"Speckled Enhancement" on Gd-EOB-DTPA Enhanced MR Imaging of Primary Hepatic Mucosa-associated Lymphoid Tissue Lymphoma

PURPOSE

To elucidate MRI features of primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma, particularly, the "speckled enhancement" on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI.

METHODS

The institutional review board approved this retrospective observational study and waived informed consent. Using our picture archiving and communication systems and electronic medical records, five patients histopathologically diagnosed as hepatic MALT lymphoma and clinically confirmed as primary lesions who had undergone dynamic contrast-enhanced (DCE)-CT and DCE-MRI with Gd-EOB-DTPA were identified from September 2009 to December 2020. Two radiologists assessed their CT and MRI data in consensus with a pathologist's advice.

RESULTS

Overall, five lesions in five patients were included in this study. Precontrast CT showed hypoattenuation in all lesions. In the arterial phase of DCE-CT, four lesions (80%) showed hyperattenuation, whereas all lesions showed iso- to hypoattenuation in the delayed phase. A vessel penetration sign was also observed in all lesions. On MRI, all lesions showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and restricted diffusion on diffusion-weighted images. Both DCE-CT and DCE-MRI with Gd-EOB-DTPA showed similar enhancement patterns, except for the hepatocyte phase. Notably, however, four out of five lesions showed characteristic "speckled enhancement" that refers to punctate positive enhancements within the low signal lesions on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI pathologically confirmed to be hepatocyte clusters that remained in the tumor.

CONCLUSION

Primary hepatic MALT lymphomas were characterized by arterial phase enhancement, restricted diffusion, vessel penetration sign, and more specifically "speckled enhancement" in the hepatobiliary phase of DCE-MRI with Gd-EOB-DTPA.

Postendovascular Aneurysmal Repair Increase in Local Energy Loss for Fusiform Abdominal Aortic Aneurysm: Assessments With 4D flow MRI

BACKGROUND

Although endovascular aneurysmal repair (EVAR) is a preferred treatment for abdominal aortic aneurysm (AAA) owing to its low invasiveness, its impact on the local hemodynamics has not been fully assessed.

PURPOSE

To elucidate how EVAR affects the local hemodynamics in terms of energy loss (EL).

STUDY TYPE

Prospective single-arm study.

FIELD STRENGTH/SEQUENCE

A 3.0 T/4D flow MRI using a phase-contrast three-dimensional cine-gradient-echo sequence.

POPULATION

A total of 13 consecutive patients (median [interquartile range] age: 77.0 [73.0, 78.8] years, 11 male) scheduled for EVAR as an initial treatment for fusiform AAA.

ASSESSMENT

4D flow MRI covering the abdominal aorta and bilateral common iliac arteries and the corresponding stent-graft (SG) lumen was performed before and after EVAR. Plasma brain natriuretic peptide (BNP) was measured within 1 week before and 1 month after EVAR. The hemodynamic data, including mean velocity and the local EL, were compared pre-/post-EVAR. EL was correlated with AAA neck angle and with BNP. Patients were subdivided into deformed (N = 5) and undeformed SG subgroups (N = 8) and pre-/post-EVAR BNP compared in each.

STATISTICS

Parametric or nonparametric methods. Spearman's rank correlation coefficients (r). The interobserver/intraobserver variabilities with Bland-Altman plots. A P value < 0.05 is considered significant.

RESULTS

The mean velocity (cm/sec) at the AAA was five times greater after EVAR: 4.79 ± 0.32 vs. 0.91 ± 0.02. The total EL (mW) increased by 1.7 times after EVAR: 0.487 (0.420, 0.706) vs. 0.292 (0.192, 0.420). The total EL was proportional to the AAA neck angle pre-EVAR (r = 0.691) and post-EVAR (r = 0.718). BNP (pg/mL) was proportional to the total EL post-EVAR (r = 0.773). In the deformed SG group, EL (0.349 [0.261, 0.416]) increased 2.4-fold to 0.848 (0.597, 1.13), and the BNP 90.3 (53.6, 105) to 100 (67.2, 123) post-EVAR.

CONCLUSION

The local EL showed a 1.7-fold increase after EVAR. The larger increase in the EL in the deformed SG group might be a potential concern for frail patients.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Embolization using patient-specific vascular models created by a 3D printer for difficult cases: a report of two cases

With the widespread use of three-dimensional printers, organ models created by these printers are now being used in the medical field for preoperative planning of surgeries. In this article, we report two cases in which embolization was expected to be difficult, and the three-dimensional printer-based vascular modeling was helpful in planning the surgery. The first case involved an aneurysm of the splenic artery. We attempted to embolize the aneurysm but were unable to advance the catheter into the distal artery and discontinued the procedure. The second case was a perianal varicose vein, which was initially treated with percutaneous transhepatic obliteration but was recanalized and required embolization. However, we expected difficulty in selecting the inferior mesenteric vein. In both cases, the vascular models were created using a 3D printer from the patients' computed tomography images. Preoperative planning, including treatment simulation, was based on these models. The time required to print a three-dimensional vascular model was approximately 12 hours at a cost of less than $10 each. Patient-specific vascular models using a three-dimensional printer can be a simple and inexpensive tool that can increase the success of embolization in difficult cases.

A case of stent-graft implantation for postpancreaticoduodenectomy hemorrhage in a patient with a reconstructed gastric tube

In patients with a reconstructed gastric tube, the right gastroepiploic artery is a very important feeding artery of the tube, which must be preserved when performing a pancreaticoduodenectomy. A 76-year-old man with a reconstructed gastric tube underwent pancreaticoduodenectomy for distal bile duct carcinoma. On postoperative day 8, he had an arterial hemorrhage from a drain, apparently from a ligation of the anterior superior duodenal artery. He, therefore, underwent stent-graft placement in the gastroduodenal artery. The stent-grafts were temporarily occluded, and the gastric tube was necrotizing. However, thrombolytic therapy allowed the stent-grafts to reopen and prevented gastric tube necrosis. We believe our case of stent-graft implantation in the gastroduodenal artery is the first of this kind to successfully prevent lethal necrosis of the gastric tube.

Evaluation of segment 4 portal vein embolization added to right portal vein for right hepatic trisectionectomy: A retrospective propensity score-matched study

BACKGROUND

Adding segment 4 (S4) portal vein embolization (PVE) to right PVE before right hepatic trisectionectomy is controversial. We retrospectively examined the effect of S4 PVE on segments 2 and 3 (S2 + 3) hypertrophy.

METHODS

We reviewed patients with biliary carcinoma who underwent right PVE with (R3PVE) or without (R2PVE) S4 PVE using gelatin sponge particles and coils (2010-2019). Propensity score matching balanced the cohort for baseline characteristics, including total liver volume and S2 + 3 volume before PVE. We compared the groups regarding the S2 + 3 volume changes after PVE.

RESULTS

Of 178 enrolled patients, 38 underwent R3PVE for right hepatic trisectionectomy and 140 underwent R2PVE for right hepatectomy. Twenty-eight patients from each group were respectively matched. The median absolute volume increase in (146 cm³ vs 70 cm³ ), hypertrophy rate of (52.4% vs 32.3%), and kinetic growth rate of (3.1%/wk vs 2.0%/wk) S2 + 3 were significantly higher in the R3PVE group than in the R2PVE group. In the pre-matched cohort, the rate of posthepatectomy liver failure and postoperative hospital stay did not significantly differ between the patients who underwent right hepatic trisectionectomy and right hepatectomy.

CONCLUSION

R3PVE increased the S2 + 3 volume more effectively than R2PVE in patients with biliary carcinoma.

Efficacy of percutaneous transhepatic portal vein embolization using gelatin sponge particles and metal coils

Background

Percutaneous transhepatic portal vein embolization (PTPE) can increase the future liver remnant (FLR) volume before extended liver resection; however, there is no current consensus regarding the best embolic material for PTPE.

Purpose

To evaluate the efficacy of PTPE using gelatin sponge particles and coils.

Material and Methods

The medical records of 136 patients who underwent PTPE using gelatin sponge particles and metal coils were retrospectively reviewed. We evaluated the procedural details, liver volume on CT, and clinical status before and after PTPE.

Results

The mean FLR volume increased significantly from 390 ± 147 cm³ to 508 ± 141 cm³ (P < 0.001). A mean of 22.1 ± 9.4 days after PTPE, the mean increase in the ratio of FLR volume to total liver volume was 9.4 ± 6.5%. Complications related to PTPE occurred in five patients, including arterial damage (n = 4) and biloma (n = 1). The white blood cell count and C-reactive protein level increased significantly and then returned to baseline within seven days. Aspartate aminotransferase and alanine aminotransferase showed no significant changes. Fever (defined by the Common Terminology Criteria for Adverse Events v4.0) was reported in 74 patients (54%), but it was generally mild (Grade 1/2; n = 72). None of the patients experienced severe complications that required cancellation of surgery.

Conclusion

PTPE with gelatin sponge particles and coils may impose low physical stress on patients and is a safe method of inducing a significant increase of FLR.

Occlusal Support, Dysphagia, Malnutrition, and Activities of Daily Living in Aged Individuals Needing Long-Term Care: A Path Analysis

OBJECTIVES

This study aimed to examine the interrelationships among occlusal support, dysphagia, malnutrition, and activities of daily living in aged individuals needing long-term care.

DESIGN

Cross-sectional study and path analysis.

SETTING

Long-term health care facilities, acute care hospitals, and the community.

PARTICIPANTS

Three hundred and fifty-four individuals aged ≥ 65 years with dysphagia or potential dysphagia in need of long-term care.

MEASUREMENTS

The modified Eichner Index, Dysphagia Severity Scale, Mini Nutritional Assessment Short Form, and Barthel index.

RESULTS

The participants included 118 males and 236 females with a mean (standard deviation) age of 83 (8) years. A total of 216 participants had functional occlusal support with or without dentures. Of the total participants, 73 were within normal limits regarding the severity of dysphagia, 119 exhibited dysphagia without aspiration, and 162 exhibited dysphagia with aspiration. Only 34 had a normal nutritional status, while 166 participants were malnourished, and 154 were at risk of malnutrition. The median Barthel index score was 30. Path analysis indicated two important findings: occlusal support had a direct effect on dysphagia (standard coefficient = 0.33), and dysphagia was associated directly with malnutrition (standard coefficient = 0.50). Dysphagia and malnutrition were associated directly with impaired activities of daily living (standard coefficient = 0.57, 0.22).

CONCLUSION

In aged individuals needing long-term care, occlusal support is associated directly with dysphagia and indirectly with malnutrition and activities of daily living via dysphagia.

Clinical and mutational spectrum of Charcot-Marie-Tooth disease type 2Z caused by MORC2 variants in Japan

BACKGROUND AND PURPOSE

The microrchidia family CW-type zinc finger 2 gene (MORC2) was newly identified as a causative gene of Charcot-Marie-Tooth disease (CMT) type 2Z in 2016. We aimed to describe the clinical and mutational spectrum of patients with CMT harboring MORC2 mutations in Japan.

METHODS

We analyzed samples from 781 unrelated patients clinically diagnosed with CMT using deoxyribonucleic acid microarray or targeted resequencing by next-generation sequencing, and samples from 434 mutation-negative patients were subjected to whole-exome sequencing. We extracted MORC2 variants from these whole-exome sequencing data and classified them according to American College of Medical Genetics standards and guidelines.

RESULTS

We identified MORC2 variants in 13 patients. As the second most common causative gene of CMT type 2 after MFN2, MORC2 variants were detected in 2.7% of patients with CMT type 2. The mean age of onset was 10.3 ± 8.7 years, and the inheritance pattern was mostly sporadic (11/13 patients, 84.6%). The clinical phenotype was typically length-dependent polyneuropathy, and electrophysiological studies revealed sensory-dominant axonal neuropathy. Mental retardation was identified in 4/13 patients (30.8%). p.Arg190Trp, as a mutational hotspot, was observed in eight unrelated families. We also identified two novel probably pathogenic variants, p.Cys345Tyr and p.Ala369Val, and one novel uncertain significance variant, p.Tyr332Cys.

CONCLUSIONS

Our study is the largest report of patients harboring MORC2 variants. We revealed a clinical and mutational spectrum of Japanese patients with MORC2 variants. More attention should be paid to cognitive impairment, and the responsible mechanism requires further research for elucidation.

Promoting Effect of Metal Compounds on Rat Renal Tumorigenesis

Five metal compounds, zinc chloride (ZnCl2), mercury chloride (HgCl2), chromium chloride (CrCl3) hexahydrate, cadmium chloride (CdCl2) hemidihydrate, and nickel chloride (NiCl2) hexahydrate, were selected and tested for potential modifying influence on renal tumorigenesis. Six groups, each consisting of 15 male F344 rats, were given N-ethyl-N-hydroxyethylnitrosamine (EHEN) at a concentration of 500 ppm in their drinking water for the first 2 weeks as the initiation of carcinogenesis. Thereafter, the rats were treated orally for 25 weeks with ZnCl2, HgCl2, CrCl3, CdCl2, and NiCl2, respectively, at concentrations of 450, 40, 600, 100, and 600 ppm in the drinking water. The control group was given unsupplemented distilled water (DW) after EHEN initiation. Renal neoplastic lesions were classified histologically into dysplastic foci (DF) and renal cell tumors (RCT). As a result, statistically significant increases were found in the mean numbers of DF per cm2 in rats treated with the five metal compounds. On the other hand, the incidence of RCT was significantly higher only in rats treated with NiCl2. It is concluded that NiCl2 exerted a potential for promotion of renal tumorigenesis under the conditions of this study.

Lack of Promoting Effect of Sodium Chlorate and Potassium Chlorate in Two-Stage Rat Renal Carcinogenesis

Sodium chlorate (NaClO3) and potassium chlorate (KClO3), which are byproducts of water disinfection with chlorine dioxide (ClO2), were tested for potential promoting effect in two-stage rat renal carcinogenesis. Three groups of 15 male F344 rats each were given N-ethyl-N-hydroxyethylnitrosamine (EHEN) at the level of 0.05% for the first 2 weeks during the initiation phase. Thereafter, the rats were treated orally for 25 weeks with NaClO3 (1%), KClO3 (1%), or distilled water (DW). Three other groups (controls) were treated similarly, except that DW was given in the initiation phase. All animals survived for the duration of the experiment. Renal neoplastic lesions were classified histologically as dysplastic foci (DF) and renal cell tumors (RCT). The number of these lesions per unit area, in six sections from each kidney, was determined microscopically. There were no statistically significant differences in the incidences and in the mean number of DF and RCT of the kidney between compound-and DW-treated rats initiated with EHEN. It is concluded that NaClO3 and KClO3 show no promoting effect in rat renal carcinogenesis under the conditions of this study.

Neck Circumference Is Not Associated with Dysphagia but with Undernutrition in Elderly Individuals Requiring Long-term Care

OBJECTIVES

The purpose was to assess the association between neck circumference, dysphagia, and undernutrition in elderly individuals requiring long-term care.

DESIGN

Cross-sectional study.

SETTING

Geriatric health services facilities, acute hospitals, and the community.

PARTICIPANTS

Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=385).

MEASUREMENTS

Neck circumference, the Dysphagia Severity Scale (DSS) and the Mini Nutritional Assessment Short Form (MNA-SF).

RESULTS

Participants included 130 males and 255 females with a mean age (± standard deviation) of 83 ± 8.0 years. Sixty-six were in acute hospitals, 195 were in geriatric health services facilities, and 124 were community-dwelling. The mean neck circumference in males and females was 37.1 ± 3.0 cm and 33.3 ± 3.3 cm, respectively. Based on the DSS, 81 participants were within normal limits, 137 had dysphagia without aspiration, and 167 had dysphagia with aspiration. The MNA-SF revealed that 173 were malnourished, 172 were at risk of malnutrition, and 40 had a normal nutritional status. Neck circumference was not significantly correlated with the DSS (r=-0.080) but was significantly correlated with the MNA-SF (r=0.183) in the Spearman rank correlation analysis. In the logistic regression, neck circumference was not independently associated with the DSS after adjusting for the MNA-SF, the Barthel Index, age, sex, setting, and cerebrovascular disorders. However, the multiple regression analysis showed that neck circumference had an independent effect on the MNA-SF after adjusting for the Barthel Index, age, sex, setting and cerebrovascular disorders.

CONCLUSIONS

Neck circumference is not associated with dysphagia but with undernutrition in elderly individuals requiring long-term care.

Dysphagia Assessed by the 10-Item Eating Assessment Tool Is Associated with Nutritional Status and Activities of Daily Living in Elderly Individuals Requiring Long-Term Care

OBJECTIVES

The 10-item Eating Assessment Tool (EAT-10) is a self-administered questionnaire for dysphagia screening, with each item scored from 0 to 4. We assessed the associations among the EAT-10 score, nutritional status and activities of daily living (ADL) in elderly individuals requiring long-term care.

DESIGN

Cross-sectional study.

SETTING

Geriatric health services facilities, acute hospitals, and the community.

PARTICIPANTS

Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=237).

MEASUREMENTS

The EAT-10, the Mini Nutritional Assessment Short Form (MNA-SF) and the Barthel Index.

RESULTS

There were 90 males and 147 females. Mean age was 82 ± 8 years. Eighty-nine were in geriatric health services facilities, 28 were in acute hospitals, and 120 were community-dwelling. The median Barthel Index score was 55 (interquartile range: 25, 80). The median EAT-10 score was 1 (interquartile range: 0, 9), and 101 respondents a score > 3, indicating the presence of dysphagia. The MNA-SF revealed that 81 were malnourished, 117 were at risk of malnutrition, and 39 had a normal nutritional status. The Barthel Index score and MNA-SF score were significantly lower in those with an EAT-10 score between 3 and 40, compared to those with an EAT-10 score between 0 and 2. The EAT-10 has an independent effect on the Barthel Index and the MNA-SF by adjusting for covariates such as age, gender, and setting in multiple regression analysis.

CONCLUSIONS

Dysphagia assessed by the EAT-10 is associated with nutritional status and ADL in elderly individuals requiring long-term care.

BMI is associated with larger index tumors and worse outcome after radical prostatectomy

BACKGROUND

To investigate the impact of body mass index (BMI) on tumor characteristics and biochemical recurrence (BCR) after radical prostatectomy (RP) for prostate cancer (PCa) in Japanese men.

METHODS

We evaluated data from consecutive patients who had undergone RP. Data analyzed included age, preoperative serum PSA, prostatic volume, BMI (continuous or categorized (≤ 25 kg/m(2)) values), clinical and pathological findings including index tumor volume (ITV), and current status in areas such as smoker or nonsmoker and presence or absence of diabetes. We analyzed association between BMI and BCR, especially based on ITV using univariate and multivariate analysis.

RESULTS

We analyzed data from a total of 703 patients. The median follow-up time was 38.4 months. BCR was diagnosed in 154 patients (21.9%) at a median of 9.7 months postoperatively. Multivariate linear regression analysis adjusted for preoperative variables showed a significant positive association between BMI and ITV (continuous BMI: P=0.002; categorical BMI: P<0.001, respectively), especially for higher-grade tumors (Gleason score ≥ 7). Cox proportional hazards analysis showed a significant association between continuous BMI and BCR after surgery (preoperative variables, hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.02-1.16, P=0.008), independent of clinical and pathological findings. In patients with high-risk cancer, the positive association between BMI and BCR was strengthened (preoperative variables, continuous BMI, HR 1.16, 95% CI 1.07-1.26, P<0.001; categorical BMI, HR 2.11, 95% CI 1.29-3.45, P=0.003, respectively).

CONCLUSIONS

Greater BMI significantly correlates with higher rates of BCR after surgery; BMI is a preoperative variable associated with high-grade ITV. Our results suggest that the biological environment created by greater BMI may contribute to increasing tumor aggressiveness.

Chronic kidney disease categories and renal-cardiovascular outcomes in type 2 diabetes without prevalent cardiovascular disease: a prospective cohort study (JDDM25)

AIMS/HYPOTHESIS

In type 2 diabetic patients at low risk for cardiovascular disease (CVD), the relationship between the clinical course of nephropathy by stage of chronic kidney disease (CKD) and onset of CVD remains unclear. Clarification of this relationship is important for clinical decision-making for both low- and high-risk diabetic patients.

METHODS

This 4 year prospective study enrolled 2,954 type 2 diabetic patients with no prevalent CVD, and serum creatinine <176.8 μmol/l. The risk for CVD onset (non-fatal and fatal CVD and stroke, and peripheral arterial disease) was assessed according to CKD stage categorised by urinary albumin-to-creatinine ratio (ACR; mg/mmol) and estimated GFR (eGFR; ml min(-1) 1.73 m(-2)). Association of progression from 'no CKD' stage (ACR <3.5 mg/mmol and eGFR ≥ 90 ml min(-1) 1.73 m(-2)) with risk for CVD onset was also evaluated.

RESULTS

During follow-up (median 3.8 years), 89 CVD events occurred. Compared with patients with 'no CKD' as reference, those with ACR ≥ 35.0 mg/mmol with co-existing eGFR 60-89 ml min(-1) 1.73 m(-2) or <60 ml min(-1) 1.73 m(-2) showed increased risk for CVD onset, whereas those with eGFR ≥ 90 ml min(-1) 1.73 m(-2) did not. Those with ACR <3.5 mg/mmol and eGFR <60 ml min(-1) 1.73 m(-2) did not show any increased risk. Among patients with 'no CKD' stage at baseline, those who progressed to ACR ≥ 3.5 mg/mmol during follow-up showed an increased risk compared with those who did not, whereas those who progressed to eGFR <90 ml min(-1) 1.73 m(-2) did not have increased risk.

CONCLUSIONS/INTERPRETATION

The risk for CVD was associated with progression of albuminuria stage rather than eGFR stage in type 2 diabetic patients at relatively low risk for CVD.

Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study

BACKGROUND AND STUDY AIMS

Studies have estimated that failure of cecal intubation occurs with conventional colonoscopy in up to 10 % of cases. Double-balloon endoscopy (DBE) systems, magnetic endoscope imaging (MEI), and transparent cap have been shown to improve success rates for colonoscopy. This study evaluated the utility of DBE for complete examination of the colon compared with MEI plus cap (MEI-Cap) after incomplete or technically difficult colonoscopy in a randomized comparative manner.

PATIENTS AND METHODS

A total of 94 patients with incomplete or technically difficult colonoscopy were randomly assigned to receive either DBE (n = 47) or colonoscopy with MEI-Cap (n = 47). The primary end point was cecal intubation rate within 30 minutes. Secondary end points included intubation time, pain score using a visual analog scale, abdominal pressure attempts, doses of sedative medication, and changes in patient position during colonoscopy.

RESULTS

Patient characteristics were comparable in both groups. Cecal intubation rate within 30 minutes was significantly higher for DBE (45 /47, 95.7 %) than for MEI-Cap (34 /47, 72.3 %) (P = 0.0049). Mean time to reach the cecum was significantly lower in the DBE group (13.0 ± 5.3 minutes) than in the MEI-Cap group (16.4 ± 4.8 minutes; P = 0.0003). No complications were encountered in either group.  

CONCLUSION

DBE is more useful for complete examination of the colon than MEI-Cap in patients with incomplete or technically difficult colonoscopy.

Low incidence of cardiovascular events in Japanese patients with Type 2 diabetes in primary care settings: a prospective cohort study (JDDM 20)

AIMS

To investigate whether a reduced incidence of cardiovascular disease in Type 2 diabetes can be achieved in a newly recruited cohort following the recently advanced concept of multifactorial treatment and followed in primary care settings as compared with earlier cohorts.

METHODS

A prospective study was performed in primary care settings at multiple clinics nationwide in the Japan Diabetes Clinical Data Management (JDDM) study group. Subjects were 2984 patients with Type 2 diabetes without prevalent cardiovascular disease. The main outcome measure was the first event of non-fatal or fatal coronary heart disease, ischaemic stroke or peripheral artery disease, and the incidence was compared with other representative cohorts.

RESULTS

There were 90 cardiovascular events over 10,827 person-years of follow-up with a dropout rate of 6%. The incidences (per 1000 person-years, 95% confidence interval) of composite, coronary heart disease, ischaemic stroke and peripheral artery disease in the JDDM study were 8.3 (6.6-10.0), 4.4 (3.2-5.6), 3.1 (2.1-4.2), and 0.7 (0.2-1.2), respectively. Each incidence was lowest in the JDDM study compared with other cohorts (P < 0.01 vs. each cohort). In the JDDM study, significant variables predictive of the occurrence of a cardiovascular event were age, duration of diabetes, HbA(1c), HDL cholesterol and urinary albumin.

CONCLUSION

The novel finding of low cardiovascular disease occurrence in this study may be conferred by the feasibility at primary care settings for providing patients with Type 2 diabetes with favourable control of blood glucose, blood pressure and lipids, coupled with unique ethnicity/country factors.

Use of cytokeratin 18 and EAU score to predict tumor recurrence in patients with non-muscle-invasive bladder cancer following single postoperative immediate intravesical chemotherapy instillation

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Background: We examined the prognostic factors for recurrence after TURBT using molecular markers as well as the scoring system of the EAU.

Methods: Eighty-eight patients with primary or recurrent bladder tumors who underwent TURBT followed by the single postoperative immediate instillation of pirarubicin and no further instillations were enrolled between 2003 and 2006; the median follow-up period was 46 months. The time to first recurrence was the primary end point of this study. Patients were divided into EAU recurrence risk groups as follows: low-risk group (total score, 0), intermediate-risk group (total score, 1-9) and high-risk group (total score, 9-17). The intermediate-risk group patients were subdivided into a total score of 1-4 and a total score of 5-9. Immunostaining using Ki-67, pHH3, CK18 and Survivin were performed on the TURBT specimens.

Results: According to the risk stratification, 5, 82, and 1 were assigned to the low-, intermediate-, and high-risk recurrence groups, respectively. During the follow-up, recurrences were observed in 0% of the low-risk group, 45% (37 out of 82) in the intermediate-risk group and 100% in the high-risk group. We evaluated various predictors of a recurrence-free outcome among the 82 intermediate-risk patients. In univariate analyses, EAU score (1-4, 32.1% vs 5-9, 62.1%; p = 0.0011), high CK18 expression (negative, 31.4% vs positive 88.8%; p < 0.0001), high Ki-67 index (< 5%, 35.4% vs > 5%, 52.5%; p = 0.017) and high Survivin nuclear staining (< 5%, 35.9% vs > 5%, 62.5%; p = 0.004) were associated with recurrence. In a multivariate analysis, EAU score (HR 2.95, p = 0.003) and a high CK18 immunostaining (HR 6.70, p < 0.0001) were independent predictors of disease recurrence.

Conclusions: A single immediate chemotherapy instillation is, by itself, insufficient for the treatment of patients in the intermediate- or high-risk recurrence groups defined by the EAU guidelines. Strong immunohistochemical expression of CK18 and the EAU scoring system appeared to be independent predictors of clinical outcome among patients with urothelial carcinoma of the bladder.

No significant financial relationships to disclose.

Diagnostic value of SPIO-mediated breath-hold, black-blood, fluid-attenuated, inversion recovery (BH-BB-FLAIR) imaging in patients with hepatocellular carcinomas

PURPOSE

We assessed the value of adding a breath-hold, black-blood, fluid-attenuated, inversion recovery (BH-BB-FLAIR) sequence with a small motion-probing gradient (b=10 s/mm(2)) using superparamagnetic iron oxide (SPIO) to our present studies that utilize SPIO to detect hepatocellular carcinoma (HCC). We used inversion recovery (IR) in a FLAIR sequence to suppress signals from cysts and a low b-value to suppress vessel signals and provide higher signal to noise than that using high b-value diffusion-weighted imaging. Use of SPIO is expected to reduce the signal in both normal liver parenchyma and in most benign lesions.

MATERIALS AND METHODS

In 19 patients, we reviewed 38 HCC nodules diagnosed by CT arterioportography (CTAP) and CT during hepatic arteriography (CTHA). We divided SPIO-mediated images into sets, those obtained with and without BH-BB-FLAIR. Six radiologists individually interpreted the 2 image sets and sorted them by their confidence levels for the presence of HCC, and we calculated the area under the receiver operating characteristic (ROC) curve (Az) for each image set.

RESULTS

On images obtained with BH-BB-FLAIR after SPIO administration, 33 of the 38 HCC nodules appeared as areas of high signal and cyst signal was extinguished. The ROC analysis showed significantly higher Az values in the set with BH-BB-FLAIR (0.89) than in the set without (0.83).

CONCLUSIONS

Adding BH-BB-FLAIR to existing SPIO-mediated imaging protocols improved detection of HCC nodules and added only 24 s to the scan time.

Contrast-enhanced MR imaging of metastatic brain tumor at 3 tesla: utility of T(1)-weighted SPACE compared with 2D spin echo and 3D gradient echo sequence

We evaluated the newly developed whole-brain, isotropic, 3-dimensional turbo spin-echo imaging with variable flip angle echo train (SPACE) for contrast-enhanced T(1)-weighted imaging in detecting brain metastases at 3 tesla (T). Twenty-two patients with suspected brain metastases underwent postcontrast study with SPACE, magnetization-prepared rapid gradient-echo (MP-RAGE), and 2-dimensional T(1)-weighted spin echo (2D-SE) imaging at 3T. We quantitatively compared SPACE, MP-RAGE, and 2D-SE images by using signal-to-noise ratios (SNRs) for gray matter (GM) and white matter (WM) and contrast-to-noise ratios (CNRs) for GM-to-WM, lesion-to-GM, and lesion-to-WM. Two blinded radiologists evaluated the detection of brain metastases by segment-by-segment analysis and continuously-distributed test. The CNR between GM and WM was significantly higher on MP-RAGE images than on SPACE images (P<0.01). The CNRs for lesion-to-GM and lesion-to-WM were significantly higher on SPACE images than on MP-RAGE images (P<0.01). There was no significant difference in each sequence in detection of brain metastases by segment-by-segment analysis and the continuously-distributed test. However, in some cases, the lesions were easier to detect in SPACE images than in other sequences, and also the vascular signals, which sometimes mimic lesions in MP-RAGE and 2D-SE images, were suppressed in SPACE images. In detection of brain metastases at 3T magnetic resonance (MR) imaging, SPACE imaging may provide an effective, alternative approach to MP-RAGE imaging for 3D T(1)-weighted imaging.

Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula

BACKGROUND

This study was undertaken to evaluate the accuracy of endoanal ultrasonography for preoperative assessment of anal fistula, with special reference to the difference between acute and chronic fistula.

METHODS

The subjects comprised 401 patients treated for acute or chronic anorectal sepsis of cryptoglandular origin during the period January through December 2005. All patients underwent physical examination and endoanal ultrasonography. Agreement between the physical and endosonographic findings and the definitive surgical findings were evaluated with special reference to classification of the primary tract and horseshoe extension and localization of the internal opening. The difference in accuracy of endosonographic assessment between acute and chronic fistula was also evaluated.

RESULTS

The accuracy of endoanal ultrasonography was significantly higher than that of physical examination in detecting the primary tract (88.8% vs. 85.0%, p=0.0287) and horseshoe extension (85.7% vs. 58.7%, p<0.0001) and in localizing the internal opening (85.5% vs. 69.1%, p<0.0001). Furthermore, localization of the internal opening by endosonography was significantly more accurate in chronic fistula than in acute fistula (89.5 % vs. 76.8%, p<0.0001), although the accuracy in detecting the primary tract and horseshoe extension was not significantly different.

CONCLUSIONS

Endoanal ultrasonography is reliable and useful for preoperative assessment of anal fistula, particularly for detecting horseshoe extension and localizing the internal opening. Endosonographic assessment provides clearer depiction of the internal opening during periods of quiescence than during the period of abscess formation. For patients with acute anorectal sepsis, initial surgical drainage and subsequent fistula surgery, rather than one-stage fistula surgery, may be advisable to avoid misidentification of the internal opening.

Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-year-old woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.

[Short-term results of the Fontan operation in patients with Down syndrome]

Despite an extensive experience with Fontan operation, there is a paucity of information to guide the indication of the procedure in patients with Down syndrome. Of 79 patients who had undergone a Fontan operation in our hospital between 1995 and 2003, 3 had Down syndrome. All 3 patients had complete atrioventricular septal defect with single ventricular physiology. Two patients survived, and 1 died of chylothorax and respiratory infection. The 2 survivors have done well in the short-term without complications. We consider that in appropriately selected patients with Down syndrome in whom biventricular repair is precluded, the Fontan operation is the choice of the procedures.

Crystallization and preliminary X-ray analysis of the primary receptor (PotD) of the polyamine transport system in Escherichia coli

The primary receptor (potD, M(r) = 39 000) of the polyamine transport system in Escherichia coli has been crystallized by the vapor-diffusion method. Two crystal forms were obtained in the presence of spermidine, and were examined by X-ray analysis. Form I crystals, which diffract to 2.5 A resolution, belong to the space group P2(1), with unit-cell dimensions a = 145.3, b = 69.1, c = 72.5 A and beta = 107.6 degrees. Four molecules are contained in an asymmetric unit. These form two dimers that are related to each other by a local translation of about half of the unit cell along the a axis. The two protein molecules in each dimer are similarly related by a local dyad. Form II crystals diffract to 1.8 A resolution and belong to the space group I4(1), with unit-cell dimensions a = b = 130.3 and c = 38.7 A. They contain one molecule per asymmetric unit.

Advantages of oxygen inhalation therapy for postoperative pulmonary hypertension

Total correction was performed in a case of complete transposition of the great arteries (TGA) with severe pulmonary vascular obstructive disease (PVOD). Although severe pulmonary hypertension remained after surgery, oxygenation was continued for 15 months, which included a shift to at-home oxygen inhalation therapy (HOT). Cardiac catheterization 15 months after surgery demonstrated that pulmonary hypertension was greatly improved. For patients in whom the palliative Mustard operation is considered due to severe PVOD on the basis of lung biopsy diagnosis, total correction of TGA is possible by employing HOT after surgery.

Inhibition of arthritis by systemic administration of endostatin in passive murine collagen induced arthritis

OBJECTIVE

To investigate the arthritis inhibiting effect of endostatin, known to have potent antiangiogenic activity, systemically given to animal models of rheumatoid arthritis (RA).

METHODS

Four kinds of monoclonal anti-type II collagen antibody followed by lipopolysaccharide (LPS) three days later were given to 6 week old, female Balb/c mice to induce arthritis. Three groups of mice received 0.2 mg/kg/day, 2 mg/kg/day, and 10 mg/kg/day of endostatin, respectively, whereas a control group received phosphate buffered saline (PBS). Endostatin or PBS was given for 13 days, starting before the development of arthritis. Arthritis was evaluated by arthritis scores and hind paw thicknesses. Mice were killed for histological examination on the 22nd day after the administration of monoclonal anti-type II collagen antibody.

RESULTS

Arthritis developed within three days after LPS administration in both the control and endostatin treatment groups. No difference in the development rate of arthritis was noted between the control and endostatin treatment groups. Arthritis scores remained significantly lower in the endostatin 10 mg/kg/day group than in the control group. Hind paw thicknesses also remained significantly smaller in the endostatin 10 mg/kg/day group than in the control group. Histopathological examination showed that synovial thickening and subchondral bone erosion improved more in the endostatin treatment groups than in the control group.

CONCLUSION

The systemic administration of endostatin had an arthritis inhibiting effect in RA animal models. Endostatin inhibited, in particular, pannus formation and bone destruction.

Clinical study of urine NMP 22 (nuclear matrix protein 22) as a tumor marker in urinary epithelial cancer

The prognosis of urinary epithelial cancer is still poor, and early detection of this cancer is strongly desirable. The sensitivity of conventional urinary cytology is not satisfactory enough. It is hoped that a specific tumor marker will be established. In recent years, it has been reported that urine NMP 22 is very useful and that urine BFP is also relatively useful. We have now determined urine NMP22 and BFP and studied their clinical usefulness as a tumor marker. Using patients diagnosed with histologically confirmed urinary epithelial cancer as the subjects, we retrospectively studied the usefulness of NMP 22, BFP and cytology mainly with regard to the sensitivity (positivity rate), and also in relation to atypia, degree of infiltration and clinical course.

Endothelin protein expression as a significant prognostic factor in oesophageal squamous cell carcinoma

The aim of this study was to investigate if the expression of endothelin (ET), a vasoactive peptide, in cancerous oesophageal lesions, adjacent dysplastic tissue and normal mucosa might be prognostic. Tissue samples from a total of 101 patients with oesophageal squamous cell carcinoma were obtained and stained with ET antibody in an immunohistochemical analysis. High staining levels of ET within normal mucosa were related to lymph vessel invasion, regional lymph node metastasis and distant metastasis, as well as a reduced relapse-free survival (log-rank test; P=0.0066). After adjustment for several histological prognostic risk factors and each component of the TNM classification system, high ET expression within dysplastic tissue more than doubled the hazard ratio of relapse with significant model improvement. These results suggest that, in addition to known histological risk factors and TNM classification criteria, measurement of ET expression with a simple immunohistochemical analysis might further help in predicting the prognosis of patients with oesophageal squamous cell carcinoma.

[Repair of tetralogy of Fallot in an adult; the importance of preoperative examination for major aorto-pulmonary collateral arteries]

We report the repair of tetralogy of Fallot in a 51-year-old man. He underwent a left classical Blalock-Taussig (B-T) shunt when he was ten years old. Preoperative angiography showed a patent B-T shunt. Total corrective surgery was performed. Postoperatively, he suffered from left ventricular failure. Re-intubation was required three times. Postoperative catheterization showed excellent correction of the right ventricular system, however, descending aortography revealed a great many aorto-pulmonary collateral arteries, which caused the left ventricular failure. Coil embolization of these 13 collateral arteries was performed and he recovered from the left ventricular failure. We conclude that even in an elderly patient with tetralogy of Fallot, total correction should be performed, since the surgical risk is acceptable and the procedure improves the capacity for physical activity and quality of life. Preoperative examination of collateral arteries is important, especially in elderly patients, and coil embolization should be considered.

Nephropathy of cyanotic congenital heart disease: clinical characteristics and effectiveness of an angiotensin-converting enzyme inhibitor

AIMS

Nephropathy has long been recognized as a potential complication of cyanotic congenital heart disease (CCHD). There have been few large-scale studies or clinical reports on renal impairment in patients with CCHD; similarly, very few studies have examined the drug treatment of nephropathy in CCHD. We examined the clinical characteristics and effectiveness of enalapril, an angiotensin-converting enzyme inhibitor (ACE-I), in patients with CCHD complicated with significant proteinuria.

MATERIALS AND METHODS

The clinical records of 37 patients with CCHD were evaluated; all were older than 10 years of age (median 19, range from 10 to 27) and had regular check-ups, including urinalysis. The treatment criteria for enalapril administration included significant proteinuria (urinary excretion > 1.0 g/24 h), stable cardiac condition and blood pressure within the normal range.

RESULTS

Eleven patients (29.7%) had persistent proteinuria, 6 patients met the enalapril treatment criteria and 5 patients were treated for more than 12 months. Enalapril apparently reduced the urinary protein excretion in 4 of the 5 patients (80%). No consistent improvement of renal function, as evidenced in the glomerular filtration rate (GFR), renal plasma flow (RPF) or filtration fraction (FF) was found in these patients, but neither were any significant adverse effects noted.

CONCLUSION

The incidence of nephropathy among patients with CCHD was about 30%, which was consistent with previous studies. It is worth considering the use of ACE-I when nephropathy accompanies CCHD.

Induction of histamine release from rat peritoneal mast cells by histatins

Human salivary histatins (Hsts), which belong to a salivary polypeptide family, have potent antifungal activity against Candida albicans and Cryptococcus neoformans, and are expected to be useful as therapeutic reagents against Candida species. However, little is known about the effect of Hsts on host immune systems. Thus we conducted a series of in vitro experiments with rat mast cells to determine whether histatin 5 (Hst 5) or histatin 8 (Hst 8) has a histamine-releasing effect on mast cells. Both Hst 5 and Hst 8 induced histamine release from rat peritoneal mast cells in a dose-dependent manner (10(-9) to 10(-5) M). Hst 5 had a stronger releasing effect than Hst 8. The histamine release induced by Hst 5 (10(-6) M) was increased by the presence of 0.5 mM Ca2+, but decreased by 2mM Ca2+. Alternatively, the histamine release induced by Hst 8 (10(-6) M) was inhibited by the presence of Ca2+ (0.5 to 2 mM). These results suggest that Hsts have limited usefulness as therapeutic agents due to induction of histamine release from mast cells.

Contribution of Thr29 to the thermodynamic stability of goat alpha-lactalbumin as determined by experimental and theoretical approaches

The Thr29 residue in the hydrophobic core of goat alpha-lactalbumin (alpha-LA) was substituted with Val (Thr29Val) and Ile (Thr29Ile) to investigate the contribution of Thr29 to the thermodynamic stability of the protein. We carried out protein stability measurements, X-ray crystallographic analyses, and free energy calculations based on molecular dynamics simulation. The equilibrium unfolding transitions induced by guanidine hydrochloride demonstrated that the Thr29Val and Thr29Ile mutants were, respectively, 1.9 and 3.2 kcal/mol more stable than the wild-type protein (WT). The overall structures of the mutants were almost identical to that of WT, in spite of the disruption of the hydrogen bonding between the side-chain O-H group of Thr29 and the main-chain C=O group of Glu25. To analyze the stabilization mechanism of the mutants, we performed free energy calculations. The calculated free energy differences were in good agreement with the experimental values. The stabilization of the mutants was mainly caused by solvation loss in the denatured state. Furthermore, the O-H group of Thr29 favorably interacts with the C=O group of Glu25 to form hydrogen bonds and, simultaneously, unfavorably interacts electrostatically with the main-chain C=O group of Thr29. The difference in the free energy profile of the unfolding path between WT and the Thr29Ile mutant is discussed in light of our experimental and theoretical results.