We demonstrate that in head injuries the degree of cerebral endothelial activation or injury depends on the type of brain injury and the patients age, and that in severe head injuries measuring the serum levels of thrombomodulin (TM) and von Willebrand factor (vWF) is useful in evaluating cerebral endothelial injury and activation. The values of vWF in the cases of focal brain injury were significantly higher than in the cases of diffuse axonal injury. The serum levels of TM in focal brain injuries were higher than in diffuse axonal injuries, but the differences were not statistically significant. In patients with delayed traumatic intracerebral hematoma (DTICH), vWF levels were much higher than in patients without DTICH. The values of TM and vWF in elderly patients were significantly higher than in younger patients. These findings indicate that: 1) the degree of endothelial activation in focal brain injury is significantly higher than in diffuse brain injury; 2) the degree of cerebral endothelial injury in patients with DTICH is much higher than in those without DTICH; and 3) the degree of cerebral endothelial activation and injury in elderly head injury patients is significantly higher than in younger patients.

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Background: Colestimide has been reported to lower blood glucose levels in patients with type 2 diabetes complicated by hypercholesterolemia.
Aim: To examine the mechanism by which colestimide decreases plasma glucose levels in the above patients.
Methods: A total of 16 inpatients with type 2 diabetes complicated by hypercholesterolemia received colestimide for 1 week after their plasma glucose levels stabilized. We measured plasma glucose, serum immunoreactive insulin (IRI), serum lipid, plasma glucagon, and plasma glucagon-like peptide-1 (GLP-1) levels. These variables at baseline and 1 week of colestimide administration were compared.
Results: Preprandial plasma glucose levels (baseline: 132 ± 33 mg/dL vs. completion: 118 ± 43 mg/dL, P=0.073) tended to decrease after colestimide administration, while 1-hr postprandial plasma glucose levels (baseline: 208 ± 49 mg/dL vs. completion: 166 ± 30 mg/dL, P<0.001) and 2-hr postprandial plasma glucose levels (baseline: 209 ± 56 mg/dL vs. completion: 178 ± 39 mg/dL, P=0.015) decreased significantly at 1 week of colestimide administration. The 2-hr postprandial plasma GLP-1 level was significantly (P=0.015) higher at 1 week of colestimide administration as compared with the baseline level, while there were no significant changes in preprandial and 1-hr postprandial plasma GLP-1 levels.
Conclusions: The GLP-1-increasing activity of colestimide may explain, at least in part, the mechanism of its blood glucose-lowering activity in patients with type 2 diabetes complicated by hypercholesterolemia.

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The status of angiogenic switching was examined in alveolar capillaries of primary lung adenocarcinoma (ADC) from 10 patients and primary squamous cell carcinoma (SCC) from 11 patients, using immunostaining for CD31, thrombomodulin, von Willebrand factor (vWF), collagen types IV and VII, and α-smooth muscle actin (α-SMA). We applied the TdT-mediated dUTP nick-end labeling assay and the reverse transcription-polymerase chain reaction for vascular endothelial growth factor (VEGF) and its receptors (VEGFRs). In bronchioloalveolar and papillary subtypes of ADC, the neoplastic cells, replacing the normal alveolar epithelial cells, had spread over alveolar walls and adhered firmly to alveolar interstitium as shown by the development of type IV collagen. Neoplastic cells of SCC were characterized by local proliferation in alveolar sacs without firm attachment to alveolar walls. Tumor lesions of SCC had often developed necrotic foci of various size. In ADC and SCC, alveolar capillary endothelial cells newly obtained reactivity to vWF. Such segments of endothelial cells lost surface thrombomodulin expression. CD31 was consistently expressed in normal and ADC tissues, but each endothelial cell marker was often attenuated or even lost in SCC, suggesting degeneration or necrosis of the alveolar capillaries. The capillary pericytes and interstitial fibroblasts were often hypertrophic and developed α-SMA in the cytoplasm in ADC, but they became atrophic in SCC. In ADC, apoptosis occurred in cells of alveolar capillaries more frequently in the peripheral zone than in the deeper zone of the tumor, whereas the frequency was not consistent in SCC. In microdissected alveolar wall tissues, mRNA expression patterns of VEGF isoforms and VEGFRs were similar in both ADC and SCC. In ADC, de novo angiogenic switching took place in cytoplasm as a unit of cells segments in alveolar capillary endothelium. Suppression of angiogenic switching in SCC implies that factors other than VEGF-VEGFR interaction, such as physical contact and compression of tumor cells, might play a critical role in alveolar capillaries.

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Background: Malignant ascites may produce a cluster of symptoms that include abdominal distention, early satiety, respiratory embarrassment, impaired mobility, and lethargy, and relief of these symptoms is often difficult to achieve. We report on the placement of peritoneovenous shunts (PVSs) in a group of patients with malignant ascites, with particular reference to the effectiveness and complications of the procedure.
Patients and Method: PVSs were inserted in 9 patients with malignant ascites after obtaining their informed consent. The patients were 6 men and 3 women with a median age of 59 years. All had previously been treated with vigorous diuretic therapy or repeated paracentesis or both. Shunt insertion was carried out via a percutaneous approach under local anesthesia.
Results: The procedure was well tolerated by all patients. The abdominal distention resolved in all patients, and urine volume increased significantly, demonstrating that the PVS did not affect renal function. The platelet count was reduced, and prothrombin time was prolonged. Two patients had the complication of shunt occlusion, and both patients underwent shunt replacement. There were no lethal complications. Median survival time after PVS placement was 21 days (range, 10∼90 days), and the shunt was functioning at the time of death with good control of ascites in all patients.
Conclusions: Malignant ascites produces troublesome symptoms for patients, who may live for some time. Placement of a PVS is a well-tolerated, relatively minor surgical procedure that can provide excellent control of ascites in most patients selected. The selection of optimal patients requires further study.

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A 77-year-old woman was urgently admitted for the treatment of diabetic ketoacidosis and a duodenal ulcer hemorrhage in March 1999. She had a history of diabetes and angina pectoris. After admission, she received oral calcium polystyrene sulfonate and sorbitol to treat hyperkalemia. Nine days later, severe abdominal pain developed. A colonoscopic examination revealed a sigmoid colonic ulcer and stenosis; the patient was treated conservatively. At a 1-year follow-up examination, the colonic stenosis was found have worsened; pneumaturia developed in January 2001. The patient was found to have a sigmoidovesical fistula and underwent sigmoidectomy and partial resection of the ileum and urinary bladder. The histological findings were a benign colonic ulcer with the infiltration of inflammatory cells, mainly lymphocytes. Rhomboidal, dark violet Kayexalate^® crystals were observed on microscope examination in the submucosa in both the first and second colonic biopsy specimens. We concluded that the colonic ulcer and the sigmoidovesical fistula had been caused by the administration of calcium polystyrene sulfonate and sorbitol. Reports of colonic perforation as a result of the administration of calcium polystyrene sulfonate and sorbitol are rare. Here, we report the successful treatment of a colonic ulcer that had penetrated the urinary bladder.

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Interdigital pilonidal sinus is a rare occupational disease related to work with short hair. Hair dresser's disease is the interdigital pilonidal sinus encountered in male barbers. A case of pilonidal sinus in the interdigital web is reported. We performed surgical excision and primary closure. There were neither complications nor recurrence in the third month after excision. We propose that surgical excision is inevitable and that any primary treatment can improve the patients' postoperative comfort. Thus, primary closure or closure with a flap, instead of secondary healing, should always be the first choice of treatment for a defect due to excision of an interdigital pilonidal sinus.

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Background: Perforator flaps are thin free-tissue transfers consisting of skin and subcutaneous tissue which have the advantage of decreasing donor site morbidity. We have reconstructed postburn scar contractures using "propeller flaps" of the remaining healthy skin around the recipient sites. In this paper, we report on two cases and describe the concept of using "perforator flaps" and "propeller flaps" together as what are called "perforator pedicled propeller (PPP) flaps."
Cases: Patient 1 was an 18-year-old man with a sacral pressure ulcer. The soft tissue defect was reconstructed with a rotated superior gluteal artery PPP flap. Patient 2 was a 53-year-old woman who presented with an open fracture of the right elbow. The skin defect over the fracture was covered with a rotated deep brachial artery PPP flap raised on the lateral upper arm.
Conclusion: The PPP flaps are useful for burn reconstruction and repairing various types of wound. Moreover, microsurgery is unnecessary. The PPP flap may be classified into two types: the central axis type and the acentric axis type. The central axis PPP flap is significant when used as a 90-degree-rotation island flap, and the acentric axis PPP flap is significant when used as a 180-degree-rotation island flap. Both types are easy to harvest and useful for repairing various kinds of wound.

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Hemophilia A is a sex-linked hereditary disease, and the total number of patients with this condition is small. It is quite rare for general surgeons to encounter a patient with hemophilia A. Moreover, it is extremely rare for surgeons to encounter adult patients with undiagnosed hemophilia. We describe a patient in whom intra-abdominal bleeding persisted after open abdominal surgery, leading to a diagnosis of hemophilia A. The patient was a 55-year-old man with carcinoma of the papilla of Vater who underwent pancreatoduodenectomy, during and after which hemostatic difficulties were encountered. Our initial diagnosis was complex coagulopathy; however, transfusion of a large volume of fresh frozen plasma did not improve the activated partial thromboplastin time, which led us to suspect hemophilia. Thorough personal and family histories and determination of coagulation factor VIII showed that the patient belonged to a family with hemophilia A, which had not been recognized by his parents, leading to a diagnosis of mild hemophilia A based on decreased coagulation factor VIII levels. After diagnosis, intermittent administration of a coagulation factor VIII product controlled the bleeding. The patient is currently being treated on an outpatient basis and remains free of cancer recurrence.

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We report on a patient with rectal malignant melanoma. The patient was a 40-year-old man who complained of anal bleeding. His grandmother had died of pancreatic cancer and his mother had been operated for rectal cancer. Physical examination revealed a hard mass at the 12 oclock position, 2 cm from the anal verge. A colonoscopic examination revealed an irregular surface mass, approximately 4.0 cm in size, located on the anterior wall of the lower rectum. A biopsy of the rectal tumor showed the proliferation of epithelioid cells with pleomorphic features. Immunohistochemical analysis was performed. S-100 protein, CD-56, and KIT expression were positive, but HMB-45 expression was negative. Abdominopelvic computed tomography (CT) revealed multiple liver and lymph node metastases. With the diagnosis of neuroendocrine carcinoma of the rectum, abdominoperineal resection was performed. After the operation, the serum lactate dehydrogenase level had rapidly increased. An abdominal CT showed progressive liver metastases. Thirteen days after the surgery, abdominal angiography was performed, which showed multiple hypervascular tumor stains in the liver. The reservoir was implanted transcutaneously with the aid of angiography and the catheter was fixed to the proper hepatic artery. Neoadjuvant chemotherapy using cisplatin and irinotecan via the subcutaneous reservoir port was performed and a partial response was obtained. However, the final pathological diagnosis of the surgically resected specimen was malignant amelanotic melanoma of the rectum. Immunohistochemical expression differed between rectal biopsy specimens and surgically resected specimens. HMB-45 expression was positive and KIT expression was negative in the resected specimen. As preoperative pathological diagnosis showed rare rectal tumor, we measured the chemosensitivity of the rectal tumor using the collagen gel droplet-embedded culture drug sensitivity test (CD-DST) to determine the most appropriate chemotherapy regimen for the patient. However, there were no anticancer drugs tested by CD-DST for malignant melanoma. With informed consent, the patient received two cycles of immunochemotherapy consisting of dacabazine, nimustine hydrochloride, vincristine sulfate, and interferon -beta. Although the patient was treated with immunochemotherapy for metastatic liver tumor, he died because of progression of metastases.

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