Effectiveness of endoscopic resection for colorectal neoplasms in ulcerative colitis: a multicenter registration study

BACKGROUND AND AIMS

Patients with ulcerative colitis (UC) are at risk of developing colorectal cancer. The feasibility of endoscopic resection (ER) for UC-associated neoplasia has been suggested, but its efficacy and safety remain unclear. We aimed to assess the efficacy and safety of ER for colorectal neoplasms in patients with UC.

METHODS

This was a retrospective, multicenter cohort study of patients with UC who initially underwent ER or surgery for colorectal neoplasms between April 2015 and March 2021. Patients who had prior colorectal neoplastic lesions were excluded.

RESULTS

Among 213 men and 123 women analyzed, the mean age at UC onset was 41.6 years, and the mean age at neoplasia diagnosis was 56.1 years for 240 cases of total colitis, 59 cases of left-sided colitis, 31 cases of proctitis, and 6 cases of segmental colitis. EMR was performed for 142 lesions, and endoscopic submucosal dissection (ESD) was performed for 96 lesions. The perforation rate was 2.5% for all 238 lesions removed by ER and 6.3% for the 96 lesions removed by ESD. Among 146 ER lesions followed up with endoscopy, the local recurrence rate was 2.7%. The incidence of metachronous neoplasia after ER was 6.1%. All patients were followed a median of 34.7 months after initial treatment, and 5 died (all surgical cases). Overall survival was significantly higher in the ER group than in the surgery group (P = .0085).

CONCLUSIONS

ER for colorectal neoplasms in UC may be acceptable in selected cases, although follow-up for metachronous lesions is necessary.

Thiopurine naivety at tacrolimus induction is a predictor of long-term remission in patients with intractable ulcerative colitis who responded to tacrolimus

BACKGROUND

The short-term efficacy of tacrolimus (Tac) for steroid-dependent and steroid-resistant refractory ulcerative colitis (UC) has been demonstrated; however, its long-term outcomes have not been well documented. Thus, this study aimed to clarify the long-term outcomes of patients who achieved Tac-induced remission and identify its predictors.

METHODS

This study included patients with moderate-to-severe active UC who started receiving Tac at our hospital between July 2004 and December 2016. Short-term treatment response was assessed using the Lichtiger index 3 months after starting Tac, and responding patients were further followed up to assess long-term outcomes. The primary endpoint was the relapse-free survival after Tac-induced remission, and the secondary endpoint was the identification of factors associated with relapse after Tac-induced remission.

RESULTS

The cumulative relapse-free survival rate at 10 years after Tac-induced remission was 33.2%. Multivariate analysis revealed that being thiopurine naïve at Tac induction was associated with the absence of relapse (hazard ratio: 0.45; 95% confidence interval: 0.22-0.92).

CONCLUSIONS

Approximately one-third of patients who achieved Tac-induced remission maintained long-term remission. Being thiopurine naïve at Tac induction was a predictor of the absence of relapse.

Measurement of prostaglandin metabolites is useful in diagnosis of small bowel ulcerations

BACKGROUND

We recently reported on a hereditary enteropathy associated with a gene encoding a prostaglandin transporter and referred to as chronic enteropathy associated with SLCO2A1 gene (CEAS). Crohn’s disease (CD) is a major differential diagnosis of CEAS, because these diseases share some clinical features. Therefore, there is a need to develop a convenient screening test to distinguish CEAS from CD.

AIM

To examine whether prostaglandin E major urinary metabolites (PGE-MUM) can serve as a biomarker to distinguish CEAS from CD.

METHODS

This was a transactional study of 20 patients with CEAS and 98 patients with CD. CEAS was diagnosed by the confirmation of homozygous or compound heterozygous mutation of SLCO2A1. We measured the concentration of PGE-MUM in spot urine by radioimmunoassay, and the concentration was compared between the two groups of patients. We also determined the optimal cut-off value of PGE-MUM to distinguish CEAS from CD by receiver operating characteristic (ROC) curve analysis.

RESULTS

Twenty Japanese patients with CEAS and 98 patients with CD were enrolled. PGE-MUM concentration in patients with CEAS was significantly higher than that in patients with CD (median 102.7 vs 27.9 μg/g × Cre, P < 0.0001). One log unit increase in PGE-MUM contributed to 7.3 increase in the likelihood for the diagnosis of CEAS [95% confidence interval (CI) 3.2-16.7]. A logistic regression analysis revealed that the association was significant even after adjusting confounding factors (adjusted odds ratio 29.6, 95%CI 4.7-185.7). ROC curve analysis revealed the optimal PGE-MUM cut-off value for the distinction of CEAS from CD to be 48.9 μg/g × Cre with 95.0% sensitivity and 79.6% specificity.

CONCLUSION

PGE-MUM measurement is a convenient, non-invasive and useful test for the distinction of CEAS from CD.

Crohn's disease-specific mortality: a 30-year cohort study at a tertiary referral center in Japan

BACKGROUND

In this study, survival and cause of death were investigated in patients with Crohn's disease (CD) at a tertiary referral center.

METHODS

A database was created based on the medical records of 1108 CD patients who had a history of visiting our hospital to investigate background characteristics, cumulative survival rates from diagnosis, causes of death, and the standardized mortality ratio (SMR) for each cause of death. A follow-up questionnaire survey of patients followed up inadequately was also conducted. The cumulative survival rate from diagnosis was determined using the life table method and compared with that of a sex- and age-matched population model from the year 2000.

RESULTS

The study included 1108 patients whose mean age at diagnosis was 25.6 ± 10.8 years. The mean duration of follow-up was 14.6 ± 9.4 years, and there were 52 deaths. The cumulative survival rate was significantly lower 25 years after the diagnosis of CD (91.7%) than in the standard population model (95.7%). SMRs for both all causes [3.5; 95% confidence interval (CI): 2.7-4.6] and CD-specific causes (36.7; 95% CI 26.1-51.6) were high. Among the CD-specific causes, SMRs were especially high for small intestine and colorectal cancers, gastrointestinal diseases including intestinal failure (IF), perioperative complications, and amyloidosis.

CONCLUSION

The SMRs for both all causes and CD-specific causes were high in CD patients. CD-specific causes including intestinal cancer, IF, perioperative complications, and amyloidosis showed especially high SMRs.

Risk factors for severity of colonic diverticular hemorrhage

BACKGROUND/AIMS

Colonic diverticular hemorrhage (DH) was a rare disease until the 1990s, and its incidence has increased rapidly since 2000 in Japan. In recent years, colonic DH has been the most frequent cause of lower gastrointestinal bleeding (LGIB). Nearly all cases of DH are mild, with the bleeding often stopping spontaneously. Some cases, however, require surgery or arterial embolization. In this study, using a cohort at Fukuoka University Chikushi Hospital, we investigated factors associated with severe colonic DH.

METHODS

Among patients with LGIB who underwent colonoscopy at our hospital between 1995 and 2013, DH was identified in 273 patients. Among them, 62 patients (22.7%) were defined as having severe colonic DH according to recurrence of bleeding in a short period, and/or the necessity of transfusion, arterial embolization, or surgery. We then evaluated risk factors for severe DH among DH patients in this retrospective cohort.

RESULTS

Among the 273 patients with DH, use of non-steroidal anti-inflammatory drugs (NSAIDs) (odds ratio [OR], 2.801; 95% confidence interval [CI], 1.164-6.742), Charlson Risk Index (CRI) ≥2 (OR, 3.336; 95% CI, 1.154-7.353), right-sided colonic DH (OR, 3.873; 95% CI, 1.554-9.653), and symptoms of cerebral hypoperfusion (such as light-headedness, dizziness, or syncope) (OR, 2.926; 95% CI, 1.310-6.535) showed an increased risk of severe DH even after controlling for other factors.

CONCLUSIONS

Severe DH occurred in 23% of DH patients, and NSAID use, CRI ≥2, right-sided colonic DH, and symptoms of cerebral hypoperfusion are suggested to be predictors of severe DH.

Clinical features of chronic enteropathy associated with SLCO2A1 gene: a new entity clinically distinct from Crohn's disease

BACKGROUND

Chronic enteropathy associated with SLCO2A1 gene (CEAS) is a hereditary disease caused by mutations in the SLCO2A1 gene and characterized by multiple small intestinal ulcers of nonspecific histology. SLCO2A1 is also a causal gene of primary hypertrophic osteoarthropathy (PHO). However, little is known about the clinical features of CEAS or PHO.

METHODS

Sixty-five Japanese patients recruited by a nationwide survey of CEAS during 2012-2016 were enrolled in this present study. We reviewed the clinical information of the genetically confirmed CEAS patients.

RESULTS

We identified recessive SLCO2A1 mutations at 11 sites in 46 patients. Among the 46 patients genetically confirmed as CEAS, 13 were men and 33 were women. The median age at disease onset was 16.5 years, and parental consanguinity was present in 13 patients (28%). Anemia was present in 45 patients (98%), while a single patient experienced gross hematochezia. All patients showed relatively low inflammatory markers in blood tests (median CRP 0.20 mg/dl). The most frequently involved gastrointestinal site was the ileum (98%), although no patient had mucosal injuries in the terminal ileum. Mild digital clubbing or periostosis was found in 13 patients (28%), with five male patients fulfilling the major diagnostic criteria of PHO.

CONCLUSIONS

The clinical features of CEAS are distinct from those of Crohn's disease. Genetic analysis of the SLCO2A1 gene is therefore recommended in patients clinically suspected of having CEAS.

A Hereditary Enteropathy Caused by Mutations in the SLCO2A1 Gene, Encoding a Prostaglandin Transporter

Previously, we proposed a rare autosomal recessive inherited enteropathy characterized by persistent blood and protein loss from the small intestine as chronic nonspecific multiple ulcers of the small intestine (CNSU). By whole-exome sequencing in five Japanese patients with CNSU and one unaffected individual, we found four candidate mutations in the SLCO2A1 gene, encoding a prostaglandin transporter. The pathogenicity of the mutations was supported by segregation analysis and genotyping data in controls. By Sanger sequencing of the coding regions, 11 of 12 other CNSU patients and 2 of 603 patients with a diagnosis of Crohn’s disease were found to have homozygous or compound heterozygous SLCO2A1 mutations. In total, we identified recessive SLCO2A1 mutations located at seven sites. Using RT-PCR, we demonstrated that the identified splice-site mutations altered the RNA splicing, and introduced a premature stop codon. Tracer prostaglandin E2 uptake analysis showed that the mutant SLCO2A1 protein for each mutation exhibited impaired prostaglandin transport. Immunohistochemistry and immunofluorescence analyses revealed that SLCO2A1 protein was expressed on the cellular membrane of vascular endothelial cells in the small intestinal mucosa in control subjects, but was not detected in affected individuals. These findings indicate that loss-of-function mutations in the SLCO2A1 gene encoding a prostaglandin transporter cause the hereditary enteropathy CNSU. We suggest a more appropriate nomenclature of “chronic enteropathy associated with SLCO2A1 gene” (CEAS).

Advanced diagnostic innovations such as capsule endoscopy and balloon endoscopy have provided better understanding of endoscopic findings of small bowel diseases. However, it remains difficult to diagnose small intestinal diseases such as Crohn’s disease, intestinal tuberculosis, and nonsteroidal anti-inflammatory drug-induced enteropathy by the endoscopic findings alone. We previously reported a rare autosomal recessive inherited enteropathy characterized by persistent blood and protein loss from the small intestine. This enteropathy has an intractable clinical course with ineffectiveness of immunosuppressive treatment. In this study, we identified recessive mutations in the SLCO2A1 gene, encoding a prostaglandin transporter, as causative variants of this disorder by exome sequencing of four families, and showed that this disease is distinct from Crohn’s disease. We also showed that the mutations found in the patients caused functional impairment of prostaglandin E2 uptake within cells. The present findings suggest that genetic analysis together with detailed clinical information is invaluable for diagnosis of the disease, and that there may be a concept of enteropathy referred to as “prostaglandin-associated enteropathy”, irrespective of ethnic background.

Dissolution of residual microfragments with citrate therapy after extracorporeal shock wave lithotripsy

Residual microfragments after ESWL were studied for their presence and for possibility of dissolution with citrate therapy. Among 123 patients with renal stones who became stone-free following ESWL, a computed tomogram (CT) identified remaining microfragments within the treated kidney in 31.7% of the patients, even though stone fragments were not detectable on ordinary x-ray (KUU). The experiments, in which calcium oxalate stone fragments collected after ESWL were incubated in buffer solutions with citrate 0 to 4 mmol/L, showed that citrate dissolved the stone fragments. Using human urine as a solution, the dissolving effect was greater in spot urines after alkali citrate administration than in control urines. Eighteen patients with microfragments underwent a follow-up CT 3 months later. The results showed that the microfragments had disappeared in 6 of 11 (54.5%) patients who had been taking alkali citrate, whereas microfragments remained unchanged in all 5 patients without medication. Our results suggest that citrate therapy would be advisable as a prophylaxis for stone recurrence especially after ESWL treatment.

Analysis of lymphocyte subsets in a renal allograft recipient infected with human immunodeficiency virus

OBJECTIVE

To study the change in lymphocyte subsets of a renal allograft recipient who acquired human immunodeficiency virus (HIV) infection.

PATIENT AND METHODS

A 53-year-old Japanese man who acquired HIV infection at the time of renal transplantation and died from opportunistic infection 3 years later was studied. Lymphocyte subsets were examined serially throughout his clinical course.

RESULTS

The numbers of CD4 positive cells were severely decreased but those of CD8 positive cells were stable; the CD 4/8 ratio was extremely low. The numbers of B cells were also decreased but production of immunoglobulin was increased. In spite of this immunosuppressive state, graft rejection was noted when the patient's immunosuppressive medication was reduced.

CONCLUSION

The lymphocyte subsets of renal transplant patients with HIV infection should be closely observed, as should the nature and timing of opportunistic infection in relation to transplantation, and the administration of immunosuppressive medication.

[Renal actinomycosis: a case report]

A 56-year-old male presented with a history of dull pain in the abdomen, accompanied by anorexia and weight loss. On examination, he had a moderate tenderness in the right kidney region. Radiological investigation could not deny renal tumor, and the right kidney was removed. Microscopically, characteristic colonies of actinomyces were seen. Preoperatively it is difficult to differentiate renal actinomycosis and renal tumor. Removal of the involved kidney followed by appropriate antibiotic therapy may be promptly curative.

[Retroperitoneal fibrosis suspected to be ureteral tumor because of its localization at the unilateral distal ureter: a case report]

The patient was a 32-year-old female with the complaint of right flank pain. Drip infusion pyelogram showed right hydronephrosis and retrograde urogram demonstrated a marked stenosis about 2 cm in length at the right distal ureter. The passage of the ureteral catheter and the contrast medium through the narrowing portion of the ureter could not be performed. The abdominal computerized tomographic (CT)-scan disclosed renal subcapsular urinoma, although no abnormal findings which caused ureteral stenosis were revealed. A suspicion of right ureteral tumor was entertained and total nephroureterectomy was performed. Histopathological diagnosis was the idiopathic retroperitoneal fibrosis, which involved the right ureter. One hundred and fifty five cases of idiopathic retroperitoneal fibrosis in the Japanese literature were reviewed.

[A case of congenital cystic adenomatoid malformation of the lung in 18-year-old male]

A case of congenital cystic adenomatoid malformation (CCAM) of the lung is reported. The patient had recurrent pneumonia after the second day of delivery, and was admitted to our hospital, at the age of 18. He received right pneumonectomy under the diagnosis of CCAM. The resected lung was composed of multiple cysts with thin wall measuring 20-30 mm in diameter. Microscopic examination showed that the cyst wall was lined by ciliated columnar epithelium, and infiltration of chronic inflammatory cells was found in the submucosal layer. Bronchial cartilage was absent through the specimen. These microscopic findings are identical with those of CCAM, which is very rare in this age.

[Citrate as an inhibitor of stone formation--with reference to intestinal citrate absorption and the influence of citrate on intestinal calcium absorption]

The response of serum citrate to the oral citrate load was studied in seven healthy subjects. Serum citrate was significantly elevated from 15 to 60 min post-load with some individual variations. In 27 stone-formers serum citrate and the response to the oral citrate administration was studied and compared with the results obtained on healthy subjects. The serum citrate concentration of stone-formers was 1.99 +/- 0.49 mg/dl as compared to 1.61 +/- 0.35 mg/dl in healthy subjects. After citrate administration serum citrate increased significantly in both groups, but no significant difference was shown in response to the oral citrate load between these two groups (3.44 +/- 0.94 mg/dl in stone-formers, 3.16 +/- 0.38 mg/dl in healthy subjects). In Sprague-Dawley rats each weighing about 200 g urinary citrate and calcium excretion were studied after administration of sodium citrate or calcium chloride or both. The concomitant equimolar administration of sodium citrate and calcium chloride did not have significant influence on urinary citrate or calcium excretion as compared when citrate or calcium was given alone. However, the calcium excretion was significantly decreased with the administration of citrate and calcium ata molar ratio of 1:2.

[Congenital perineal lipoma with accessory scrotum: a case report]

A tumor mass covered with scrotum-like skin on its tip was found on the perineal region of 3-year-old boy since his birth. The mass was diagnosed as congenital lipoma, which was resected, because of its gradual enlargement. Histopathological findings of the tumor indicated perineal lipoma, and the scrotum-like portion was diagnosed as an accessory scrotum. In the Japanese literature, 7 congenital perineal lipomas (6 males, 1 female) have been reported and all male cases except 1 case (no description about scrotum) were accompanied with an accessory scrotum. We conclude that there may be a close relationship between congenital perineal lipoma and accessory scrotum.

Results of long-term rice bran treatment on stone recurrence in hypercalciuric patients

A series of 182 calcium stone formers with idiopathic hypercalciuria underwent treatment with rice bran for 1 to 94 months. Urinary calcium excretion was considerably reduced, but there was some increase in urinary phosphate and oxalate. Urinary excretion of magnesium and uric acid, serum calcium, magnesium, phosphate, uric acid, parathyroid hormone (PTH) and ALP was unaffected. There were no obvious changes in serum iron, zinc and copper even when patients were treated for long periods. Rice bran was well tolerated in almost all cases and there were no serious side effects; 49 patients have undergone treatment for more than 3 years (average duration of administration 5.09 years). The frequency of new stone formation was drastically reduced (individual stone formation rate (no./year) from 0.720 +/- 0.533 to 0.125 +/- 0.204; group stone formation rate (no./patient-year) from 0.721 to 0.120) compared with the 3-year period before treatment. During treatment, 61.2% of patients remained in remission. Although rice bran therapy should be effective in correcting absorptive hypercalciuria, there may be limits to the overall ability of rice bran monotherapy to prevent recurrence.

Electrostatic interaction of microcapsules with guinea-pig polymorphonuclear leucocytes

Electrostatic interaction of microcapsules with guinea-pig polymorphonuclear leucocytes was investigated at different ionic strengths of the medium through measurements of the degree of phagocytosis by the cells of microcapsules. At any ionic strength, the interaction exhibited a maximum when the surface potential of microcapsules was equal to that of the leucocytes to make phagocytosis of microcapsules by the cells minimum. The experimental findings were analyzed by a novel model for the electrostatic interaction between ion-penetrable membranes. In this analysis, it was assumed that the leucocytes have an area (or areas) which permits cations to partition much more into the membrane than anions on their surface to reduce the electric potential of the area.

[Medical management for the prevention of the recurrence of urolithiasis--with special recurrence to the patients who underwent percutaneous nephrolithotripsy (PNL) or extracorporeal shock wave lithotripsy (ESWL)]

Questionnaires about stone recurrence after treatment with percutaneous nephrolithotripsy (PNL) or extracorporeal shock wave lithotripsy (ESWL) were sent to 11 hospitals in the central section of Japan. We received 255 replies on PNL cases and 157 replies on ESWL cases. These patients were evaluated for the recurrence of renal stones and the enlargement of residual stone fragments. The effect of the medical management for the prevention of recurrent stone disease on postoperative recurrence rate was also evaluated. The average follow-up period of patients treated with PNL was 21.6 months, and 18.5 months for patients treated with ESWL. In patients who underwent PNL, 25 of 162 patients (15.4%) who were treated completely without any residual stones have suffered from new stones. The residual stone or fragments enlarged in 14 of the 93 patients (15.1%) who had residual stones or fragments after the treatment. The recurrence rate was significantly higher for the recurrent stone former than the single stone former. The recurrence rate for the patients who had multiple stones, staghorn calculi and metabolic disorders such as hypercalciuria also had a high incidence. Patients who received medical treatment for the prevention of stone recurrence had a lower recurrence rate than the group not treated. Especially among the patients with hypercalciuria, the recurrence rate of stone disease in the treatment group was significantly lower than that in the group not treated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Renal cell carcinoma associated with tuberous sclerosis: a case report]

Renal angiomyolipoma associated with tuberous sclerosis is well known. On the other hand, few cases of renal cell carcinoma in connection with tuberous sclerosis have been reported. We report a patient with tuberous sclerosis whose kidney was involved with renal cell carcinoma. A 18-year-old woman was first admitted in August 1987 for evaluation of left renal tumor. Diagnosis of tuberous sclerosis was made when she was 11 years old on the basis of mental retardation, papules on her face, seizures, white leaf-shaped macules and periventricular calcifications. Computerized tomographic scan demonstrated a large mass arising from the left kidney and small masses in the right kidney. Angiography confirmed bilateral hypervascular renal tumors. On these bases, a clinical diagnosis of bilateral renal angiomyolipomas was made and surgical treatment of the left kidney was recommended because of its large size. However, her parents did not permit treatment until March, 1988. Finally, left nephrectomy of 4,750 g was performed and histological examination revealed renal cell carcinoma with clusters of spindle cells. In the literature available to us, we found twelve reports of malignant renal tumors associated with tuberous sclerosis including five renal cell carcinomas in Japan.

[Clinical studies on urinary tissue polypeptide antigen (TPA): problems and improvement in determination]

The reliability of measurement of urinary TPA using a Prolifigen TPA kit (Sangtec, Sweden) was investigated, and an improved method for stabilizing TPA was tested. Samples were filtrated with a cellulose nitrate membrane filter to remove impurities as a possible cause of a high false positive rate which has been a problem in urinary TPA measurement. Serum TPA and Tween 40-treated urinary TPA was not adsorbed by the filter, whereas TPA in the non-treated urine showed a marked affinity to the filter. This shows the instability of TPA in the original urine, and the impropriety of filtration as a measure of purification of urine samples. The dilution test of urine and the standard TPA, and the recovery test of the standard TPA added to 6 different urine samples showed reasonable results only when the samples were treated with Tween 40; otherwise the values were lower than expected. Thirty-four spot urine samples were tested to examine the change in TPA value during the storage for 24 hours. TPA values decreased when urine was stored at room temperature, but this change was prevented by treatment of urine with Tween 40.

[Foreign body in the kidney: report of a case]

A 49-year-old man was admitted with the suspicion of renal foreign body. A fragment of wire rope was penetrated from his right lumbar region while working. Drip infusion pyelography and computed tomography films revealed a linear metallic object in the region of the right kidney. The foreign body was successfully extracted from the right renal parenchyma. The 38 cases of foreign bodies in the upper urinary tract including 12 in the renal parenchyma found in the literature are reviewed.

[Citrate (CG-120) therapy in urolithiasis. 2. Effect on urinary and serum biochemistry ]

The long-term effects of citrate therapy (CG-120, 3 g/day or 4 g/day) were examined in 398 patients with upper urinary tract calculi. We studied the influence of citrate therapy on urinary and blood biochemistry in 353 of them. CG-120 caused a sustained increase in urinary citrate, urinary pH and potassium, but no substantial or significant changes in other urinary parameters (uric acid, phosphate, oxalate, sodium, chloride and urine volume). Although urinary calcium decreased significantly up to the 24th week, it did not change significantly there after and it tended to increase at the 54th week. Urinary creatinine excretion decreased after 34 weeks of administration, but this phenomenon could not be explained, because the level of blood urea nitrogen and serum creatinine was not elevated in any case before administration. There were no changes in the serum calcium, magnesium, phosphate, uric acid, sodium, potassium or chloride level.

[Citrate (CG-120) therapy for urolithiasis. 1. Clinical effects]

Urinary citrate is an important determinant for crystallization of calcium salts, and recently oral administration of citrate has been suggested to be clinically useful in the management of renal stone disease. The effect of CG-120, a citrate compound (potassium citrate, sodium citrate and citric acid) produced by Dr. Madaus (Germany), on upper urinary tract stones was investigated in 398 patients in this study group. The patients were treated with 3 or 4 g CG-120 daily. Two hundred thirty-one of them were treated accurately according to the protocol of the study for more than 32 weeks. The cumulative percentage of positive clinical effect for the stone (disappearance, passage or decrease in size) was 30.3% (70/231). There were no differences in the clinical effect between the group of 3 g/day and the group of 4 g/day. CG-120 seemed to be more effective in the cases of ureteral stone, young patients and females, but was less effective in the recurrent stone formers. Although there were 45 episodes of side effects in 38 patients in this study, no serious side effects attributed to CG-120 were experienced. CG-120 was proved as a useful drug in the treatment of upper urinary tract calculi as well as its prevention.

[Primary hyperparathyroidism in 23 cases]

Twenty-three cases of primary hyperparathyroidism were experienced at Wakayama Medical College Hospital and affiliated hospitals between January, 1969 and December 1985. Histopathological findings were adenoma in 22 cases, hyperplasia in 1 case. On the clinical diagnosis of this disease, the most sensitive laboratory test was serum calcium level, which was elevated in 21 patients (91%), and in 87.8% of all samples measured. Serum ionized calcium and phosphorus were also sensitive measures. The positive rate of serum PTH was 67% in 18 cases. Tl-chloride scintigraphy identified preoperatively the site of the adenomas in 8 out of 10 cases, and computed tomography in 10 out of 15 cases. Both methods are non-invasive, and are beneficial for the preoperative examination of the localization of parathyroid adenoma. After parathyroidectomy, serum calcium and ionized calcium levels recovered rapidly within the normal limit in 12 hours. On the other hand, serum phosphorus level increased gradually up to the normal limit in about 1 week.

Effect of dietary calcium and magnesium on experimental renal tubular deposition of calcium oxalate crystal induced by ethylene glycol administration and its prevention with phytin and citrate

Oral administration of ethylene glycol to rats, and the resultant intratubular depositions of microcrystals of calcium oxalate were studied investigating the influences of dietary calcium or magnesium and assessing the protective efficacies against the crystallizations by treatment with phytin and sodium citrate. With increase of calcium intake and consequent increase of urinary calcium excretion there was a marked increase in the amount of tubular deposit of calcium oxalate crystal and in the calcium content of renal tissue. Although magnesium deficiency accelerated renal tubular calcium oxalate deposition, the protection against the crystal formation was not observed with excessive dietary magnesium. When rats were fed a high-calcium diet supplemented with phytin, a significant inhibition of the intratubular crystallization was observed. It appeared obvious that a hypocalciuric action of phytin was attributed to the effect of the prevention. There was vigorous protection of crystal formation by treatment with sodium citrate, which correlated with the level of citrate concentration in the drinking water.

Rice-bran treatment for calcium stone formers with idiopathic hypercalciuria

The efficacy of rice-bran therapy was studied in patients with hypercalciuria who were suffering from calcium stones. The frequency of stone episodes was reduced dramatically, especially in "active recurrent stone formers". Urinary calcium excretion was considerably reduced, while urinary phosphate and oxalate were slightly increased. Urinary magnesium, uric acid, serum calcium, phosphate, magnesium and uric acid were not affected. There were no changes in serum iron, copper and zinc even when patients were treated for long periods. The treatment was tolerated well and there were no serious side effects. Rice-bran therapy is particularly useful in patients with hyperabsorptive hypercalciuria and it is effective in the prevention of recurrent urinary stone disease.

[Renal oxalate excretion following oral oxalate load in patients with urinary calculus disease and healthy controls]

Oral oxalate loading using sodium oxalate or a vegetable juice was done to evaluate the intestinal absorption of exogenous oxalate in 30 patients with renal stones and 13 healthy controls. Fifteen calcium oxalate stone formers, 7 non-oxalate stone formers and 10 healthy volunteers were given an oral loading of sodium oxalate (500 mg). Urinary oxalate increased promptly, reaching a peak value within 4 to 8 hours after administration of a synthetic oxalate orally in a fasting state. In calcium oxalate stone formers, the mean increment of urinary oxalate and the bioavailability following oral sodium oxalate load were significantly higher than in the healthy controls and non-oxalate stone formers. Furthermore, intestinal hyperabsorption of oxalate in our criterion was defined in six patients with calcium oxalate stones (40%). On the other hand, eight calcium oxalate stone formers and three healthy controls were given vegetable juice. Urinary oxalate was increased only slightly after the ingestion, and there was no difference between calcium oxalate stone formers and normal controls. These results suggest that a certain hyperoxaluria might be induced by intestinal absorption of exogenous oxalate, and that the hyperabsorption might indicate a possible risk factor for calcium oxalate stone formation.

[Circadian rhythms of lithogenic and inhibitory substances in the urine]

The diurnal variations of urine composition with respect to urinary pH, volume, creatinine, calcium, magnesium, phosphate, uric acid, citrate and oxalate were studied in five healthy men. Generally, there was considerable variations in the excretion of the different urine constituents with meal related peaks except phosphate, which was most pronounced after dinner. The analysis of a 24-hour urine collection cannot account fully for the crystallization properties of urine and a fractionated urinalysis might be of value for therapeutic decisions. However, such procedures probably will not be possible in clinical practice and more reliable methods for evaluation of the crystallization propensity in whole 24-hour urine have to be developed.

The adult type pulmonary hamartoma in an 11-year-old boy

Hamartoma of the lung occurs most often in persons after the age of 40, but quite rarely among children. This paper reports on an 11-year-old boy with a pulmonary hamartoma in the right upper lobe. The patient was asymptomatic, but a well demarcated, solitary, lobulated nodule with a "popcorn"-shaped calcification was visualised on chest x-ray film. An upper lobectomy was carried out to remove the lesion. The post-operative course was uneventful. Two years post-operatively, the child was symptom-free and has been developing normally.

[Studies of urinary risk factors in urolithiasis]

Urinary excretions of calcium, oxalate and uric acid were estimated in 160 stone-formers (male 118, female 42) and 257 healthy controls (male 207, female 50). Stone-formers were divided into two groups according to their stone analysis: calcium containing stone-formers and non-calcium stone-formers. Calcium stone-formers were divided again into those who had a single stone episode and multiple or recurrent stone episodes. Urinary calcium and oxalate showed significant increases in calcium stone-formers, while urinary uric acid increased only in male calcium stone-formers. Recurrent calcium stone-formers demonstrated significant high levels of urinary calcium excretion especially in males, whereas no difference of urinary oxalate excretion between recurrent and single stone-formers. The frequency distributions on the excretion of three subjects were estimated respectively in patients with calcium stone and in controls. Relative risks, risk curves and stone probabilities were proposed and compared. The higher excretion values of urinary calcium and oxalate closely related to higher risks of forming calcium stones. On the other hand, urinary uric acid did not have such a relation to calcium stone formation. We defined the states which urinary excretions exceeded 95% upper confidence limits of normal controls as hyperexcretions. Hypercalciuria was more than 200 mg/day in male and female, hyperoxaluria was 50 mg/day in male and 45 mg/day in female and hyperuricosuria was 850 mg/day in male and 650 mg/day in female according to our definition. Among male calcium stone-formers, hypercalciuria was found in 45.3%, hyperoxaluria in 26.4% and hyperuricosuria in 15.1%. While in female calcium stone-formers, hypercalciuria in 23.7%, hyperoxaluria in 26.3% and hyperuricosuria in 13.2%. Of the male calcium stone-formers 57.5% showed either or both hypercalciuria and hyperoxaluria, and recurrent stone-formers also demonstrated a higher incidence among them. Excretion products of urinary calcium and oxalate were calculated and compared in each group. Calcium stone-formers showed significant high values especially in male recurrent stone-formers. The estimation by combining some risk factors will provide more useful means of assessing severity of urinary calculous diseases and therapeutic effects of their various treatments.

Rice bran treatment for patients with hypercalciuric stones: experimental and clinical studies

The purpose of this study is to confirm the hypocalciuric effect of rice bran experimentally and clinically. Urinary calcium excretion and its absorption in the intestine were reduced significantly by rice bran or phytin in rats fed high calcium diets, while there were no significant decreases with a low calcium diet. For the clinical study 70 patients with idiopathic hypercalciuria were treated with rice bran (10 gm. twice daily) for 1 month to 3 years. In almost all patients rice bran caused a significant decrease in urinary calcium excretion, which was maintained during treatment. Evidence of stones has decreased clearly among patients treated with rice bran for 1 to 3 years, although this might be a halfway judgment of the long-term treatment. We suggest that phytin should be the most effective substance to reduce the intestinal absorption of calcium and that rice bran treatment should be effective for prevention of recurrent urinary stone disease.

[Clinical statistics on inpatients and operations in the Urological Department of the Wakayama Red Cross Hospital (April, 1979 to March, 1983)]

Statistical observations made on the 1,102 inpatients and 1,127 operations at our clinic between April 1979 and March 1983 were reviewed. The patients were most frequently in their sixties, and lately patients under 10 are increasing. The most frequent diseases of the inpatients were benign prostatic hypertrophies, ureteral calculi, undescended testicles and bladder tumors. The frequently performed operations were those for bladder tumors, phimosis and benign prostatic hypertrophies in order of frequency.

[Gynecological urologic disease: a summary of clinical experience during the last 4 years at Wakayama Red Cross Hospital]

From April 1979 to March 1983, sixty seven patients with gynecological urologic disease were experienced at our department. Forty one of them were inpatients, i.e., 15.3% of the total number of female in patients admitted during the same period. Thirty three urologic operations were performed on them which corresponded to 16.1% of the total operations on female patients. Ten of these patients had ureteral obstruction following gynecological operation, 8 had ureteral fistula, 7 had vesicovaginal fistula, 11 had tumor invasion to urinary tract, 14 had radiation cystitis, 16 had neurogenic bladder dysfunction, and 1 had other complication. The treatment of these patients and the results are summarized and discussed.

The trend of acquired immunity with live poliovirus vaccine and the effect of revaccination: follow-up of vaccinees for ten years

The persistence of neutralizing antibody (NA) against three types of poliovirus acquired after two doses of trivalent live attenuated poliovirus vaccine (LPV) has been followed up for ten years in individual vaccinees. Sixty-seven children were bled once a year over a five year period following the primary vaccination. More than 80% of them retained NA against all three types of poliovirus. Thirty-two individuals whose NA titres were 1:16 or over for types 1 and 2 and 1:4 or over for type 3 at the fifth year were further followed up for a further five years and it was shown that during this period some of them had a naturally-acquired antibody rise, mostly against type 3 virus. At the sixth to eighth year after the primary vaccination, one further dose of the trivalent vaccine was administered to the children whose NA titres were down to 1:8 or less and the effect of booster vaccination on NA was followed. Other subjects were revaccinated with LPV and their fecal excretion of the vaccine virus was investigated. The results showed that a decrease in serum antibody level could be a good indicator of the local resistance of the alimentary tract and that reinfection could occur if serum NA had decreased to 1:8 or less, which allowed a virus excretion in the stools.