Prognostic factors of operated Rathke’s cleft cysts with special reference to re-accumulation and recommended surgical strategy

Background  

Rathke’s cleft cyst is known as an indolent disease, but has become intractable in a few cases. In this clinical investigation, the initial operative outcomes of Rathke’s cleft cyst and the mechanism of re-accumulation were investigated to identify the optimum surgical strategy for the second operation.     

Clinicopathological characteristics in patients presenting with acute onset of symptoms caused by Rathke’s cleft cysts

Background  

Symptomatic Rathke’s cleft cyst is usually accompanied by a long history of headache, visual disturbance, and hypopituitarism; however, rare cases present with acute onset and the clinical features in such cases remain uncertain. We report herein the clinical features of Rathke’s cleft cyst with acute onset and discuss the clinical significance.     

Rathke’s cleft cysts: differentiation from other cystic lesions in the pituitary fossa by use of single-shot fast spin-echo diffusion-weighted MR imaging

Summary Objective. Rathke’s cleft cysts are often difficult to differentiate from other sellar cystic lesions using conventional MR imaging. The purpose of this study was to investigate the usefulness of single-shot fast spin-echo (SSFSE) diffusion-weighted MR imaging (DWI) in the diagnosis of a Rathke’s cleft cyst. Pateients and Methods. We examined retrospectively 29 patients with a histologically verified sellar or suprasellar lesion containing a fluid component; 12 patients had a Rathke’s cleft cyst, 6 patients a craniopharyngioma, 5 patients a haemorrhagic pituitary adenoma, and 6 patients a cystic pituitary adenoma). Several regions of interest (ROIs) for apparent diffusion coefficient (ADC) measurements were identified in the fluid components of the lesions. For comparison, ADC values were normalized using a relative ADC (rADC), which was determined by dividing the ADC values of lesions by those of normal white matter and expressing the quotient as a ratio. Results. SSFSE provides diffusion-weighted images without significant susceptibility artifacts. DWI-SSFSE revealed Rathke’s cleft cysts as hypointense relative to the normal brain parenchyma in all cases. The mean value of ADC for Rathke’s cleft cysts was 2.12 × 10⁻³ mm²/sec. Both the ADC and relative ADC of the Rathke’s cleft cysts were significantly increased compared to those of the cystic components of craniopharyngiomas and haemorrhagic components of pituitary adenomas in the subacute phase (P < 0.05). There was not a statistically significant difference between Rathke’s cleft cysts and cystic components of pituitary adenomas (P < 0.05). Conclusions. DWI-SSFSE with ADC values provides objective information in the differential diagnosis of Rathke’s cleft cysts from other sellar cystic lesions. In addition, DWI-SSFSE with ADC values is useful for differentiating Rathke’s cleft cysts from craniopharyngiomas and haemorrhagic pituitary adenomas.     

The usefulness of chromoendoscopy with methylene blue in Barrett’s metaplasia and early esophageal carcinoma

Background Barrett’s esophagus is a condition that is premalignant for adenocarcinoma of the esophagus and the esophagogastric junction. Early detection of Barrett’s metaplasia and dysplasia is very important to decrease the mortality and morbidity from esophageal adenocarcinoma cancer. This study aimed to evaluate the effectiveness of methylene blue–targeted biopsies in the differential diagnosis of intestinal metaplasia, dysplasia, and superficial esophageal carcinoma. Methods A total of 109 patients (43 women and 66 men; average age, 62.32 ± 10.61 years; range, 33–82 years) were enrolled for the study. Four groups were designed before endoscopic examinations. The patients for these groups were selected at the conventional endoscopy, and then chromoendoscopy was performed. The esophagus was stained with methylene blue, after which six biopsies were taken from stained and unstained areas. Results Conventional and chromoendoscopic assessments were compared with histopathologic examination. The sensitivity of chromoendoscopy for Barrett’s epithelium was superior to that of conventional endoscopy (p < 0.05). However, there was no statistical difference between the two methods in the diagnosis of esophagitis or esophageal carcinoma (p > 0.05). Stained biopsies were superior to unstained biopsies in terms of sensitivity for Barrett’s epithelium and esophageal carcinoma (p < 0.001). Conclusion Chromoendoscopy is useful for delineating Barrett’s epithelium and for indicating the correct location for securing biopsies where dysplasia or early esophageal cancer is suspected.     

The association of cigarette smoking with a high risk of recurrence after ileocolonic resection for ileocecal Crohn’s disease

The purpose of this retrospective study was to examine the influence of cigarette smoking on the recurrence of Crohn's disease after resection. Between 1975 and 1990, 141 patients underwent primary ileocolonic resection for ileocecal Crohn's disease, 79 of whom were nonsmokers and 62 of whom were smokers at the time of their operation. The 5-and 10-year cumulative recurrence-free rates were 65% and 45% for the smokers, and 81% and 64% for the nonsmokers, the former values being significantly lower than the latter values (P=0.007). The smokers were further divided into two subgroups according to the number of cigarettes smoked per day; as mild smokers who smoked fewer than 15 per day (n=31) and heavy smokers who smoked 15 or more per day (n=31). The cumulative recurrence-free rate was lower in the heavy smokers compared with the mild smokers. These findings strongly suggest that smoking is associated with a high recurrence rate after ileocolonic resection for ileocecal Crohn's disease.     

Rathke’s cleft cyst rupture as potential initial event of a secondary perifocal lymphocytic hypophysitis: proposal of an unusual pathogenetic event and review of the literature

Herein, we report on a lymphocytic hypophysitis related to a ruptured Rathke’s cleft cyst which is not associated with pregnancy. A 45-year-old woman initially presented with headache and temporary double vision followed by amenorrhea. Preoperative imaging showed an intra- and suprasellar cystic mass. Complete resection of the tumor mass was performed via a transnasal, transseptal approach. Pathological examination displayed lymphocytic infiltrates within fibrotic tissue and residual pituitary cells accompanied by epithelial tissue of a Rathke’s cleft cyst. The strongest inflammatory reaction was observed at the site of disrupture of the cyst integrity, suggesting that high protein levels from ruptured Rathke’s cleft cyst might have triggered a lymphocytic hypophysitis. Our review of the literature provides further insights regarding the clinical behavior and different histological types of the lesions as well as the inflammatory changes that can occur in Rathke’s cleft cysts.     

Assessment of men’s risk thresholds to proceed with prostate biopsy for the early detection of prostate cancer

Purpose

To delineate the range of “risk thresholds” for prostate biopsy to determine how improved prostate cancer (CaP) risk prediction tools may impact shared decision-making (SDM).

Methods

We conducted a cross-sectional survey study involving men 45–75 years old attending a multispecialty urology clinic. Data included demographics, personal and family prostate cancer history, and prostate biopsy history. Respondents were presented with a summary of the details, risks, and benefits of prostate biopsy, then asked to indicate the specific risk threshold (% chance) of high-grade CaP at which they would proceed with prostate biopsy.

Results

Of a total of 103 respondents, 18 men (17%) had a personal history of CaP, and 31 (30%) had undergone prostate biopsy. The median risk threshold to proceed with prostate biopsy was 25% (interquartile range 10–50%). Risk thresholds did not vary by race, education, or employment. Personal history of CaP or prostate biopsy was significantly associated with lower mean risk thresholds (19% vs. 32% [P?=?0.02] and 23% vs. 33% [P?=?0.04], respectively). In the lowest versus highest risk threshold quartiles, there were significantly higher rates of CaP (36% vs. 1%, P?=?0.01) and prior prostate biopsy (46% vs. 17%, P?<?0.01).

Conclusions

Men have a wide range of risk thresholds for high-grade CaP to proceed with prostate biopsy. Men with a prior history of CaP or biopsy reported lower risk thresholds, which may reflect their greater concern for this disease. The extent to which refined risk prediction tools will improve SDM warrants further study.

     

Homocysteinemia and methylene tetrahydrofolate reductase gene’s relation to increased risk of coronary artery disease

Objective To review the association of methylene tetrahydrofolate reductase (MTHFR) C677T mutant with coronary artery disease, as well as to highlight the results of some of these studies and to emphasize the need to focus on the genetic architecture of CAD. Data SourcesData used in this article is mainly from relevant articles obtained through Pubmed, OVID and Google Scholar published from 1980 to 2008. Major studies and trials in this period were taken into account to draw accurate conclusion on the relation of those mutations in MTHFR with homocysteinemia and CAD. ResultOur analysis shows that hyperhomocysteinemia, a risk factor for occlusive arterial diseases, can be caused by disruptions of homocysteine metabolism catalyzed by MFTHR. A common alanine to valine mutation in MTHFR may contribute to mild heperhomocysteinemia in CAD. Individuals with the homozygous mutant genotype had higher plasma homocysteine, particularly when plasma folate was below the median value. ConclusionThis MTHFR mutant in the setting of insufficient folate may be a risk factor of CAD and can be regarded as a model of genetic-environmental interaction in the development of CAD.     

Sister’s fracture history may be associated with perimenopausal bone fragility and modifies the predictability of fracture risk

Summary  The present study investigated the effects of first degree relatives’ fractures on fracture incidence after the menopause. Sister’s, but not other relatives’, wrist or hip fracture history was associated with increased risk of fragility fractures after the menopause. This suggests genetic predisposition to bone fragility among postmenopausal women. Objective  The aim of the present study was to investigate the association between first degree relatives’ fractures and perimenopausal bone fragility. Materials and methods  The study sample of 971 perimenopausal women was extracted from randomly selected Kuopio Osteoporosis Risk Factor and Prevention cohort and measured with dual X-ray absorptiometry in femoral neck (FN) in baseline (1989–1991), in 5 years (1994–97), and in 10 years (1999–2001). All low-trauma energy fractures during the 10-year follow-up were recorded based on self-reports and validated from medical records. First degree relatives’ history of life-time hip and wrist fractures (exact classification or trauma energy not specified) was questioned by postal inquiries. Results  There was a significant correlation between fathers’ vs. brothers’ and mothers’ vs. sisters’ fractures (p < 0.01 in Pearson bivariate correlations). Sister’s, but not mother’s, father’s, or brother’s wrist and hip fractures were associated with significantly lowered 10-year fragility fracture-free survival rate (HR = 0.56, p = 0.006). Sisters’ or other relatives’ fractures were not associated with FN bone loss rate or bone mineral density (BMD) in the follow-up measurements (p = NS in ANCOVA). The predictive power of BMD for fragility fractures differed according to sisters’ fracture history: Baseline FN T score predicted fracture-free survival only among women without sisters’ fracture history (HR 0.62, p < 0.001 vs. women with sisters’ fracture in Cox regression). Conclusions  In conclusion, sisters’ fracture history is associated with 10-year fracture-free survival in perimenopausal women but not with BMD or its changes. Predictability of fragility fracture risk with BMD may depend on sister’s fracture history. This may indirectly suggest genetic predisposition to bone fragility independently of BMD.     

Evaluation of Monaldi’s approach with regard to needle decompression of the tension pneumothorax—A cadaver study

BackgroundAlthough needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi’s approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels.MethodsSix participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed.ResultsThe needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06 cm in right and from 3.00 to 5.00 cm in left hemithoraces. The distance C-B lay between 1.03 cm and 1.87 cm (right side), and 0.84 cm and 2.02 cm (left side).ConclusionIn our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi’s approach is a safe method for needle decompression of pneumothorax.     

Epidemiological study for personal risk factors and quality of life related to Dupuytren’s disease in a mountain village of Japan

Background

This study investigated the etiology, personal risk factors, and quality of life related to Dupuytren’s disease among residents of a mountain village in Japan.

Methods

Medical examinations were conducted of 401 adult residents (163 men, 238 women; average age of 66.7 years, range 40–92) of a mountain village in Japan. All had completed a self-administered questionnaire including items for gender, weight, height, dominant hand, occupation, history of diabetes mellitus, and frequency of smoking tobacco and drinking alcohol, in addition to EuroQol-5-Dimensions-3-level Japanese version. Blood samples were collected and assessed for biochemical markers related to Dupuytren’s disease. The Dupuytren’s disease diagnosis was based on clinical signs. Meyerding’s classification was used to ascertain the disease severity. After examining background data and physical examination data related to Dupuytren’s disease, we evaluated the association of Dupuytren’s disease with those factors using univariate and logistic regression analysis.

Results

Dupuytren’s disease was diagnosed in 28 subjects (7.0 %). Univariate analysis revealed associations of age, male gender, occupation, history of diabetes mellitus, and alcohol intake with Dupuytren’s disease. Logistic regression analysis after adjustment for age revealed a significant association between Dupuytren’s disease and male gender, occupation, and history of alcohol intake. No significant difference was found between Dupuytren’s disease patients and participants without this disease in the scoring and visual analog scale of EuroQol. No relation was found in scoring, the visual analog scale of EuroQol, or grading of Meyerding’s classification in participants with Dupuytren’s disease.

Conclusion

This cross-sectional study revealed Dupuytren’s disease in 7.0 % of 401 subjects among the general population of a mountain village in Japan. The prevalence is higher with age and is apparently associated with male gender, occupation and alcohol intake. Risk factors associated with Dupuytren’s disease were identified as age, male gender, occupation, and alcohol consumption habits.     

Risedronate and Pamidronate Treatment in the Clinical Management of Patients with Severe Paget’s Disease of Bone and Acquired Resistance to Bisphosphonates

The aim of this study was to evaluate the efficacy and safety of risedronate and pamidronate in 30 patients (mean age = 57.86 ± 8.90 years) with severe Pagets disease of bone (PDB), showing acquired resistance to intravenous (IV) clodronate treatment. Fifteen patients were treated with oral risedronate (30 mg/day for 8 weeks). Treatment was repeated in patients without evidence of PDB remission [total alkaline phosphatase (tALP) serum levels in the normal range] at day 120. Fifteen patients were treated with IV pamidronate (30 mg/day for 3 days). Pamidronate treatment (60 mg/day for 3 days) was repeated in patients without evidence of PDB remission at day 120. At day 60, a significant decrease in tALP serum levels was obtained in all pagetic patients. At day 360, 13 (86.6%) patients treated with risedronate achieved PDB remission, 9 patients during the initial treatment and 4 after retreatment. Two patients showed a significant decrease in tALP serum levels without clinical remission after two risedronate treatments. At the same time, 12 (80%) patients treated with pamidronate achieved PDB remission, 6 patients during the first treatment and 6 after retreatment. Three patients showed a significant decrease in tALP serum levels but no clinical remission after two pamidronate courses. Two of these patients showed a relapse during the study. The incidence of minor side effects and transient hyperparathyroidism related to bisphosphonate treatment was significantly lower after risedronate therapy. In patients with resistant PDB, oral risedronate therapy has comparable efficacy to IV pamidronate with a lower incidence of treatment-related side effects.     

A case of Goodpasture’s syndrome complicating pregnancy with dialysis requiring renal failure responding to plasmapheresis and termination of pregnancy

Abstract

Goodpasture’s syndrome complicating pregnancy is extremely rare and dialysis requiring anti GBM disease with renal recovery is uncommon. We report a case of a 23-year-old primi gravida who presented with Goodpasture’s syndrome during thirteenth week of pregnancy. She was initiated on steroids and cytotoxic drugs along with intensive plasma exchange and alternate day hemodialysis. Her pregnancy was terminated at 15 weeks. Patient improved dramatically with treatment, her renal functions normalized and her Anti GBM antibody titer became negative.     

Wegener’s granulomatosis with massive gastrointestinal hemorrhage due to jejunal and colonic involvement: Report of a case

Wegener’s granulomatosis (WG) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by the involvement of the upper airways, lungs, and kidneys. Although most organ systems can be involved, gastrointestinal involvement in WG is notably uncommon. We herein present the case of a WG patient who developed two massive gastrointestinal hemorrhages treated respectively by surgery and angiographic embolization of the bleeding artery. The present case indicates that gastrointestinal manifestations might thus be considered in the natural history of WG.     

Scintigraphic, biochemical, and clinical response to zoledronic acid treatment in patients with Paget’s disease of bone

Bisphosphonates have long been used with success in the treatment of Paget’s disease of bone (PDB). The aim of this study was to evaluate the early (up to 3 months) and late (at 12 months) scintigraphic, biochemical, and clinical response to a single intravenous infusion of zoledronic acid (ZOL) in patients with PDB serially assessed for 1 year. Nine patients with 30 bone lesions caused by PDB were prospectively evaluated. Total serum alkaline phosphatase (SAP) was serially measured. Scintigraphy was performed before and at 3 and 12 months after ZOL administration, and bone lesions were assessed quantitatively. After treatment, pain was alleviated in five of six patients starting from the first month. At 3 months, a significant decrease of SAP levels compared to baseline values was found (322 ± 211 IU/l before vs. 101 ± 36 IU/l 3 months after; P < 0.05), with normal values attained in all except one patient. The scintigraphic index of involvement (SII), a marker for the perpatient activity of the disease, was reduced from 14.4 ± 7.6 to 7.2 ± 1.8 (P = 0.01). The scintigraphic ratio (SR), a marker for the per-lesion activity of the disease, was reduced from 12.8 ± 7.7 to 7.0 ± 2.9 (P < 0.001). The values of markers of disease activity remained unchanged up to 12 months. A single intravenous administration of ZOL leads to a favorable clinical, biochemical, and scintigraphic response in patients with PDB starting as early as 3 months after treatment and lasting no less than 12 months (i.e., considerably longer than the other existing therapies).