Three‐dimensional endoscopic ultrasonography for the assessment of early gastric carcinoma invasion: could it provide diagnostic innovations?

Background: This study aimed to evaluate a three‐dimensional endoscopic ultrasonographic (3‐D EUS) system in the assessment of the tumor invasion depth of early gastric carcinoma. Methods: Sixty‐nine macroscopically early cancer lesions in 67 patients were recruited in an in vivo study. The surgically resected gastric specimens of 30 of them were re‐examined in an ex vivo study. An Olympus 3‐D EUS imaging system was employed in both studies. Diagnostic accuracy for tumor invasion depth was evaluated and compared with histopathological sections stained by H&E and Masson’s trichrome stain. Reconstructed surface‐rendering images were evaluated and compared with the endoscopic and macroscopic findings. Results: Three‐dimensional EUS allowed rapid tomographic assessment of the lesions in both the in vivo and ex vivo studies. The accuracy of 3‐D EUS for the assessment of tumor invasion depth was 87% in the in vivo study. The accuracy rate was significantly lower (P = 0.03) for the cancer lesions associated with ulcer fibrosis (74%) than for those with no fibrosis (97%). In the 30 subjects who underwent both studies, the accuracy rates were higher in the ex vivo than the in vivo study (94%vs 77% for all the lesions, and 93%vs 74% for cancers associated with fibrosis), but were not statistically significant. The rates of good surface‐rendering images were 64% and 94% in the in vivo and ex vivo studies, respectively. The differences were attributed to the clearer dual‐plane reconstruction images obtained in the ex vivo study in absence of motion artifacts. Conclusions: Three‐dimensional EUS is a promising imaging technique for the assessment of tumor invasion depth of early gastric cancer.     

Exfoliative Cytopathology of Atypical Pulmonary Carcinoid: A Case Report

A 35-year-old man was diagnosed as having lung cancer and diedsix years later. In spite of an initial histological diagnosisof squamous cell carcinoma from the biopsy material, the correctdiagnosis of atypical carcinoid was made by sputum cytology.The carcinoid cells had exfoliated into the sputum collectedimmediately after bronchofiberscopic examination although thebronchial tissues obtained at this time did not reveal any histologicalfindings suggestive of neo-plasia. The distinctive cytologicalfeatures in sputum of atypical carcinoid that differentiateit from small cell carcinoma are considered to be the relativelyabundant vesicular cytoplasm and the finely reticular or granularchromatin pattern observed in well-preserved tumor cells. Thepresent case also suggests that clinical data may be indispensableto the differential cytological diagnosis of such tumors.     

The pH Measurement of Fasting Gastric Juice in Acute Gastric Mucosal Lesions

Abstract: Fasting gastric juice acidity was assessed to elucidate its role in the cause of acute gastric mucosal lesions (AGML). Gastric juice was aspirated through an auxiliary endoscopic channel during routine endoscopic examinations, and its pH was measured with a glass electrode PH meter. The pH of 100 cases with AGML (acute hemorrhagic erosions (AHE), acute gastric ulcer and acute hemorrhagic gastritis), and 586 cases with other ulcerative or inflammatory lesions were compared with the gastric juice pH in 1775 endoscopically normal subjects. The pH value was classgied into four acid groups: Hyperacidity (pH < 1.4), Normoacidity (1).5 < pH < 2.0), Hypoacidity (2).1 < pH <4.0) and Anacidity (4). 1 < pH). In cases with AHE, a signifcant hyperacidity was recognized both in the periods preceding and just after the onset. This hyperacidity was followed by signgicant anacidity, and thereafter a return to normoacidity. These pH changes coincided well with endoscopic appearances; preceding stage-hypernormacidity, black-slough stage—hyperacidity, white-slough stage-anacidity and scarring stage-;normoacidity. These results suggest that an elevation of gastric acidity etiologically relates with the formation of AGML, especially Shin.     

Changes in lung function and health status in patients with COPD treated with tiotropium or salmeterol plus fluticasone

Background and objective: The effects of tiotropium, a long‐acting anticholinergic drug, were compared with those of the combination of salmeterol, a long‐acting β₂‐agonist, and fluticasone, an inhaled corticosteroid, in patients with COPD. Methods: A 4‐month, randomized, open cross‐over study of tiotropium, 18 µg once daily, versus salmeterol, 50 µg, plus fluticasone, 200 µg, twice daily, was conducted in patients with COPD. Efficacy was assessed by spirometry and responses to the St George's Respiratory Questionnaire (SGRQ). After 4 months, patients were asked to select their subsequent therapy and indicate the reasons for their selection. Results: A total of 78 patients completed the study. There were no significant differences in the improvements in FEV₁ or SGRQ scores between the therapies. Similar numbers of patients selected tiotropium (42.3%) and salmeterol plus fluticasone (57.7%). However, those who preferred one of the therapies demonstrated greater improvements in SGRQ scores with that therapy. One subgroup of patients (30.8%) showed greater improvements in dyspnoea and FEV₁ in response to tiotropium, and the other subgroup of patients (35.9%) showed greater improvements in dyspnoea and FEV₁ in response to salmeterol plus fluticasone. Some patients (14.1%) selected salmeterol plus fluticasone because of positive effects on sputum expectoration. Conclusions: The study was unblinded and the results need to be interpreted with caution. However, tiotropium and salmeterol plus fluticasone had similar overall effects on pulmonary function and SGRQ scores in patients with COPD. Responses to the two therapies were heterogeneous, and the patients who showed greater improvements in FEV₁ or SGRQ scores with one of the therapies preferred it for their subsequent treatment.     

Percutaneous Epicardial Left Atrial Appendage Closure: Preliminary Results of an Electrogram Guided Approach

Background: Pharmacologic therapies to prevent stroke in atrial fibrillation (AF) have numerous limitations, prompting the development of device-based therapies. We investigated whether an electrogram-based approach using a novel hollow suture can safely capture and ligate the left atrial appendage (LAA).
Methods and Results: A novel system for closure of the LAA within the confines of the closed pericardium with a single sheath puncture was tested in 4 dogs. The tool used to grasp the appendage was fitted with electrodes and utilized electrical navigation to identify and confirm LAA capture. A hollow suture preloaded with a mechanical support wire to permit its manipulation and fluoroscopic visualization was advanced over the grasper, and the wire removed after the suture was positioned. The LAA was successfully closed in all dogs. In 2 dogs, after closure, a thoracotomy was performed and the LAA amputated without bleeding, confirming closure integrity. Necropsy confirmed closure in all animals.
Conclusions: Using electrical navigation, percutaneous epicardial LAA ligation with a remotely tightened suture was performed successfully within the confines of the intact pericardial space. This technique may allow decreasing the risk of stroke in AF patients without the need for thoracotomy or an endocardially placed prosthetic device.     

Optimal dosage and differences in therapeutic efficacy of IGIV in Kawasaki disease

In an initial study, three groups of patients with Kawasaki disease received either aspirin alone or alkylated immunoglobulin G intravenous preparation (IGIV) 200 mg/kg daily x3 days + aspirin, or 400 mg/kg alkylated IGIV daily x3 days + aspirin. In a second study, three groups of patients were treated with either 100, 200 or 400 mg/kg of native IGIV in combination with aspirin daily for 5 days. While the regimen of 200 mg/kg native IGIV daily x 5 days was found to be effective, the incidence of coronary artery lesions (CAL) was even less on a regimen of 400 mg/kg daily x 5 days. It is therefore suggested that a better therapeutic effect can be achieved with a 400 mg/kg dose of native IGIV. Based on the results from these two studies, it is assumed that native IGIV is more effective in inhibiting CAL formation and persistence than the chemically modified preparation in which the biological activity of the Fc region in the immunoglobulin G molecule is altered.     

Relationship Between Early and Advanced Gastric Cancers: --Retrospective Follow-up Study of Gastric Cancer--

A total of 2,726 cases of gastric cancer consisting of 670 casesof early cancer and 2,056 cases of advanced cancer were reviewed.Sixty-three out of 2,056 patients with advanced gastric cancerhad been examined endoscopically at least twice with an intervalof more than six months before surgical operations were performed.Retrospective study of these 63 cases showed that it is notuncommon to find some abnormalities suggesting malignancy inthe past endoscopic pictures of patients with advanced gastriccancer. Four demonstrable cases were selected for presentation.The course of these cases seems to support the concept thatearly gastric cancer as defined by Japanese researchers developsinto advanced gastric cancer.     

Epidemiology of Dural Arteriovenous Fistula in Japan: Analysis of Japanese Registry of Neuroendovascular Therapy (JR-NET2)

We developed the Japanese Registry of Neuroendovascular Therapy 2 (JR-NET2) database and used the information for a retrospective, nation-wide multicenter, observational study to clarify the clinical characteristics, current status of procedures, and outcome of patients treated by neuroendovascular therapy in Japan. In this report, we analyzed the clinical characteristics of dural arteriovenous fistulas (dAVFs) in the JR-NET2 database. All patients with dAVFs treated with endovascular therapy in 150 Japanese hospitals were included. Patient characteristics, clinical presentations, and imaging characteristics were analyzed. A total of 1,075 patients with dAVFs underwent 1,520 endovascular procedures. Of 1,075 patients, 45% were men and 55% were women. The mean age was 65 ± 13 years. The most frequent location of dAVFs was the cavernous sinus (43.6%), followed by the transverse-sigmoid sinus (TSS) (33.4%). Twelve percent of the patients had intracranial hemorrhage, 9% had venous infarction, and 3% had convulsion. The statistically significant independent risk factors of intracranial hemorrhage were TSS, superior sagittal sinus (SSS), tentorium, anterior cranial fossa, cranio-cervical junction, cortical venous reflux (CVR), and varix. Risk factors of venous infarction were age older than 60 years, male sex, TSS, SSS, and CVR. Risk factors of convulsion were male sex, SSS, and CVR. This is the largest nationwide report, to date, of the clinical characteristics of dAVFs treated by neuroendovascular therapy. CVR was a major risk factor of aggressive symptoms.     

Pathomorphological study of HCV antibody-positive liver cirrhosis

A morphological investigation was carried out to study the pathological features of liver cirrhosis caused by hepatitis C virus (HCV) infection. The materials consisted of liver specimens taken from 47 cases of anti-HCV antibody-positive liver cirrhosis (37 by surgery for hepatocellular carcinoma and 10 by autopsy), and from 21 cases of hepatitis B surface antigen-positive liver cirrhosis as the control. Liver specimens containing more than 10 regenerative nodules were examined. In addition, a histometric study was conducted to determine the degree of fibrosis and the size of regenerative nodule using a computer image-analysis system. The results showed that the histological characteristics of HCV antibody-positive liver cirrhosis are: (i) broadly expanded fibrous septa and small regenerative nodules; (ii) relatively strong inflammatory reaction and prominent lymphoid aggretation in the fibrous septum; and (iii) mild regenerative activity of the liver parenchyma, and infrequent liver cell dysplasia. These findings may facilitate better understanding of the pathology of HCV antibody-positive liver cirrhosis and more accurate pathological diagnosis by needle biopsy.     

Mycotic aneurysm of the renal transplant artery

A case of mycotic aneurysm secondary to septicemia is reported. A 59-year-old man with end-stage renal failure underwent renal transplantation from a living donor. On the fifteenth postoperative day, he was febrile and his arm around an entry wound of the drip infusion had infectious signs. Cultures of the blood and pus discharge grew Methicillin-resistant Staphylococcus aureus. Vancomycin was administered intravenously for 30 days. Then the existence of a mycotic aneurysm on the transplant artery was not suspected by computed tomography. After his infectious signs disappeared, examinations revealed a pseudoaneurysm measuring 4 cm in diameter at the site of anastomosis between the renal transplant and external iliac arteries by computed tomography. He has been carefully followed up with a conservative management. This is the first case of a mycotic aneurysm treated conservatively and displaying an uneventful course without rupture.