residual volume to total lung capacity and the nonuniform distribution of inspired gas as shown in the significant high value of ΔN₂ were found in DEP of ages from 30 to 59 years. In addition to these findings the obstructive disturbance was highly significant in DEP.
Though the lung functional disturbance of the same degree as IND was found in DEP of over 60 years, the value of ΔN₂ was found to be significantly different between DEP and IND, and the nonuniform distribution of inspired gas was similarly suggested.
It is suggested that the higher collapse of the small airway due to the destroyed parenchyma of lung and the lower volume of pulmonary diffusing capacity due to the destroyed alveoli were found in the pulmonary function of BA+CPE.

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We amplified a DNA segment of the second exon of HLA-DRB genes with polymerase chain reaction (PCR) using pairs of DR or group specific primers, exon which codes for allogeneic determinants. Blotting the amplified products on nylon membrane filter, we tested their reactivity against dig-SSO probes without radioisotopes.
As a result, DR types of DR1, DR2, DR4, DR7, DR9, DRw10, and DRw53 of 136 healthy volunteers by the DNA method were almost identical with those by the serological method that used our standard typing trays. The specificities of DRw8, DRw11, DRw12, DRw13, DRw14, and DRw52 were properly typed by the genotyping method but not, either mistyped or untyped, by the serological method. The DNA typing resolved serologically unknown HLA-DR types, and furthermore defined HLA-D specificities. Thus the DNA typing was a powerful method for detecting HLA-D/DR types.

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We assessed the efficacy of CD₄/CD8 ratio of the peripheral lymphocytes as a prognostic factor in 25 severely handicapped subjects with mental retardation, who were admitted to Suzuka Byoin National Sanatorium. The patients were divided into two groups; Group A (CD₄/CD8<1, 12 patients) and Croup B (CD₄/CD8>1, 13 patients). Three-year follow-up study revealed that six patients beloging to the Group A died but all patients belonging to the Group B survived. These data suggest that the CD₄/CD8 ratio of peripheral lymphocytes might be one of the beneficial prognostic factors in severely handicapped subjects with mental retardation.

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The effects of fentanyl and its combination with midazolam on controlling the hemodynamic responses to laryngoscopy and endotracheal intubation have been studied in 24 hypertensive patients undergoing elective surgery.
Patients were allocated to group F (n=12) receiving 4μg/kg fentanyl, or group FM (n=12) receiving the same dose of fentanyl and 0.1mg/kg midazolam. Anaesthesia was induced with fentanyl (group F) or fentanyl and midazolam (group FM) followed by 3-4mg/kg thiamylal and 1mg/kg suxamethonium. Patients were intubated within 25 seconds in all cases. Heart rate, systolic, diastolic and mean arterial pressures were automatically recorded before and after induction and at 1-minute intervals from 0 to 10 minutes after intubation. Both groups prevented increases in mean values of heart rate, mean arterial pressure and rate pressure product after intubation. Mean heart rates in two groups were almost identical throughout the study, except for the significant fall in group FM before intubation. However, mean arterial pressure and rate pressure product were significantly lower in group FM than in group F from immediately after intubation to two minutes after intubation. It is concluded that the combination of fentanyl and midazolam reduces the cardiovascular responses to laryngoscopy and intubation more effectively than fentanyl alone by means of the synergism between fentanyl and midazolam.

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Sympathoadrenal responses to laryngoscopy and tracheal intubation were investigated in aged patients under midazolam-mexiletine-vecuronium anesthesia.
Anesthesia was induced with midazolam in a sleep dose followed by mexiletine, 1.5mg/kg and vecuronium, 1.0mg/kg. Heart rate and blood pressure were recorded before, 1 and 3min after tracheal intubation. Free and total catecholamine (CA) in plasma were measured in each time. Dopamine, norepinephrine and epinephrine (EN) were determined in fluorescens derivatization with diphenylethylenediamine by high performance liquid chromatography (HPLC).
Blood pressure did not change significantly after tracheal intubation. Heart rate changed significantly 1 min after tracheal intubation. Free and total CA concentrations did not increase during the study period. Free EN levels decreased significantly 1 and 3min after intubation. These results suggest the suppressive effect of the anesthetic method we appUed on the sympathoadrenal system during tracheal intubation. However, the increase in heart rate without elevation in plasma CA suggests the possible role of vasoactive peptides other than CA.

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We measured urinary organic acids precisely and sensitively by gas chromatography/mass spectrometry (GC/MS). We examined basic problems related to quantitative analysis for pyrimidine metabolites by means of stable isotope dilution method. The recovery and precision test of pyrimidine metabolites were 94.3% and 8.58%, respectively. But in regard to orotic acid, the extraction of the compound should be improved because this compound was poorly extracted by the organic solvents, its derivatives were unstable and so the quantitative values had some errors. It suggested that the values of the metabolites should be caliculated from relative peak height to stable isotope standards instead of n-heptadecanoic acid.
In this application, this method could be adapted to differential diagnosis between ornitine transcarbamylase deficiency and carbamylphosphate synthetase-I deficiency.

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We have previously reported that the quantitative analysis of pyrimidine metabolites in urine was established by this stable isotope dilution method. In this study, the urinary C₅, C₆, C₁₀-dicarboxylic acids were also measured by this method and adapted to differential diagnosis for β-oxidation defects, for example, diabetes, drug intoxication and aryl-CoA dehydrogenase deficiencies.
This method had a high sensitivity, recovery and good accuracy. Normal range of glutaric, adipic and sebacic acids, were 2.9±1-2μg/mg Crea, , 5.5±2.18μg/mg Crea., 2.6±0.8 μg/mg Crea., respectively. In acyl-CoA dehydrogenase deficiencies or drugs intoxication, adipic acid was 20 times more than any diabetes, sebacic acid was also more than 100 times. The ratios of adipic/sebacic acid could be defined whether the functions of β-oxidation were defected or not.

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An 11-year-old boy with ethosuximide treatment for epilepsy was admitted to our hospital because of pale face and subcutaneous bleeding in August, 1989. Peripheral blood analysis showed pancytopenia of WBC 2, 700/mm³, RBC 1.88×10⁶/mm³, platelet 7, 000/mm³. Bone marrow examination revealed hypocellularity. Antinuclear antibody was positive at 1:1280 with homogenous pattern and also anti-histone antibody was positive. The diagnosis of ethosuximide-induced aplastic anemia was made by clinical course and laboratory findings. In view of the above immune abnormalities, prednisolone was initially indicated orally and two courses of bolus methylprednisolone therapy followed with no hematological improvement. After two months with low dose of oral prednisolone therapy, three courses bolus methylprednislone were given. After last course of bolus methylprednisolone therapy, hematological response was obtained promptly and ANA became negative. We conclude that bolus methylprednisolone therapy is useful for ethosuximide-induced aplastic anemia.

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A 78-year-old Japanese woman visited the Kumamoto National Hospital in June 1988, because of a tumor on the left arm and multiple infiltrated circular erythematous lesions on the trunk. These erythematous lesions had appeared 3 years before and the tumor arose recently on the erythema, resembling skin lesions of mycosis fungoides. The lesion was histopathologically diagnosed as malignant lymphoma. As her serum gave a positive ATLL antibody and the proviral DNA of HTLV-1 was integrated in the tumor tissue, she was diagnosed as having ATLL. Seven months after the first visit, she died from tumor invasion, in spite of several courses of chemotherapy. ATLL should be differentiated from classical mycosis fungoides, although the clinical pictures of these diseases resembling each other.
An autopsy showed that a lot of tumors invaded the body and the skull. Although hypercalcemia in ATLL is believed to be usually caused by the humoral factor of PTHrP, which is made by the tumor cells, these tumors directly invaded the bone, resulting in hypercalcemia

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The alveolar soft-part sarcoma is a rare soft tissue tumor and it has biologically peculiar characteristics showing very low growth in spite of the sarcoma. Although cerebral metastasis is very uncommon in other sarcoma, the incidence of cerebral metastasis of this sarcoma is high because of long course of the disease. Therefore, approach to the treatment of its metastatic cerebral tumor, especially operative indication should be considered differently from that of the cancerous metastasis.
We experienced a 39-year-old female patient who developed 6 multiple cerebral metastases after 12 years from surgery of the primary lesion of the left thigh. Although the tumors were noted in the entire brain, most of them were small tumors except for the tumor in the right occipital lobe in which increase of the intracranial pressure, hemianopsia and hemiplegia was noted. Then the tumor in the occipital lobe was extirpated judging from the point of view that long-term useful life can be maintained by extirpa-tion of the tumor in the occipital lobe from its characteristics. Unfortunately this case died of cardiac metastasis after 13 months postoperatively, while she could spend her daily life without neurological deficit during its period.

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In a preliminary study, interferon therapy was carried out in patients with chronic hepatitis C including 3 chronic inactive hepatitis, 5 chronic active hepatitis and 2 liver cirrhosis. The activities of serum ALT and AST became lower than those of pretreatment values at the end of interferon therapy, although a half of which were reactivated during observation period (mean duration of 7.3 months) after interferon therapy. Complete remission was obtained in 3 patients, of which 2 were chronic inactive heatitis and 1 was chronic active hepatitis. These suggested that interferon therapy might be more effective in patients with lower grade of disease activity. Serum anti-HCV values by ELISA were not changed significantly between patients with and without response to interferon therapy. Overall, serum anti-HCV became nagative only in one patient, although serum aminotransferase activity remained high values. On the other hand. serum HCV RNA became negative in 3 responders to interferon therapy, whereas other 7 non-responders remained negative, suggesting that serum HCV RNA was more valuable as a predicting indicator of interferon therapy than serum anti-HCV by ELISA. Unlike in chronic hepatitis B, serum β 2-microglobulin did not seem to be related with interferon therapy in chronic hepatitis C, because of no relation between the response of β 2-microglobulin to interferon therapy and outcome of disease activity during and/or after interferon therapy in chronic hepatitis C.

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This time, we studied clinically 2 cases of urinary diversion by using jejunal conduit which were experienced during 15 years from 1975 to 1989. The case reports concerning jejunal conduit are very few because there is a risk of developing unbalance of the electrolyte being called as a jejunal conduit syndrome. Case 1 is a 73-year-old man, who developed bilateral hydronephrosis and renal dysfunction after total cystectomy and uretero-ureterocutaneostomy due to bladder cancer. The lithotomy was carried out because this renal dysfunction was caused by calculosis in the uretero-ureterostomic region. Because adhesion at the surroundings was remarkably noted, jejunal conduit utilizing about 30cm of the jejunum was prepared for the reconstruction of the urinary tract. Case 2 is a 61-year-old woman, who was admitted for bilateral hydronephrosis and renal dys-function after total hysterectomy due to uterine cancer and the cobalt irradiation. The jejunal conduit utilizing about 25cm of the jejunum was prepared because intestinal tube in the lower abdominal region was pale white from irradiation. The improvement of the blood gas analysis in these 2 cases was noted by administration of 2g and 4g of sodium bicarbonate a day for approx. 8 months after the discharge from the hospital.

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The anesthetic management in 6 patients undergoing intraoperative radiation therapy (TORT) is described.
In all patients undergoing abdominal operations, anesthesia was induced with midazolam and maintained with 66% N₂O and epidural mepivacaine. In our hospital the patients must be moved to and from radiation unit through an elevator and 130 meters public corridor. During transportation the lungs were ventilated with 100% oxygen using portable ventilator, and direct arterial pressure and ECG were monitored. Dopamine infusion was used for hemodynamic management. The surgical field was covered with surgical drape and sterile towels during transportation. During TORT, anesthesia was maintained by another anesthesia machine, while ECG, direct arterial pressure and arterial oxygen saturation were monitored by remote television system. Although there is no combined operating room/radiation room at our hospital, anesthesia for TORT can be managed successfully with realtime monitoring, careful observation and using general anesthesia combined with epidural block.

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There are few cancer patients who have the opportunity to receive psychiatric consultation for mental disturbances of any kind. However, discovering that one has cancer can be an extremely stressful crisis, to the extent that some patients develop suicidal impulses.
The authors gave psychiatric consultation to two breast cancer patients with suicidal impulses. Both patients had severe depression and restlessness. One of the patients comitted suicide in spite of consultation, but the other patient was admitted to the psychiatric department of a general hospital for medical care and custody with the purpose of patient management from the view point of ‘medical psychiatry’ and the crisis was avoided.
When psychological reaction such as severe grief and depression are observed in cancer patients, crisis intervention such as therapeutic counselling should be started at an early stage.

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