Phase II study of a trastuzumab biosimilar in combination with paclitaxel for HER2-positive recurrent or metastatic urothelial carcinoma: KCSG GU18-18

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) is a widely explored therapeutic target in solid tumors. We evaluated the efficacy and safety of trastuzumab-pkrb, a biosimilar of trastuzumab, in combination with paclitaxel, in HER2-positive recurrent or metastatic urothelial carcinoma (UC).

PATIENTS AND METHODS

We enrolled 27 patients; they were administered a loading dose of 8 mg/kg trastuzumab-pkrb on day 1, followed by 6 mg/kg and 175 mg/m2 paclitaxel on day 1 every 3 weeks, intravenously. All patients received six cycles of the combination treatment and continued to receive trastuzumab-pkrb maintenance until disease progression, unacceptable toxicity, or for up to 2 years. HER2 positivity (based on immunohistochemistry analysis) was determined according to the 2013 American Society of Clinical Oncology /College of American Pathologists HER2 testing guidelines. The primary endpoint was objective response rate (ORR); the secondary endpoints were overall survival (OS), progression-free survival (PFS), and safety.

RESULTS

Twenty-six patients were evaluated via primary endpoint analysis. The ORR was 48.1% (1 complete and 12 partial responses) and the duration of response was 6.9 months [95% confidence interval (CI) 4.4-9.3 months]. With a median follow-up of 10.5 months, the median PFS and OS were 8.4 months (95% CI 6.2-8.8 months) and 13.5 months (95% CI 9.8 months-not reached), respectively. The most common treatment-related adverse event (TRAE) of any grade was peripheral neuropathy (88.9%). The most common grade 3/4 TRAEs were neutropenia (25.9%), thrombocytopenia (7.4%), and anemia (7.4%).

CONCLUSIONS

Trastuzumab-pkrb plus paclitaxel demonstrates promising efficacy with manageable toxicity profiles in patients with HER2-positive recurrent or metastatic UC.

Liposomal irinotecan plus fluorouracil/leucovorin versus FOLFIRINOX as the second-line chemotherapy for patients with metastatic pancreatic cancer: a multicenter retrospective study of the Korean Cancer Study Group (KCSG)

Background

There is no clear consensus on the recommended second-line treatment for patients with metastatic pancreatic cancer who have disease progression following gemcitabine-based therapy. We retrospectively evaluated the clinical outcomes of liposomal irinotecan (nal-IRI) plus fluorouracil/leucovorin (FL) and FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin) in patients who had failed on the first-line gemcitabine-based therapy.

Patients and methods

From January 2015 to August 2019, 378 patients with MPC who had received nal-IRI/FL (n = 104) or FOLFIRINOX (n = 274) as second-line treatment across 11 institutions were included in this retrospective study.

Results

There were no significant differences in baseline characteristics between groups, except age and first-line regimens. With a median follow-up of 6 months, the median progression-free survival (PFS) was 3.7 months with nal-IRI/FL versus 4.6 months with FOLFIRINOX (P = 0.44). Median overall survival (OS) was 7.7 months with nal-IRI/FL versus 9.7 months with FOLFRINOX (P = 0.13). There was no significant difference in PFS and OS between the two regimens in the univariate and multivariate analyses. The subgroup analysis revealed that younger age (<70 years) was associated with better OS with FOLFIRINOX. In contrast, older age (≥70 years) was associated with better survival outcomes with nal-IRI/FL. Adverse events were manageable with both regimens; however, the incidence of grade 3 or higher neutropenia and peripheral neuropathy was higher in patients treated with FOLFIRINOX than with nal-IRI/FL.

Conclusions

Second-line nal-IRI/FL and FOLFIRINOX showed similar effectiveness outcomes after progression following first-line gemcitabine-based therapy. Age could be the determining factor for choosing the appropriate second-line therapy.

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This multicenter retrospective study investigated nal-IRI/FL and FOLFIRINOX outcomes after gemcitabine-based therapy.

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We found no significant differences in outcome between nal-IRI/FL and FOLFIRINOX treatment.

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Both regimens were well tolerated; however, neutropenia and peripheral neuropathy were more frequent with FOLFIRINOX.

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Age (cut-off, 70 years) showed differential efficacy between chemotherapy regimens.

Non-Markovian Exciton-Phonon Interactions in Core-Shell Colloidal Quantum Dots at Femtosecond Timescales

We perform two-dimensional coherent spectroscopy on CdSe/CdZnS core-shell colloidal quantum dots at cryogenic temperatures. In the two-dimensional spectra, sidebands due to electronic coupling with CdSe lattice LO-phonon modes are observed to have evolutions deviating from the exponential dephasing expected from Markovian spectral diffusion, which is instantaneous and memoryless. Comparison to simulations provides evidence that LO-phonon coupling induces energy-gap fluctuations on the finite timescales of nuclear motion. The femtosecond resolution of our technique probes exciton dynamics directly on the timescales of phonon coupling in nanocrystals.

Endoscopic ultrasound-guided fine needle aspiration with liquid-based cytology preparation in the diagnosis of metastatic small-cell carcinoma in the pancreas

Pancreatic metastasis is extremely rare, particularly from small-cell lung cancer (SCLC). Studies on the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with liquid-based cytology (LBC) in the diagnosis of metastatic small-cell carcinoma in the pancreas have been rarely conducted. We report herein a case of pancreatic metastasis from SCLC diagnosed using EUS-FNA with LBC (ThinPrep). A 71-year-old man presented with chief complaints of hemoptysis and jaundice over the past 1 month. Lung & pancreas tumors with multiple liver nodules were detected on computed tomography. The aspirated material from the pancreas using EUS-FNA was prepared as a cytologic specimen with ThinPrep method, which revealed scattered and clustered "small blue cells" with scant cytoplasm and stippled chromatin with frequent apoptotic bodies. Immunocytochemical staining of the cellblock material revealed strong positivity for CD56 and thyroid transcription factor-1. Endobronchial biopsy for lung mass revealed nests of small, round, blue tumor cells with hyperchromatic nuclei showing salt and pepper chromatin, scant cytoplasm, and brisk mitotic activity. Therefore, a diagnosis of metastatic small-cell carcinoma to the pancreas with an extensive stage was finally made.

Type 2 Autoimmune Pancreatitis with Crohn's Disease

Autoimmune pancreatitis (AIP) is a distinct subtype of pancreatitis, which is classified into type 1 and 2 based on the clinicopathological features. According to the international consensus diagnostic criteria, pancreas resection or core biopsy specimens are recommended to make an accurate histological evaluation. However, the usefulness of endoscopic ultrasonography (EUS) guided fine needle aspiration (FNA) for histological evaluation has also been reported. Furthermore, the simultaneous presentation of type 2 AIP and Crohn's disease (CD) is very rare, especially in the Asian population. Therefore, we herein report a case of type 2 AIP with CD, which was diagnosed using EUS guided FNA with a 22-gauge needle.

The Usefulness of Argon Plasma Coagulation Compared with Endoscopic Submucosal Dissection to Treat Gastric Adenoma

Background/Aims

To date, the best therapeutic modality for gastric adenoma, especially low-grade adenoma, has not been established. The aim of this study was to assess the usefulness of argon plasma coagulation (APC) in treating gastric adenoma compared with endoscopic submucosal dissection (ESD).

Methods

We included 210 patients with gastric adenoma, who underwent treatment with either APC (97 patients) or ESD (113 patients). The clinical and pathologic characteristics, mean duration of hospital stay, complications, and recurrence rates between the two groups were compared.

Results

The mean adenoma size was 0.9 cm and 1.1 cm in the APC group and ESD group, respectively (p<0.001). The mean duration of hospital stay was significantly shorter in the APC group than in the ESD group (1.6 days vs. 5.8 days, p<0.001). Complications did not occur in the APC group. However, one case of perforation (0.9%) and 6 cases of bleeding (5.3%) occurred in the ESD group. The recurrence rates were 15.3% (15/97 patients) in the APC group and 3.5% (4/113 patients) in the ESD group (p=0.003). The proportion of hospitalization was less in the APC group (43.3%, 42/97) than in the ESD group (100.0%, 113/113) (p<0.001). Medical expense was less in the APC group (377,172 won) than in the ESD group (1,430,610 won) (p<0.001).

Conclusions

The findings of this study suggest that APC is a safe treatment method for gastric adenoma without serious complications. However, regular endoscopic follow-up is necessary to detect any residual or recurrent lesions due to the relatively high rate of local recurrence after APC.

Acute hemorrhagic rectal ulcer syndrome: Comparison with non-hemorrhagic rectal ulcer lower gastrointestinal bleeding

OBJECTIVE

The aim of this study was to describe the clinical characteristics of acute hemorrhagic rectal ulcer (AHRU) and to elucidate its predictive factors.

METHODS

The medical records of patients with AHRU were retrospectively reviewed. Their baseline clinical characteristics were compared with those of patients with non-AHRU lower gastrointestinal bleeding to identify predictive factors for AHRU.

RESULTS

Among the 118 patients who underwent emergency endoscopy due to acute massive hematochezia from 2013 to 2015, 25 (21.2%) were diagnosed as having AHRU. Of them, 22 (88.0%) were successfully managed endoscopically and 3 (12.0%) underwent surgery. Six (24.0%) patients developed rebleeding within 1-9 days after the initial bleeding, which was controlled by a repeat endoscopy. Five (20.0%) died during follow-up. A multivariate-adjusted logistic regression analysis revealed that a lower serum albumin level, worse Eastern Cooperative Oncology Group (ECOG) performance status and history of constipation were significant factors for predicting AHRU. Hypoalbuminemia (<30 g/L) had a sensitivity, specificity and positive and negative predictive values of 84.0%, 78.5%, 51.2% and 94.8% for predicting AHRU, respectively.

CONCLUSIONS

Approximately 20% of patients with massive hematochezia had AHRU. Most patients with AHRU can be managed endoscopically. Low serum albumin level, poor ECOG performance status and prior constipation could be used in distinguishing patients with and without AHRU, facilitating the selection of optimal bowel preparation method for massive hematochezia.

Extramedullary plasmacytoma mimicking pancreatic cancer: A case report and literature review

Pancreatic adenocarcinoma may account for more than 80% of all pancreatic neoplasms. Occasionally, other rare tumors such as lymphoma, metastatic tumor, and solid pseudopapillary neoplasm can be considered in the differential diagnosis. We report the case of an 82-year-old man with a pancreatic solid mass. This case suggests that endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) with biopsy, that is, EUS-FNA is recommended in the differential diagnosis of the pancreatic solid mass apart from pancreatic adenocarcinoma. In particular, the histologic core obtained by EUS-guided biopsy is helpful for the immunostaining of molecular markers to confirm the final diagnosis.

Obstructive ileus caused by phlebosclerotic colitis

A 57-year-old man with chronic kidney disease and a history of using numerous herbal medications visited Inje University Ilsan Paik Hospital for abdominal pain and vomiting. An abdominal radiograph showed diffuse small bowel distension containing multiple air-fluid levels and extensive calcifications along the colon. Computed tomography showed colon wall thickening with diffuse calcification along the colonic mesenteric vein and colonic wall. Colonoscopy, performed without bowel preparation, showed bluish edematous mucosa from the transverse to the distal sigmoid colon, with multiple scar changes. At the mid transverse colon, a stricture was noted and the scope could not pass through. A biopsy of the stricture site revealed nonspecific changes. The patient was diagnosed with phlebosclerotic colitis. After the colonoscopy, the obstructive ileus spontaneously resolved, and the patient was discharged without an operation. Currently, after 2 months of follow-up, the patient has remained asymptomatic. Herein, we report the rare case of an obstructive ileus caused by phlebosclerotic colitis with a colon stricture.

Acute pancreatitis associated with pegylated interferon-alpha-2a therapy in chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma. Combination therapy of pegylated interferon-alpha (PEG-IFN-α) and ribavirin (RBV) is a current standard treatment for chronic HCV infection in Korea, which has considerable adverse effects. Acute pancreatitis is a rare complication of PEG-IFN-α administration. We report a case of a 62-year-old female who experienced acute pancreatitis after 4 weeks of PEG-IFN-α-2a and RBV combination therapy for chronic HCV infection. The main cause of the acute pancreatitis in this case was probably PEG-IFN-α rather than RBV for several reasons. A few cases have been reported in which acute pancreatitis occurred during treatment with PEG-IFN-α-2b. This is the first report of acute pancreatitis associated with PEG-IFN-α-2a in Korea.

Influence of urban neighbourhood environment on physical activity and obesity-related diseases

OBJECTIVES

The impact of characteristics of neighbourhood environment on physical activity and obesity-related diseases is still the subject of debate. This study aimed to explore the impact of urban neighbourhood environment on physical activity and obesity-related diseases.

STUDY DESIGN

Cross-sectional study.

METHODS

Individuals who participated in the 2009 national health-screening programme, submitted all necessary information, and had lived in Community 1 (Haengdang) or Community 2 (Ilsan) for at least 2 years (n = 16,178) were selected for inclusion in this study. Anthropometric measures were taken and physical activity was assessed using a short questionnaire.

RESULTS

No significant difference in the trigger factors for walking, including the amount of neighbourhood park space, number of shopping malls, and distance between the community and shopping malls, was found between the two communities. However, Community 2 had a better street environment than Community 1. Participants who lived in Community 2 were more physically active [adjusted odds ratio (OR) 1.31, 95% confidence interval (CI) 1.16-1.48] and walked more regularly (adjusted OR 1.09, 95% CI 1.02-1.17) than participants who lived in Community 1, and were less likely to have abdominal obesity (adjusted OR 0.83, 95% CI 0.77-0.91), hypertension (adjusted OR 0.88, 95% CI 0.80-0.97) and diabetes (adjusted OR 0.86, 95% CI 0.75-0.99). However, the risk of dyslipidaemia, especially in terms of low-density lipoprotein cholesterol, was higher in Community 2.

CONCLUSIONS

These results suggest that a walkable environment has a positive influence on hypertension and diabetes, and physical activity is the possible mechanism for this association. A walkable environment may function as an important tool for health promotion in urban areas.

Tenofovir disoproxil fumarate monotherapy for nucleos(t)ide analogue-naïve and nucleos(t)ide analogue-experienced chronic hepatitis B patients

Background/Aims

This study investigated the antiviral effects of tenofovir disoproxil fumarate (TDF) monotherapy in nucleos(t)ide analogue (NA)-naive and NA-experienced chronic hepatitis B (CHB) patients.

Methods

CHB patients treated with TDF monotherapy (300 mg/day) for ≥12 weeks between December 2012 and July 2014 at a single center were retrospectively enrolled. Clinical, biochemical, and virological parameters were assessed every 12 weeks.

Results

In total, 136 patients (median age 49 years, 96 males, 94 HBeAg positive, and 51 with liver cirrhosis) were included. Sixty-two patients were nucleos(t)ide (NA)-naïve, and 74 patients had prior NA therapy (NA-exp group), and 31 patients in the NA-exp group had lamivudine (LAM)-resistance (LAM-R group). The baseline serum hepatitis B virus (HBV) DNA level was 4.9±2.3 log IU/mL (mean±SD), and was higher in the NA-naïve group than in the NA-exp and LAM-R groups (5.9±2.0 log IU/mL vs 3.9±2.0 log IU/mL vs 4.2±1.7 log IU/mL, P<0.01). The complete virological response (CVR) rate at week 48 in the NA-naïve group (71.4%) did not differ significantly from those in the NA-exp (71.3%) and LAM-R (66.1%) groups. In multivariate analysis, baseline serum HBV DNA was the only predictive factor for a CVR at week 48 (hazard ratio, 0.809; 95% confidence interval, 0.729-0.898), while the CVR rate did not differ with the NA experience.

Conclusions

TDF monotherapy was effective for CHB treatment irrespective of prior NA treatment or LAM resistance. Baseline serum HBV DNA was the independent predictive factor for a CVR.

Long-term virological outcome in chronic hepatitis B patients with a partial virological response to entecavir

BACKGROUND/AIMS

The clinical outcome of patients with a partial virological response (PVR) to entecavir (ETV), in particular nucloes(t)ide analogue (NA)-experienced patients, has not been thoroughly investigated. The aim of the present study was to assess long-term outcomes in NA-naive and NA-experienced chronic hepatitis B patients with a PVR to ETV.

METHODS

Chronic hepatitis B patients treated with ETV (0.5 mg/day) for at least 1 year were enrolled retrospectively. PVR was defined as a decrease in hepatitis B virus (HBV) DNA titer of more than 2 log10 IU/mL, yet with residual serum HBV DNA, as determined by real time-polymerase chain reaction, at week 48 of ETV therapy.

RESULTS

A total of 202 patients (127 NA-naive and 75 NA-experienced, male 70.8%, antigen positive 53.2%, baseline serum HBV DNA 6.2 ± 1.5 log10 IU/mL) were analyzed. Twenty-eight patients demonstrated a PVR. The PVR was associated with a high serum HBV DNA titer at baseline and at week 24. Virological response (< 60 IU/mL) was achieved in 46.2%, 61.5%, 77.6%, and 85% of patients with PVR at week 72, 96, 144, and 192, respectively. Resistance to antivirals developed in two NA-experienced patients. Failure of virological response (VR) in patients with PVR was associated with high levels of serum HBV DNA at week 48.

CONCLUSIONS

Patients with PVR to ETV had favorable long-term virological outcomes. The low serum level of HBV DNA (< 200 IU/mL) at week 48 was associated with subsequent development of a VR in patients with PVR to ETV.

Treatment of hepatocellular carcinoma in elderly patients

BACKGROUND/AIMS

The aim of this study was to compare the survival in elderly hepatocellular carcinoma (HCC) patients treated with curative modalities (radiofrequency ablation (RFA), percutaneous ethanol injection (PEIT) and surgery) to those treated with transcatheter arterial chemoembolization (TACE) and supportive care.

METHODOLOGY

Medical records of patients with HCC older than 75 years who had visited a single tertiary medical center from January 2000 to December 2011 were reviewed (n = 58). Multivariable-adjusted hazard ratios (HR) for mortality with 95% confidence intervals (CI) were estimated using Cox proportional hazard models.

RESULTS

Twenty-nine patients were treated by TACE, 19 patients by supportive care, and 10 patients by curative treatment (four by PEIT, three by surgery and three by RFA).Variables associated with increased survival were better Child-Pugh class and lower TNM stage. Treatment with curative intent showed significant survival benefit compared to TACE (HR for mortality, 0.10; 95% CI, 0.01-0.95). In a subgroup analysis among patients with resectable HCC, supportive care showed significantly worse survival over TACE (HR for mortality, 6.47; 95% CI, 2.14-19.56) and curative intent (HR for mortality, 16.23; 95% CI, 1.92-136.83).

CONCLUSIONS

Curative treatment seems to have a better survival benefit in comparison with other treatment modalities in elderly HCC patients.

[A case of small cell neuroendocrine tumor occurring at hilar bile duct]

Neuroendocrine tumors of the extrahepatic biliary tree are extremely rare malignancies accounting for 0.2-2.0% of all gastro-intestinal carcinoid tumors. Neuroendocrine tumors obstructing the biliary tree are extremely difficult to diagnose preoperatively and nearly impossible to differentiate from cholangiocarcinoma. Statistically, the most common anatomic location in the biliary tree is the common bile duct, followed by the perihilar region. Herein, we present a case of a small cell neuroendocrine carcinoma of the hilum in a 79-year-old man following laparotomy. To our knowledge, this is the first case of small cell type neuroendocrine carcinoma of hilar bile duct reported in Korea.

Risk factors of cryptogenic hepatocellular carcinoma in patients with low body mass index or without metabolic syndrome

BACKGROUND/AIMS

Many patients are diagnosed with cryptogenic hepatocellular carcinoma (HCC) without metabolic syndrome (MS). We investigated the risk factors for cryptogenic HCC in patients with a low body mass index (BMI) or without MS.

METHODS

Thirty-six patients were diagnosed with cryptogenic HCC over a 10-year period at a tertiary research hospital. Data including BMI score and risk factors for MS were analyzed retrospectively. Patients with fewer than two risk factors for MS (n = 16) were compared with those with two or more risk factors (n = 20). Patients with high BMI (≥ 23 kg/m(2), n = 20) were also compared with those with lower BMI (n = 16).

RESULTS

Patients with fewer than two risk factors for MS were significantly more likely to smoke and be hepatitis B surface antibodies (anti-HBs)-positive vs. patients with two or more risk factors. However, only smoking was statistically significant on multivariate analysis. Peaks of BMI were observed in two regions. Lower BMI was significantly associated with the presence of anti-HBs compared with high BMI, although this association was not statistically significant on multivariate analysis.

CONCLUSIONS

Smoking is a potential risk factor for cryptogenic HCC in patients without MS. Remote hepatitis B virus infection may be a risk factor for cryptogenic HCC in patients without MS or with a low BMI.

[A case of autoimmune hepatitis following acute hepatitis A]

The pathogenesis of autoimmune hepatitis (AIH) is unclear, but viral infections have been proposed as a potential trigger in patients with genetic predisposition. We report a case of AIH following acute hepatitis A (AHA). A 57-year-old woman presented with fatigue and pitting edema for last 3 months. She had been diagnosed as an AHA 15 months ago based on clinical features, biochemical tests and positive HAV IgM antibody at a local clinic. Her biochemical tests was normalized one month after AHA diagnosis, but the serum levels of aminotransferase started to rise four months after AHA diagnosis. Antinuclear antibody was positive at a titer of 1:40, and anti-smooth muscle antibody was also positive. Hypergammaglobulinemia and liver pathology were typical for AIH. The patients had a score of 17 according to the International Autoimmune Hepatitis Group's system. She was given prednisolone and azathioprine and showed complete response to immunosuppressive therapy. The present case is the first report on AIH triggered by AHA in Korea.

Renal Dysfunction Induced by Bacterial Infection other than Spontaneous Bacterial Peritonitis in Patients with Cirrhosis: Incidence and Risk Factor

Background/Aims

Deterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis (SBP) is a predictor for in-hospital mortality; however, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. The aim of this study was to investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis.

Methods

Retrospective data from inpatients with bacterial infections other than SBP were analyzed.

Results

Eighty patients were recruited for the analysis. The types of infections included that of urinary tract (37.5%), pneumonia (23.8%), biliary tract (20%), cellulitis (12.5%), and bacteremia of unknown origin (6.3%). Renal dysfunction developed in 29 patients (36.3%), of which 11 patients had irreversible renal dysfunction. The initial MELD score, neutrophil count, albumin, and blood pressure were significant risk factors in the univariate analysis, whereas only the MELD score was an independent risk factor for the development of renal dysfunction (p<0.001) after multivariate analysis.

Conclusions

The prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 36.3%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients.

Colonic mucosal necrosis following administration of calcium polystryrene sulfonate (Kalimate) in a uremic patient

Colonic necrosis is known as a rare complication following the administration of Kayexalate (sodium polystryrene sulfonate) in sorbitol. We report a rare case of colonic mucosal necrosis following Kalimate (calcium polystryrene sulfonate), an analogue of Kayexalate without sorbitol in a 34-yr-old man. He had a history of hypertension and uremia. During the management of intracranial hemorrhage, hyperkalemia developed. Kalimate was administered orally and as an enema suspended in 20% dextrose water to treat hyperkalemia. Two days after administration of Kalimate enema, he had profuse hematochezia, and a sigmoidoscopy showed diffuse colonic mucosal necrosis in the rectum and sigmoid colon. Microscopic examination of random colonic biopsies by two consecutive sigmoidoscopies revealed angulated crystals with a characteristic crystalline mosaic pattern on the ulcerated mucosa, which were consistent with Kayexalate crystals. Hematochezia subsided with conservative treatment after a discontinuance of Kalimate administration.

Effects of antioxidant supplements on cancer prevention: meta-analysis of randomized controlled trials

BACKGROUND

This meta-analysis aimed to investigate the effect of antioxidant supplements on the primary and secondary prevention of cancer as reported by randomized controlled trials.

METHODS

We searched Medline (PubMed), Excerpta Medica database, and the Cochrane Review in October 2007.

RESULTS

Among 3327 articles searched, 31 articles on 22 randomized controlled trials, which included 161 045 total subjects, 88 610 in antioxidant supplement groups and 72 435 in placebo or no-intervention groups, were included in the final analyses. In a fixed-effects meta-analysis of all 22 trials, antioxidant supplements were found to have no preventive effect on cancer [relative risk (RR) 0.99; 95% confidence interval (CI) 0.96-1.03). Similar findings were observed in 12 studies on primary prevention trials (RR 1.00; 95% CI 0.97-1.04) and in nine studies on secondary prevention trials (RR 0.97; 95% CI 0.83-1.13). Further, subgroup analyses revealed no preventive effect on cancer according to type of antioxidant, type of cancer, or the methodological quality of the studies. On the other hand, the use of antioxidant supplements significantly increased the risk of bladder cancer (RR 1.52; 95% CI 1.06-2.17) in a subgroup meta-analysis of four trials.

CONCLUSIONS

The meta-analysis of randomized controlled trials indicated that there is no clinical evidence to support an overall primary and secondary preventive effect of antioxidant supplements on cancer. The effects of antioxidant supplements on human health, particularly in relation to cancer, should not be overemphasized because the use of those might be harmful for some cancer.

The association between the serum sodium level and the severity of complications in liver cirrhosis

BACKGROUND/AIMS

Dilutional hyponatremia associated with liver cirrhosis is caused by impaired free water clearance. Several studies have shown that serum sodium levels correlate with survival in cirrhotic patients. Little is known, however, regarding the relationship between the degree of dilutional hyponatremia and development of cirrhotic complications. The aim of this study was to evaluate the association between the serum sodium level and the severity of complications in liver cirrhosis.

METHODS

Data of inpatients with cirrhotic complications were collected retrospectively. The serum sodium levels and severity of complications of 188 inpatients were analyzed.

RESULTS

The prevalence of dilutional hyponatremia, classified as serum sodium concentrations of <or=135 mmol/L, <or=130 mmol/L, and <or=125 mmol/L, were 20.8%, 14.9%, and 12.2%, respectively. The serum sodium level was strongly associated with the severity of liver function impairment as assessed by Child-Pugh and MELD scores (p<0.0001). Even a mild hyponatremia with a serum sodium concentration of 131-135 mmol/L was associated with severe complications. Sodium levels less than 130 mmol/L indicated the existence of massive ascites (OR, 2.685; CI, 1.316-5.477; p=0.007), grade III or higher hepatic encephalopathy (OR, 5.891; CI, 1.490-23.300; p=0.011), spontaneous bacterial peritonitis (OR, 2.562; CI, 1.162-5.653; p=0.020), and hepatic hydrothorax (OR, 5.723; CI, 1.889-17.336; p=0.002).

CONCLUSIONS

Hyponatremia, especially serum levels <or=130 mmol/L, may indicate the existence of severe complications associated with liver cirrhosis.

Efficacy of low-calorie, partial meal replacement diet plans on weight and abdominal fat in obese subjects with metabolic syndrome: a double-blind, randomised controlled trial of two diet plans - one high in protein and one nutritionally balanced

BACKGROUND

Little is known about the relative efficacy of high-protein vs. conventional diet plans that include partial meal replacements on body fat loss in obese subjects with metabolic syndrome.

OBJECTIVE

We aimed to evaluate the efficacy of two low-calorie diets with partial meal replacement plans-a high-protein plan (HP) and a nutritionally balanced conventional (C) plan-on reducing obesity in obese subjects with metabolic syndrome.

DESIGN

In a 12-week, double-blind study, we randomised 75 participants to either the HP- or the C-plan group. We recorded key metrics at 0 and 12 weeks.

RESULTS

The overall mean weight loss was 5 kg in the HP-plan group and 4.9 kg in the C-plan group (p = 0.72). Truncal fat mass decreased 1.6 kg in the HP-plan group (p < 0.05) and 1.5 kg in the C-plan group (p < 0.05), while whole body fat mass decreased 2.5 kg in the HP-plan group (p < 0.05) and 2.3 kg in the C-plan group (p < 0.05). Between-group losses did not differ significantly for truncal (p = 0.52) or whole body (p = 0.77) fat mass. Among subjects with > or = 70% dietary compliance, however, truncal and whole body fat mass decreased more in the HP-plan group (Delta 2.2 kg and Delta 3.5 kg respectively) than in the C-plan group (Delta 1.3 kg and Delta 2.3 [corrected] kg respectively) (p < 0.05).

CONCLUSION

The HP- and C-plans had a similar effect on weight and abdominal fat reduction, but the HP-plan was more effective in reducing body fat among compliant subjects.

[Microbiologic study of the bile culture and antimicrobial susceptibility in patients with biliary tract infection]

BACKGROUND/AIMS

Bacterial infection of biliary tract may cause severe inflammatory response or sepsis. An immediate bile culture and appropriate antibiotic administration are important to control the biliary tract infection. The objective of the study was to identify organisms in bile and the features of antibiotic susceptibility in patients with biliary tract infection.

METHODS

We retrospectively reviewed the clinical records of 212 patients whose bile had been cultured for variable biliary tract diseases at Inje University Ilsan Paik Hospital from Jan. 2000 to Feb. 2007. Bile samples were obtained from percutaneous transhepatic biliary drainage (PTBD, n=89), percutaneous transhepatic gallbladder drainage (PTGBD, n=14) or endoscopic naso-biliary drainage (ENBD, n=49).

RESULTS

The overall positive rate of bile culture was 71.7% (152 cases). The organisms cultured were Escherichia coli (25.0%), Enterococcus spp. (13.4%), Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) in decreasing order. Effective antibiotics for Gram-negative organisms were amoxicillin/clavulanic acid, amikacin, imipenem, and piperacillin/tazobactam in order of effectiveness. Of the cultured blood samples from 160 patients, fifty (31.2%) showed positive bacterial growth. The organisms isolated from blood were similar to those found in the bile.

CONCLUSIONS

A broad spectrum penicillin/beta-lactamase inhibitor is a recommendable antimicrobial for empirical treatment for biliary tract infection. However, Gram-positive bacteria such as Enterococcus spp. or methicillin-resistant Staphylococcus aureus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

[A case of terminal ileal ulcer of Henoch-Schönlein purpura treated with high dose steroid]

Henoch-Schonlein purpura (H-S purpura) is a systemic small-vessel vasculitis involving skin, joint, gastrointestinal tract, and kidney. It is characterized by the classic tetrad of abdominal pain, arthralgia, typical rash, and renal involvement. All of these clinical findings can occur in any order and at any time over several days to weeks. Gastrointestinal manifestations such as abdominal pain, melena, or hematochezia occur in 45-85% and preceed skin lesions up to 40% in H-S purpura. However, endoscopically proven gastrointestinal lesion is rare because majority of involved sites are small intestine. We report a case of Henoch-Schonlein purpura with terminal ileal ulcer, healed after treatment with high dose steroid, proven by colonoscopy.

[Usefulness of DeltaMELD/month for prediction of the mortality in the first episode of variceal bleeding patients with liver cirrhosis: comparison with CTP, MELD score and DeltaCTP/month]

BACKGROUND AND AIMS

There are many models for predicting prognosis of liver cirrhosis including Child Turcotte Pugh (CTP), the model for end-stage liver disease (MELD) score and its changes over time (DeltaCTP and DeltaMELD/month). We investigated the ability of these models to predict the mortality of liver cirrhosis patients with the first episode of variceal bleeding and which model can be usefully applied in practice.

METHODS

Seventy-one liver cirrhosis patients hospitalized for the first episode of esophageal variceal bleeding were retrospectively analyzed. The predictive power of initial CTP, MELD score, DeltaCTP and DeltaMELD/month was compared through c-statistics and multiple logistic regression.

RESULTS

All of the prognostic predictors measured higher in patients who survived than in those who died. The area under the receiver operating characteristic (ROC) curve for DeltaMELD/month in 6 months was 1, a higher value than 0.81 for initial CTP, 0.75 for initial MELD, and 0.84 for DeltaCTP/month; the area of DeltaMELD/month in 12 months was 0.81, also showing a higher value than others. DeltaMELD/month >0.27 was a strong significant prognostic predictor in 6 (odds ratio: 40.1, p=0.001) and 12 months (odds ratio: 14.1, p<0.001). Only the DeltaMELD/month was an independent prognostic predictor with a risk ratio of 1.604 (95% CI: 1.119-2.302, p=0.01) in 6 months and 1.627 (95% CI: 1.294-2.047, p<0.001) in 12 months.

CONCLUSIONS

The DeltaMELD/month is superior to initial CTP, MELD and DeltaCTP/month to predict 6 and 12 months mortality in liver cirrhosis patients with the first episode of variceal bleeding.

[Usefulness of serum alpha-fetoprotein (AFP) as a marker for hepatocellular carcinoma (HCC) in hepatitis C virus related cirrhosis: analysis of the factors influencing AFP elevation without HCC development]

BACKGROUND/AIMS

Serum alpha-fetoprotein (AFP) is frequently used for the diagnosis of hepatocellular carcinoma (HCC). Most available data concerning AFP came from studies of patients with chronic hepatitis B or mixed etiologies. Studies concerning the diagnostic value of AFP for HCV-related liver cirrhosis (LC) are limited. We evaluated the factors influencing AFP elevation in the absence of HCC and analyzed the diagnostic value of serum AFP in HCC surveillance of HCV-related LC patients.

METHODS

We enrolled 55 patients of HCV-related LC with HCC and 62 patients without HCC as a case-control study were analyzed. The sensitivity and specificity were calculated and the clinical and biochemical factors influencing serum AFP levels.

RESULTS

The sensitivities and specificities of serum AFP for the detection of HCC in HCV-related LC were 72.7% and 59.7% for AFP>or=20 ng/mL, and 47.3% and 92.5% for AFP>or=100 ng/mL, respectively. Elevated serum AST was independently associated with elevated serum AFP level in HCV-related LC. In cases of AST<or=2 upper limit of normal (ULN), the specificity of AFP>or=100 ng/mL for the diagnosis of HCC was 100%. However, in case of AST>2 ULN, the specificity was 85.0% for AFP>or=100 ng/mL and 95.0% for AFP>or=200 ng/mL.

CONCLUSIONS

Serum AST levels influence serum AFP level in HCV-related LC. In cases of AST<or=2 ULN, AFP greater than 100 ng/mL highly indicates HCC in HCV-related LC, but not in case of AST>2 ULN.

[A case of primary neuroendocrine carcinoma of liver presenting with liver abscess]

Primary hepatic neuroendocrine cell carcinoma is a very rare tumor. We experienced a 75-year-old woman with primary hepatic neuroendocrine carcinoma presenting with pyogenic liver abscess. Abdominal CT scan revealed a multiseptated liver abscess and an enlarged lymph node in portocaval portion. We performed percutaneous drainage of the liver abscess, but the amount of drained pus did not decrease after 20 days. The follow-up abdominal CT scan showed that the cystic portion of liver abscess had been replaced by the solid tumor. Microscopic examination of the tumor tissue showed nests of epithelial cells with uniform round hyperchromatic nuclei and high nuclear to cytoplasmic ratio. Immunohistochemical staining was strongly positive for synaptophysin and chromogranin A.

Pancreatic carcinoid tumor with obstructive pancreatitis: multislice helical CT appearance: case report

Carcinoid tumor of the pancreas is rare. Moreover, obstructive pancreatitis secondary to a pancreatic carcinoid tumor is extremely rare. We report a case of pancreatic carcinoid tumor in a 50-year-old male who presented with pancreatitis. On multislice helical computed tomography, the main pancreatic duct was obstructed by a small round tumor, and the main pancreatic duct proximal to the tumor was dilated. The correlation between the main pancreatic duct and the tumor was well depicted on minimum intensity projection image. This is the first report of multislice helical computed tomorgraphic and minimum intensity projection image findings of a pancreatic carcinoid tumor presenting with pancreatitis.

Small cell carcinoma of the colon: barium study and CT findings

Extrapulmonary small cell carcinoma is a rare neoplasm. It is an aggressive malignant tumour characterized by rapid local progression and early metastasis. We report a case of small cell carcinoma arising in the transverse colon in a 34-year-old man who presented with epigastric pain. On CT, a poorly enhancing bulky mass encircling the transverse colon with extensive regional lymph node metastases was observed. A segmental annular narrowing with thick interhaustral folds of the transverse colon was found by barium enema examination. This is the first report of barium study and CT findings of extrapulmonary small cell carcinoma of the colon.

Comparison of vancomycin-resistant enterococci isolates from human, poultry and pigs in Korea

Vancomycin-resistant enterococci (VRE) have emerged as an important nosocomial pathogen. Since 1989, a rapid increase in the incidence of enterococcal bacteremia and endocarditis by VRE has been reported. The use of avoparcin in animal husbandry is reportedly associated with the appearance of VRE. In this study, a multiplex polymerase chain reaction (PCR) method was established to detect and differentiate resistant types of enterococci, which specifically amplify the four van genes that encode vancomycin resistance elements. Using this method, we investigated the incidence rates and types of VRE from two types of farms: those that had used avoparcin and those that had not used avoparcin. A total of 1091 animal fecal samples were collected from 70 pig farms and 32 poultry farms. A total of 425 enterococci were isolated from the fecal samples. Among the 425 isolates, six showed a pattern of high-level vancomycin resistance (Minimal Inhibitory Concentration, MIC: 64-256 microg/ml). Out of six high-level VRE, three were isolated from poultry farms that had used avoparcin and three were not. The six high-level VRE harbored the vanA gene. Sixty-seven of 425 isolates that showed a pattern of low-level vancomycin resistance (MIC: 4-8 microg/ml) were associated with the presence of vanC-1 or vanC-2/3 gene. We also performed a repetitive extragenic palindromic PCR (rep-PCR) method to compare the genetic relatedness between the high-level VRE of six animal isolates and 31 human isolates. None of the animal isolates had a similar rep-PCR pattern as the human isolates but similarities between human VRE isolates were observed.

Prevalence and molecular epidemiology of vancomycin-resistant enterococci (VRE) strains isolated from animals and humans in Korea

BACKGROUND

To assess the possibility of VRE transmission from animals to humans, we studied the prevalence of vancomycin-resistant enterococci (VRE) in farm animals, raw chicken meat, and healthy people. We then determined the molecular relatedness of VRE isolates between animals and humans in Korea.

METHODS

We aimed to isolate VRE from 150 enterococci specimens of farm animals, 15 raw chicken meat samples, and stools from 200 healthy people. Species differentiation was done with conventional biochemical tests. Vancomycin resistance genotyping was done by polymerase chain reaction (PCR). Using the agar dilution method, antimicrobial susceptibility was tested for 8 antimicrobials and pulsed-field gel electrophoresis (PFGE) was done to evaluate the molecular relatedness of VRE isolates.

RESULTS

The prevalence of VRE was 14.7% (22/150) in farm animal specimens, 1% (2/200) in healthy people, and 60% (9/15) in raw chicken meat. Of 22 animal VRE isolates, 1 vanA E. faecium, 15 vanC1 E. gallinarum, and 6 vanC2 E. casseliflavus were identified. All of the 9 VRE from raw chicken meat and all of the 20 clinical VRE strains were vanA E. faecium. However, in healthy people, only 2 vanC2 E. casseliflavus were isolated. These showed low-level resistance to vancomycin and susceptibility to teicoplanin. However, 9 VRE strains from raw chicken meat had high-level resistance to vancomycin (MIC(50,90): >128 microg/mL), teicoplanin (MIC(50,90): >128 microg/mL), ampicillin (MIC(50,90): >128 nicrog/mL), erythromycin (MIC(50.90): >128 microg/mL), and tetracycline (MIC(50/90): 128/>128 microg/mL).

CONCLUSION

This study demonstrated little evidence of VRE colonization in healthy people despite high recovery of VRE among raw chicken meat. It is suggested that there is little evidence of VRE transmission from animals to healthy people. However, we assumed that there exists the possibility of VRE contamination during the processing of chicken meat.

Application of extended single-reaction multiplex polymerase chain reaction for toxin typing of Staphylococcus aureus isolates in South Korea

The extended single-reaction multiplex PCR (esr-mPCR) developed in this study to detect staphylococcal enterotoxins (SEs), including SEA, SEB, SEC, SED, SEE, SEH, SEI, and SEJ, requires fewer sets of primers than other conventional multiplex PCRs and can be used to detect newly identified staphylococcal enterotoxins SEs more readily. Esr-mPCR analysis of 141 isolates of Staphylococcus aureus obtained from abattoir and livestock product samples revealed that 27 of the S. aureus isolates were toxigenic, and two were 2 multitoxigenic isolates. The most prevalent SE type was SEI followed by SEA and SEH. In addition, we investigated the clonal relatedness of toxigenic S. aureus isolates by arbitrarily primed PCR (AP-PCR). AP-PCR analysis of toxigenic S. aureus isolates revealed that the discriminatory power of AP-PCR was 9 (D=0.81), 8 (D=0.77), and 10 types (D=0.83) with primers AP1, ERIC2, and AP7, respectively. The combination of three each AP-PCR result could rearrange toxigenic S. aureus isolates into 10 types and five subtypes, with the D-value of 0.92. Interestingly, our data showed that toxigenic S. aureus isolates from different sources had different fingerprinting patterns although some of them carried the same types of SE genes. These data suggest that combinations of esr-mPCR and AP-PCR can provide a powerful approach for epidemiological investigation of toxigenic S. aureus isolates.

Three-dimensional reconstructed images using multidetector computed tomography in evaluation of the biliary tract

The recent development of multidetector computed tomography (MDCT) and the parallel escalation in the capabilities of the workstation allow the use of high-quality multiplanar and three-dimensional reconstruction images. As a noninvasive technique, MDCT dedicated to the biliary tract represents an alternative to magnetic resonance cholangiography. The usefulness of three-dimensional reconstructed images using MDCT in evaluating biliary tract abnormality is illustrated.

Antimicrobial performance of alkaline ionic fluid (GC-100X) and its ability to remove Escherichia coli O157:H7 from the surface of tomatoes

An efficacy test of GC-100X, a noncorrosive alkaline ionic fluid (pH 12) composed of free radicals and supplemented with xylitol, was carried out against six major foodborne pathogens-Staphylococcus aureus FRI 913, Salmonella enterica serovar Enteritidis ATCC 13076, S. enterica serovar Typhimurium DT104 Korean isolate, Vibrio parahaemolyticus ATCC 17803, Escherichia coli O157:H7 ATCC 43894, and Pseudomonas aeruginosa KCTC 1637-at three different temperatures (4, 25, and 36 degrees C) with or without organic load (2% yeast extract). Results revealed a more than 4-log10 (CFU/ml) reduction (1.0 x 10(4) CFU/ml reduction) against all pathogens reacted at 37 degrees C for 3 h in the absence of organic material. GC-100X solution diluted with an equal volume of distilled or standard hard water (300 ppm CaCO3) showed effective bactericidal activity, particularly against gram-negative bacteria. Washing efficacy of GC-100X solution was compared against E. coli O157:H7 on cherry tomato surfaces with those of a commercially used detergent and chlorine water (100 ppm). Viable cell counts of E. coli O157:H7 that had penetrated to the cores of tomatoes after sanitizing treatment revealed that GC-100X stock and its 5% diluted solutions had similar washing effects to 100-ppm chlorine water and were more effective than the other kitchen detergent. These results indicate that GC-100X has good bactericidal and sanitizing activities and is useful as a new sanitizer for food safety and kitchen hygiene.

Inhibitory activity of Bifidobacterium longum HY8001 against Vero cytotoxin of Escherichia coli O157:H7

Vero cytotoxin (VT)-producing Escherichia coli (VTEC), such as E. coli O157:H7, are emerging foodborne pathogens worldwide. VTs are associated with hemorrhagic colitis and hemolytic uremic syndrome in humans. Attachment of the B subunit of VTs to its receptor, globotriaosylceramide (Gb3), at gut epithelium is the primary step and, consequently, the A subunit of VTs inhibits protein synthesis in the target cell. Proinflammatory cytokines, such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta, up-regulate Gb3 expression, increase sensitivity to VTs, and enhance VT action in developing disease. Currently, there is a growing interest in probiotics, given the increasing occurrence of antibiotic-resistant bacteria. In particular, much work on bifidobacteria among probiotics, regarded as microorganisms targeted for technological and therapeutic applications, has been performed. In Korea, the neutralizing effect of the culture supernatant of Bifidobacterium longum HY8001, Korean isolate, against the VTs from E. coli O157:H7 was found. Therefore, this study focused on the raveling of the inhibitory effect of B. longum HY8001 against VTs, through the interference B subunit of VTs and Gb3 interaction. Mice were inoculated intragastrically with B. longum HY8001 culture supernatant before and after challenge with E. coli O157:H7. Control mice were inoculated intragastrically only with E. coli O157:H7. Cytokine, TNF-alpha, and IL-1beta levels in sera and expression of their mRNA were decreased, and expression of Gb3 in renal tubular epithelial cells was reduced in mice treated with B. longum HY8001 culture supernatant. In competitive enzyme-linked immunosorbent assays (ELISAs), the culture supernatant of B. longum HY8001 primarily binds VTs to interfere the VTs with Gb3 interaction. These results suggest that soluble substance(s) in B. longum HY8001 culture supernatant may have inhibitory activity on the expression of Gb3, VT-Gb3 interaction, or both. Further study should be done to elucidate the property of soluble substances in B. longum HY8001 culture supernatant.

Location of the chronic subdural haematoma: role of the gravity and cranial morphology

Chronic subdural haematoma (SDH) frequently originates from subdural hygroma (SDG). The cranial morphology can determine the location of SDG. Since SDG is the precursor of chronic SDH, the shapes of the cranium wall act an important role in location of chronic SDH. The authors tried to test this hypothesis. The computed tomographic scans or magnetic resonance images of 118 consecutive patients with chronic SDH were re-evaluated, and the symmetry of the cranium and location of the lesion were checked. The cranium was symmetrical in 55 patients (47%) and asymmetrical in 63 patients (53%). Chronic SDH was bilateral in 25 patients (21%) and unilateral in 93 patients (79%). It was more commonly bilateral in symmetrical craniums than in asymmetrical craniums (29.1% vs. 14.3%) (p = 0.0496). In 63 patients with asymmetric cranium, the chronic SDH was bilateral in nine patients, located on the opposite side of the flat side in 38 patients, and located on the same side of the flat side in 17 patients. This unequal distribution was statistically significant (p = 0.03). In four patients, the haematoma originated from the acute SDH located on the same side of the flat side. No reason could be found in the remaining 13 patients. Chronic SDH originating from SDG usually locates on the opposite to the flat side of the skull. The shape and posture of the cranium can predict the location of chronic SDH, as in the SDG.

The fate of traumatic subdural hygroma in serial computed tomographic scans

We reviewed serial computed tomographic (CT) scans of 58 patients with traumatic subdural hygroma (SDG) to investigate its natural history. All were re-evaluated with a special reference to the size and density of SDG. Thirty-four patients (58.6%) were managed conservatively and 24 patients (41.4%) underwent surgery. The lesion was described as remained, reduced, resolved, enlarged and changed. Means of interval from injury to diagnosis and any changes in CT were calculated. SDGs were resolved in 12 (20.7%), reduced in 15 (25.9%), remained in 10 (17.2%), enlarged in 2 (3.4%), and changed into chronic subdural hematoma (CSDH) in 19 patients (32.8%). SDG was diagnosed at 11.6 days after the injury. It was enlarged at 25.5 days, remained at 46.0 days, reduced at 59.3 days, resolved at 107.5 days, and changed into CSDH at 101.5 days in average. SDGs were developed as delayed lesions, and changed sequentially. They enlarged for a while, then reduced in size. The final path of a SDG was either resolution or CSDH formation. Nearly half of SDGs was resolved or reduced within three months, however, 61.3% of unresolved or unreduced SDG became iso- or hyperdense CSDH. These results suggest that the unresolved SDG is the precursor of CSDH.

Location of the traumatic subdural hygroma: role of gravity and cranial morphology

Traumatic subdural hygroma (TSH) is frequently bilateral and locates on the top of the head in a supine position. It suggests that the gravity and cranial posture act a certain role. The authors tried to test this hypothesis. The computed tomographic (CT) scans or magnetic resonance (MR) images of 86 consecutive patients with TSH were re-evaluated. The symmetry of the cranium, the posture of the head during the radiological examinations, and the location of the lesion were all checked. The cranium was symmetrical in 47 patients and asymmetrical in 39 patients. TSH was more commonly bilateral in patients with symmetrical cranium than those with asymmetrical cranium (77% vs 62%). The asymmetrical cranium tended to turn to the flat side. It was more frequently oblique in MR images, which has a long scanning time, than in CT (29% vs 18%). In 39 asymmetric craniums, TSH was bilateral and it was symmetrical in 14 cases. In the remaining 25 cases, TSH located opposite to the flat side in 18 cases. In seven patients with the same side TSHs, four patients had it on the side of atrophy, two on the opposite side of a mass lesion. The gravity and cranial posture can predict the location of TSH. TSH usually occurs at the least pressure in the cranium as a lesion of ex vacuo.

Origin of chronic subdural haematoma and relation to traumatic subdural lesions

The origin of chronic subdural haematoma (CSDH) and the pathogenesis of subdural hygroma (SDG) are still controversial issues. These issues and relationships between these traumatic subdural lesions are discussed. The origin of CSDH is usually a SDG, although a few cases are caused by acute subdural haematomas (ASDH). Subdural hygroma is produced by separation of the dura-arachnoid interface, when there is sufficient subdural space. When the brain remains shrunken, the SDG remains unresolved. Any pathologic condition inducing cleavage of tissue within the dural border layer at the dura-arachnoid interface can induce proliferation of dural border cells with production of neomembrane. In-growth of new vessels will follow, especially along the outer membrane, then bleeding from these vessels occurs. These unresolved SDGs become CSDHs by repeated microhaemorrhage from the neomembrane. Although most victims with ASDH underwent surgery or died, some patients could be managed conservatively. Since the ASDH is usually absorbed within a few weeks, only a very few ASDHs become CSDHs, when there is a sufficient potential subdural space. Chronic subdural haematoma can arise from ASDH, but more commonly from SDG. Such transformation, or development of a new subdural lesion, is a function of the premorbid status and the dynamics of absorption and expansion.

The computed tomographic attenuation and the age of subdural hematomas

The sequential change in density (attenuation coefficient) of subdural hematomas (SDHs) in computed tomography (CT) is important in understanding the pathogenesis and evolution of SDHs. We retrospectively investigated the age of SDHs by CT in 446 cases. We included 30 cases of chronic SDHs, in whom the density was directly measured in the CT. The density of acute (within 7 days) SDH was hyperdense in 98.6%, isodense in 1.1%, and hypodense in 0.3% of the cases. In subacute (8-22 days) SDHs, it was hypodense in 45.7%, isodense in 42.9%, and hyperdense in 11.4%. In chronic (over 22 days) SDHs, 86.7% was isodense and only 13.3% was hypodense. In hypodense SDHs, 64.0% was the subacute, and 73.2% of the isodense SDHs was the chronic one. The mean interval from injury to CT was 0.5 +/- 1.6 days in hyperdense SDHs, 20.9 +/- 20.7 days in hypodense SDHs, and 54.9 +/- 44.0 days in isodense SDHs. In 30 cases of chronic SDH, the average density was 38.0 +/- 6.9 Hounsfield number(H) in 20 approximately 30 days, 43.8 +/- 12.8 H in 31 approximately 60 days, 51.8 +/- 5.1 H in 61 approximately 90 days, and 44.2 +/- 8.3 H in over 90 days. The density of acute SDH is usually hyperdense. It becomes hypodense within 3 weeks. Then the density progressively increases by the repeated microhemorrhage, which is the mechanism of enlargement of chronic SDH. The density of chronic SDH increases with time up to 90 days, then decreases again after maturation of the neomembrane, which is the mechanism of spontaneous resolution.

Brain abscess from a ganglionic hemorrhage--a case report

We present a unique case of a brain abscess that occurred secondary to a ganglionic hemorrhage in a 64-year-old man. This abscess appeared to be metastatic after septicemia. Aspiration with antibiotics eliminated this infection.

Gallbladder perforation: comparison of US findings with CT

We compared the ultrasound (US) findings of gallbladder (GB) perforation with computed tomography (CT) in 13 patients with GB perforation confirmed at surgery. The common findings of GB perforation were pericholecystic fluid collection and layering of GB wall on US, pericholecystic fluid collection, streaky omentum or mesentery, and GB wall defect on CT. Pericholecystic fluid collection, layering of GB wall, and cholelithiasis were similarly detected on US or CT. GB wall defect and/or bulging of the GB wall suggested a site of perforation was revealed in five patients (38.5%) on US and nine (69.2%) on CT. CT further disclosed the findings of streaky omentum or mesentery (84.6%). CT was superior to US for diagnosis of GB perforation.

The pathogenesis and fate of traumatic subdural hygroma

We present a series of 61 traumatic subdural hygromas, and discuss the pathogenic mechanisms and natural history of this condition. It commonly occurred in patients over 50 years of age and before 5 years of age. Fifty-two cases (85.2%) were diagnosed 3 days after head injury. Glasgow Coma Score (GCS) on admission was 3-8 in 24 (39.3%), 9-12 in 15 (24.6%) and 13-15 in 22 patients (36.1%). Although three patients (4.9%) showed slow deterioration, most hygromas were clinically 'silent'. Thirty-eight patients (62.3%) were managed conservatively and 23 patients (37.7%) underwent surgery. Only five patients (21.7%) showed gross improvement after surgery, even though surgery was performed only for enlarged hygromas shown by serial computed tomography. In five patients (8.2%), a chronic subdural haematoma subsequently developed from a hygroma. A favourable outcome (good recovery or moderate disability) occurred in 59%, an unfavourable outcome (severe disability and vegetative state) in 28%, and death resulted in 13%. Outcome was closely related to the severity of primary head injury.

Natural course of spontaneously reduced lumbo-sacral fracture-dislocation--a case report

We present a case of lumbosacral fracture-dislocation, which was spontaneously reduced during radiological examination. Such rapid reduction is, however, not reliable for long-term stability. We would like to report this case briefly because spontaneous reduction of lumbosacral fracture-dislocation has not been reported previously.