Extrarenal Wilms tumor in children with unfavorable histology: a case report

Extrarenal Wilms tumor is extremely rare, and only 25 cases in children have been reported to date in Japan. A 2-year-old girl presented with a large left lower quadrant abdominal mass. Abdominal computed tomography revealed a retroperitoneal tumor located below the left kidney. At laparotomy, the tumor was encapsulated without evidence of metastasis to other abdominal organs. Pathologic diagnosis of the tumor was extrarenal Wilms tumor with diffuse anaplasia. After complete tumor resection, chemotherapy was administered according to the treatment protocol (Regimen I) of the Japan Wilms Tumor Study Group. Cyclophosphamide and etoposide were administered in combination with vincristine and doxorubicin. Two years after treatment, the patient has had no evidence of recurrence.

Feasibility and efficiency of indirect lifestyle interventions in offspring of type 2 diabetic patients

INTRODUCTION

Individuals genetically predisposed to type 2 diabetes represent an important target for preventive strategies. Genetic screening, based on information about individual genetic variants, will be possible technically, but translational research in this field is still insufficient. Family history thus represents a useful tool for detecting genetically high-risk populations in this post-genomic era.

OBJECTIVES

The purpose of this pilot study was to investigate the feasibility and efficiency of indirect lifestyle interventions in offspring of type 2 diabetic patients.

METHODS

Offspring were recruited from 74 diabetic (Group 1) and 39 non-diabetic (Group 2, control group) patients. A lifestyle intervention was conducted by mail, a total of 3 times, every 3 months. Lifestyle related to diet and physical activity was assessed using a self-administered questionnaire.

RESULTS

Ten offspring of type 2 diabetic and 6 of non-diabetic patients participated in this study. Total energy intake decreased after 3 interventions in both of the groups (Group 1: 305 ± 228.8 kcal/day, p = 0.004; Group 2: 82 ± 65.6 kcal/day, p = 0.04); however, the effect of intervention was significantly greater in Group 1 compared to Group 2 (p = 0.021). Physical activity and other physical outcomes were stable in normal levels during the study period in both of the groups.

CONCLUSIONS

The intervention program helped to reduce total energy intake in offspring of type 2 diabetic patients more than in the control group, but the acceptance rate of the intervention program was disappointingly low. Further consideration is required to access and motivate offspring to develop precautionary lifestyle principles.

Recurrent acute pancreatitis caused by a gastric duplication cyst communicating with an aberrant pancreatic duct

A 38-year-old woman was hospitalized in August 2007. This visit was her fifth episode of acute pancreatitis. Computed tomography revealed a cystic structure located near the antrum. Communication between this structure and the pancreatic duct was revealed by endoscopic retrograde cholangiopancreatography. Ultrasonography revealed that the cyst wall had a layered structure. Thus, we regarded it as a gastric duplication cyst. We thought that the gastric duplication cyst communicating with an aberrant pancreatic duct was responsible for the recurrent acute pancreatitis. In August 2008, a cyst gastrostomy was performed between the gastric duplication cyst and the stomach. No recurrence of acute pancreatitis has since occurred.

Correlation of dystrophin-glycoprotein complex and focal adhesion complex with myosin heavy chain isoforms in rat skeletal muscle

AIM

The dystrophin-glycoprotein complex (DGC) and focal adhesion complex (FAC) are transmembrane structures in muscle fibres that link the intracellular cytoskeleton to the extracellular matrix. DGC and FAC proteins are abundant in slow-type muscles, indicating the structural reinforcement which play a pivotal role in continuous force output to maintain posture for long periods. The aim of the present study was to examine the expression of these structures across fast-type muscles containing different myosin heavy chain (MHC) isoform patterns which reflect the fatigue-resistant characteristics of skeletal muscle.

METHODS

We measured the expression of dystrophin and beta1 integrin (representative proteins of DGC and FAC respectively) in plantaris, extensor digitorum longus, tibialis anterior, red and white portions of gastrocnemius, superficial portion of vastus lateralis and diaphragm, in comparison with soleus (SOL) and cardiac muscle from rats.

RESULTS

The expression of dystrophin and beta1 integrin correlated positively with the percentage of type I, IIa and IIx MHC isoforms and negatively with that of type IIb MHC isoform in fast-type skeletal muscles, and their expression was abundant in SOL and cardiac muscle.

CONCLUSION

Our results support the idea that DGC and FAC are among the factors that explain the fatigue-resistant property not only of slow-type but also of fast-type skeletal muscles.

[Treatment of a massive tracheal bleeding with percutaneous cardiopulmonary support]

A 69-year-old woman was admitted to our hospital with heart failure. Echocardiography demonstrated severe mitral valve regurgitation due to chordae rupture of the posterior mitral leaflet. Although she was intubated and ventilation was initiated, her condition did not improve. On the 17th hospital day, she was scheduled to undergo mitral valve plasty. After induction of anesthesia, massive bleeding occurred from the tracheal granuloma (diameter, 3 cm), which had developed at the tip of the tracheal tube, and the airway was obstructed. Emergency percutaneous cardiopulmonary support (PCPS) was then introduced. Thereafter, endoscopic hemostasis was performed, followed by the excision of the granulation tissue using a gastric fiberscope. After excising the tissue, the patient could be ventilated; therefore, she was weaned from PCPS. The maximum PCPS flow was 4.0 l/min, and it was conducted for a 210-minutes duration. Her respiratory condition improved, and she was weaned from the ventilator 3 days after surgery. Mitral valve plasty was performed 55 days after the first operation, and she was discharged from the hospital in good health.

Tranilast inhibits glucose-induced insulin secretion from pancreatic beta-cells

Tranilast, N-(3,4-demethoxycinnamoyl)-anthranilic acid, is an anti-allergic agent identified as an inhibitor of mast cell degranulation. Recently, tranilast was shown to decrease albuminuria in a rat model of diabetic nephropathy and to ameliorate vascular hypertrophy in diabetic rats, suggesting that it may be clinically useful in the treatment of diabetic complications. However, the effects of tranilast on glucose tolerance have not been elucidated. Thus, the aim of this study is to investigate the effect of tranilast on insulin secretion in pancreatic beta-cells. Treatment with tranilast significantly suppressed insulin secretion in INS-1E cells and rat islets induced by 16.7 mmol/l glucose. Furthermore, tranilast inhibited tolbutamide-induced insulin secretion. Treatment with tranilast increased (86)Rb (+) efflux from COS-1 cells in which pancreatic beta-cell-type ATP-sensitive K (+) (K (ATP)) channels were reconstructed and suppressed the cytosolic ATP/ADP ratio in INS-1E cells. Interestingly, treatment with tranilast enhanced glucose uptake in INS-1E cells. In the present study, we demonstrated that tranilast inhibited glucose- and tolbutamide-induced insulin secretion through the activation of K (ATP) channels in pancreatic beta-cells.

[Unruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract stenosis; report of a case]

A 51-year-old female was referred to our hospital for heart murmur and was diagnosed with right ventricular outflow stenosis by echocardiography. Six years later, follow-up echocardiogram revealed that the stenosis was caused by an aneurysm of the sinus of Valsalva (2 cm in diameter) originated from the right coronary sinus. Resection and patch closure of the aneurysm were carried out under complete cardiopulmonary bypass. The aneurysm was not associated with ventricular septal defect and was categorized as Sakakibara-Konno type I. Postoperative state was uneventful. Systolic murmur disappeared and pressure difference in the right ventricular outflow was normalized.

Investigation of formaldehyde pollution of tap water and rain water using a novel visual colorimetry

The pollution of tap water and rain water with formaldehyde in Toyama Pref., Japan was investigated by means of a simple, rapid and cost-effective visual colorimetry developed by us. The levels of formaldehyde in three tap waters from different sources of dams on mountainside and a well-water pumped in urban area in Toyama Pref. were lower than 0.01 mg L(-1) that was the detection limit of the colorimetry. On the other hand, rain waters were seriously polluted with formaldehyde. Rain waters were sampled from three different sites (urban area, top of hill and industrial area) in Toyama Pref. from autumn to winter in 2006. The levels of formaldehyde in the rain waters ranged from 0.07 to 0.30 mg L(-1). The analytical results by the visual colorimetry were in good agreement with those obtained by GC-MS method. It was confirmed that the colorimetry is excellent for practical use for the determination of formaldehyde. It must be concerned about the pollution of rainwater with formaldehyde, when rain water is applied for tap water and miscellaneous purpose.

The influence of rejection on graft motility after intestinal transplantation in swine: the possibility of using this method for the real-time monitoring of acute cellular rejection

BACKGROUND

We have previously reported that rejected allografts show dysmotility, which can be detected by real-time monitoring in swine. We examined the correlation between the motility and the mucosal histology to detect rejection at an early stage by real-time monitoring.

METHODS

Intestinal transplantation was performed orthotopically using FK506. The distal segment of the allograft measuring about 20 cm was isolated and exteriorized as "Thiry-Vella" stoma for biopsies. Strain-gage force transducers were attached on a graft for the real-time monitoring of graft motility. The pigs without intestinal transplantation were used as controls (C). The rejection was classified into 4 groups based on the histologic findings: nonrejection, mild rejection, moderate rejection, and severe rejection. Migrating motor complex (MMC) phase 3 was estimated by the following parameters: duration, amplitude, interval, motility index, velocity, and frequency of the propagation.

RESULTS

In the nonrejection group, all parameters were almost the same as in C group. In contrast, in the moderate rejection and severe rejection groups, most of the parameters were significantly lower than those in the C group. In the mild rejection group, the contractility of the MMC was not significantly altered, but the frequency of the propagation decreased significantly.

CONCLUSIONS

The graft motility detected by the real-time strain-gage method correlated closely to the grade of mucosal histology. This method is therefore considered to be useful for detecting rejection at an early stage by examining the frequency of MMC propagation.

Safe techniques for inserting the hickman catheter in pediatric patients

The placement of the Hickman catheter in the central veins is thought to be an effective method for providing venous access in various clinical situations in children. The catheter is usually inserted by the percutaneous approach, but in some cases various troublesome complications can occur, such as sheath introducer kinking or damage, in addition to other major ones. Therefore, some modified techniques, using vascular dilators, both to dilate the route and to avoid such complications, have been developed and investigated to obtain a smooth and safe percutaneous insertion of the Hickman catheter in children. A total of 41 Hickman catheters were inserted by the percutaneous method in 41 pediatric patients from 1996 to 2004 in our department. Sixteen catheters were inserted by means of a standard method, using the manufacturer's insertion kit, and 25 catheters were inserted by means of a modified method, namely, using various sized vascular dilators. The length of time for the procedure, the complication rate, and the changes in the serum C-reactive reaction (CRP) levels were then compared between the standard and the modified methods. Those parameters were also compared between a right-side and left-side approach using both methods, to clarify which side was better for the insertion of this catheter. The length of time for the catheter replacement procedure in the standard group was significantly longer than that in modified one. The occurrence rate for both the kinking and small damage to the sheath introducer in the standard group was higher than that in the modified one. The peak of serum CRP in the modified group was significantly lower than that in the standard one. When comparing a right-side and left-side approach, 7 catheters out of 16 were inserted by the right-side approach in the standard group, while 10 catheters out of 25 were done by the right-side approach in the modified group. The length of time for the procedure for the left-side approach was significantly shorter than that for the right-side one in both groups. No difference in technical complications was observed between the two different approaches in the modified group, while complications when using the right-side approach often occurred in the standard group. The peak of serum CRP in the left-side approach was lower than that in the right-side one in both groups. The use of the modified percutaneous method, using various sized vascular dilators and the left-side approach, was therefore found to be useful for the safe and smooth placement of the Hickman catheter in children.

Relationship Between Real-Time Monitoring of the Graft Motility and Mucosal Histology in Swine Intestinal Transplantation

We studied the correlation between the motility and the mucosal histology of the small bowel seeking to detect rejection in an early stage by real-time monitoring using a swine model. Intestinal transplantation (ITx) was performed orthotopically using FK506 immunosuppression. The distal about 20 cm segment of the allograft was exteriorized as a Thiry-Vella stoma for biopsies. Strain gauge (SG) force transducers were attached to the graft for real-time monitoring of graft motility. Pigs without ITx were used as controls (group 1). Rejection was classified into four groups by histologic findings: nonrejection (group 2), mild rejection (group 3), moderate rejection (group 4), and severe rejection (group 5). Migrating motor complex (MMC) phase III was analyzed for the following parameters: duration, amplitude, interval, motility index, velocity, and frequency of propagation. In group 2, all parameters were almost the same as those for group 1. In contrast, groups 4 and 5 showed most parameters significantly lower than those in group 1. In group 3, the contractility of the MMC was not significantly altered, but the frequency of the propagation was decreased significantly. In conclusion, graft motility detected by a real-time SG method correlated with the grade of mucosal histology. This method is useful to detect rejection at an early stage by examining the frequency of MMC propagation.

[Infectious endocarditis associated with multiple mycotic aneurysms; report of a case]

A 68-year-old man was referred to our hospital with infectious endocarditis (IE) of the mitral valve complicated by mycotic aneurysms located in the right middle cerebral artery (MCA) and the superior mesenteric artery (SMA). After coil embolization of the SMA aneurysm during angiography, surgical treatment of the MCA aneurysm was carried out. Antibiotic therapy for Enterococcus faecalis was continued throughout this period. After his IE was controlled, mitral valve repair was performed. The old vegetation on the edge of the anterior leaflet was resected and the defect was covered by transferring the posterior leaflet using the flip-over technique. Since there is no agreement about the optimum treatment of IE associated with multiple mycotic aneurysms, it is important to carefully plan the management of individual cases.

Efficacy of OK-432 local injection for the treatment of a neonatal branchial cleft cyst: a case report

We herein present a case of a neonatal cervical cyst, which was diagnosed prenatally, and markedly decreased in size and disappeared after a local injection therapy of OK-432. A 0-day-old boy had an abnormal prenatal ultrasonography scan suggestive of rt. cervical cyst, measuring about 25 mm in diameter at 29 weeks' gestation. At birth, an elastic soft mass, measuring about 30 mm in diameter, was found on the right side of his neck. Computed tomography (CT) scans showed a giant cyst, which extended from the upper level of epipharynx to the upper mediastinum, and the contents were air and fluid. At 20 days of age, ultrasonography (US)-guided needle aspiration was performed. The aspirated fluid contained no epithelial cells, but many lymphocytes and neutrophils based on a cytological analysis. After the local injection of OK-432 had been performed four times, the right neck cyst had almost completely disappeared on US scans. During the local injection therapy, we analyzed the other sample of the second aspiration fluid of the neck cyst. Several clusters of epithelial cells, columnar epithelium, squamous cells, and ciliated epithelium were thus cytologically observed. Therefore, a final diagnosis of a branchial cleft cyst was made. The local injection of OK-432 was thus found to be an effective treatment for branchial cleft cysts.

Decrease in hepatic circulation induces hepatic fibrosis in a neonatal piglet model with short bowel syndrome

BACKGROUND

Regarding the complications associated with short bowel syndrome (SBS), progressive liver failure is one of the most severe complications known to occur: Although several studies have suggested that many factors interactively influence this clinical condition we investigated the relationship between hepatic circulation and hepatic fibrosis using a neonatal piglet SBS model.

MATERIALS AND METHODS

This study used the following 4 groups of neonatal piglets: a group with an 80% resection of the small bowel (SBS group), a group with a bypass operation of the small bowel (functional SBS group), a group with only a laparotomy as a sham operation (sham group), and a no operative treatment group (control group). We measured the hepatic circulation just before and after the reconstruction of the intestine, as well as on the 7th and 14th postoperative day. In addition, both blood and hepatic tissue samples were collected to investigate them both biochemically and morphologically.

RESULTS

Regarding the biochemical liver function and the tissue blood flow of liver, there were no significant differences among all groups on any investigated days. However, on both the 7th and 14th postoperative days, the portal venous flow in the SBS group was significantly lower than that in other groups. According to a histological analysis, only hepatic samples on the 14th postoperative day showed mild hepatic fibrosis in the SBS group. Regarding the alpha-smooth muscle actin staining findings that expresses active stellate cells, numerous positive cells were found to be distributed in the perisinusoidal space on the 14th postoperative day in the SBS group.

CONCLUSION

Based on our data, a decrease in the hepatic circulation, especially in the portal venous flow, after a massive resection of the intestine may cause progressive liver dysfunction because of the activation of hepatic stellate cells.

Real-time monitoring for detecting rejection using strain gauge force transducers in porcine small bowel transplantation

PURPOSE

The clinical results of small bowel transplantation (SBT) have not been satisfactory mainly because of the immunological barrier. It is important to detect the presence of and to perform adequate treatment of rejection as early as possible to improve graft survival. Therefore, we have established a pig model to monitor graft motility as a means to detect rejection in real time.

METHODS

Orthotropic SBT was performed in 25 pigs using FK-506 (0.05 to 0.1 mg/kg/d) immunosuppression. The interdigestive motor patterns were evaluated using strain gauge force transducers (SG). Seven pigs without SBT were treated as controls (C). Animals that displayed migrating motor complex (MMC) activity as evidenced by duration, amplitude, and interval in the graft were alive more than 10 days with adequate oral feeding: the functional graft (FG) group. In contrast the rejection (R) group did not show these activities on data recorded within 10 days before death due to rejection.

RESULTS

The FG group showed MMC propagated throughout the graft with all parameters almost the same as the control group except for the duration. In contrast, all parameters in the group R were significantly lower than those in group FG, suggesting that group R motility was obviously impaired by rejection.

CONCLUSIONS

The SG method may afford real-time monitoring of transplanted bowel motility that could be useful to detect rejection after SBT.

Efficacy of real-time monitoring to determine motility in porcine small intestinal transplantation

Orthotropic small intestinal transplantation (SIT) was performed in outbred 20 pigs. The interdigestive motor patterns were evaluated using strain gage (SG) force transducers. Seven pigs without SIT were treated as control (C) group. Based on the obtained data, the group, which could be detected the migrating motor complex (MMC) in the graft and alive with adequate oral feeding, was regarded as functional graft (FG) group, whereas the group which had available data recorded within 10 days before the death due to rejection was regarded as rejection (R) group. The MMC was analyzed using following parameters: duration; amplitude; and interval. In group FG, all parameters were almost same as group C, thus suggesting that the allograft in group FG had a normal motor function. In contrast, all parameters in group R were significantly lower than those in group FG, suggesting that the motility in group R was impaired. The SG method could monitor the real-time motility and was efficient for detecting the rejection of SIT.

Peutz-Jeghers syndrome in children: high recurrence rate in short-term follow-up

We have managed four cases of Peutz-Jeghers syndrome (PJS) in children. Fathers of three of these patients had PJS. There was also a family history of cancer in three cases, with pancreatic cancer in a father, colonic and laryngeal cancers in a grandfather, and hepatic and gastric cancers in a grandmother. It is presumed that in each of the cases, the largest polyp was responsible for initial symptoms. Preoperative examination revealed additional small polyps in the whole alimentary tract except for the oesophagus. Patients underwent laparotomy to remove the largest polyps and subsequent intraoperative endoscopic polypectomy for other small polyps, to minimize intestinal resection. Follow-up gastrointestinal examinations, including upper gastrointestinal series, small intestinal contrast study, and barium enema, were repeated about once a year. Three of four cases showed recurrent small intestinal polyps, and one required a second laparotomy because of recurrent abdominal pain. In conclusion, patients with PJS occurring in childhood have a strong hereditary family history of cancer and a high incidence of recurrence. Careful follow-up examination is mandatory for the gastrointestinal tract, as well as other solid organs that are susceptible to malignant change, throughout a patient's life.

Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy

BACKGROUND

Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown.

METHODS

Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery.

RESULTS

Pre-to-postoperative change in vital capacity was 74.3 +/- 10.6% in the thoracotomy group and 84.9 +/- 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 +/- 0.62 in the thoracotomy group and 0.55 +/- 0.51 in the thoracoscopy group (p = 0.0003).

CONCLUSIONS

Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.

Cortisol and cytokine responses after surgery in different age groups of pediatric patients

We investigated the cortisol and cytokine responses to surgical stress in the different age groups of pediatric patients. This study included 19 neonates (0-6 days old, group I), 19 infants (1-11 months old, group II), and 20 pre-school children (1-5 years old, group III), undergoing major thoracic and abdominal surgery. We obtained blood samples preoperatively and 0, 3, 6, 12, and 24 h postoperatively to measure the plasma levels of C-reactive protein (CRP), cortisol, interleukin (IL)-6, and IL-10. The plasma CRP level in each group reached a peak value on postoperative day 2; however, the peak value was significantly lower in group I than in groups II or III (I vs II, III; p=0.0134, p=0.0017, respectively). The plasma cortisol level in each group reached a peak value just after surgery; however, the peak value was also significantly lower in group I than in groups II or III (I vs II, III; p<0.001, p=0.0104, respectively). The plasma IL-6 level in each group reached a peak level hours postoperatively; however, the peak values in groups I and II were higher than in group III (I, II vs III; p=0.003, p=0.0458, respectively). The plasma IL-10 level in each group reached a peak value just after surgery and did not differ among the three groups. The endocrine and cytokine responses to the surgical stress vary among the different age groups of pediatric patients.