Characterization of hepatocellular carcinoma and colorectal liver metastasis by means of perfusion MRI

PURPOSE: To characterize and compare hepatocellular carcinoma and liver metastases of colorectal metastatic cancer (CMC) by means of quantitative liver perfusion MRI. MATERIALS AND METHODS: Liver perfusion was assessed in 26 HCC and CMC patients (50 nodules) by means of contrast-enhanced MRI. Six perfusion parameters-hepatic perfusion index (HPI), mean transit time (MTT), distribution volume (DV), total blood flow (F(T)), arterial blood flow (F(A)), and portal blood flow (F(P))-were calculated in tumor nodules and the adjacent hepatic parenchyma. RESULTS: The values of F(T), F(A), F(P), and DV were significantly higher in the HCC than in the CMC group, whereas MTT was significantly higher in the CMC group. There was no significant difference in HPI. Arterial blood flow was higher than portal blood flow in the CMC group, while portal blood flow was slightly higher than arterial blood flow in the HCC group. CONCLUSION: The present work describes the use of dynamic MRI to quantitatively assess liver perfusion, which in the future may help studying liver cancers on the basis of their microvascular characteristics.     

Reduced 11beta-hydroxysteroid dehydrogenase activity in experimental nephrotic syndrome.

BACKGROUND: The disease state of the nephrotic syndrome is characterized by abnormal renal sodium retention that cannot be completely explained by a secondary hyperaldosteronism for the following reasons. Firstly, in rats an enhanced sodium retention is observed before proteinuria with intravascular volume depletion occurs. Secondly, in patients with the nephrotic syndrome, volume expansion with hypertension has been reported despite suppression of the renin-aldosterone system. Therefore, another mechanism for sodium retention must be postulated for this disease state. We hypothesize that this mechanism is a reduced 11beta-hydroxysteroid dehydrogenase 2 (11beta-HSD2) activity, a phenomenon known to cause enhanced access of cortisol or corticosterone to the mineralocorticoid receptor. METHODS: We assessed the 11beta-HSD activity by measuring the urinary ratio of tetrahydrocorticosterone (THB) plus 5alpha-tetrahydrocorticosterone (5alpha-THB) to 11-dehydro-tetrahydrocorticosterone (THA) by gas chromatography-mass spectrometry in rats with puromycin aminonucleoside (PAN)-induced proteinuria and with adriamycin nephrosis. Furthermore, the plasma ratios of corticosterone to 11-dehydrocorticosterone were measured. RESULTS: The urinary ratio of (THB+5alpha-THB)/THA increased in all animals following injection of PAN or adriamycin, indicating a reduced activity of 11beta-HSD. The reduced activity of 11beta-HSD was confirmed by an increased plasma ratio of corticosterone to 11-dehydrocorticosterone. The changes in the glucocorticoid metabolite ratios were already present before significant proteinuria appeared. CONCLUSION: PAN- or adriamycin-treated rats develop proteinuria with a reduced activity of 11beta-HSD, a mechanism contributing to the abnormal sodium retention in nephrotic syndrome.     

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 3-year prospective follow-up study

Introduction and hypothesis

To evaluate clinical outcomes at 3 years following total transvaginal mesh (TVM) technique to treat vaginal prolapse.

Methods

Prospective, observational study in patients with prolapse ≥stage II. Success was defined as POP-Q-stage 0-I and absence of surgical re-intervention for prolapse. Secondary outcome measures were: quality of life (QOL), prolapse-specific inventory (PSI), impact on sexual activity and complications.

Results

Ninety women underwent TVM repair, 72 a hysterectomy. Anatomical failure rate was 20.0% at 3 years. Three patients required re-intervention for prolapse. Improvements in QOL- and PSI-scores were observed at 1 and 3 years. Vaginal mesh extrusion occurred in 14.4% patients. After 3 years, 4.7% asymptomatic extrusions remained present. Of 61 sexually active women at baseline, a significant number of patients (41%) ceased sexual activity by 3 years; de novo dyspareunia was reported by 8.8%. One vesico-vaginal fistula resolved after surgery.

Conclusion

Medium-term results demonstrate that the TVM technique provides a durable prolapse repair.     

Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women

OBJECTIVE: With a prevalence of around 20%, childhood sexual abuse (CSA) is a relevant problem in obstetric care. The aim of our systematic review was to present the current knowledge on the influence of CSA on pregnancy, delivery, and early parenthood. DATA SOURCES: All English, French, or German primary and secondary literature from the reference lists found after screening the data banks Pubmed, PsycInfo, and Psyndex for publications that include the terms CSA or childhood traumatization and pregnancy, birth, delivery, labor, childbearing, breast feeding, or postpartum, and published after 1970 were reviewed for relevant data. METHODS OF STUDY SELECTION: Investigations of psychological/medical data banks and cross references revealed 43 relevant studies. Given the paucity of data on this important subject, we opted to review all of these studies. TABULATION, INTEGRATION, AND RESULTS: Although research projects on this topic are rare and the methodological quality of studies published to date is generally poor, women with a history of CSA seem to present a variety of long-term sequelae referring to pregnancy, delivery, and early parenthood. These sequelae include risk behaviors during pregnancy and disturbance of delivery by sudden memories of sexual abuse situations. Prenatal care is often complicated by the tendency to avoid situations that can trigger memories. CONCLUSIONS: As effective treatment programs to improve sequelae of CSA are available today, the question of such abuse experiences should be raised as early as possible and adequate interdisciplinary models to care for victimized patients should be established. However, to improve knowledge on the long-term effect of sexual abuse experiences in obstetrical care, methodologically well-designed research projects focusing on the kind and incidence of sequelae, mediating factors as well as prophylactic and therapeutic options are needed.     

Gyneco-psychosomatic counseling in Germany and Switzerland--aims and state of the art

OBJECTIVE: To investigate actual counseling models for gynecological patients in Switzerland and in Germany. METHODS: A questionnaire investigating psychosomatic care was sent to all Swiss (N=183) and German (N=1078) departments of gynecology, obstetrics, and/or endocrinology. RESULTS: One hundred twenty-eight (27%) completed questionnaires from Germany and 57 (31%) from Switzerland were available for statistical evaluation. Eighty-seven percent of the answering clinics from Switzerland and 93% of those from Germany (ns) considered psychosomatic counseling for gynecological and obstetrical patients as very important or important. Seventy-two percent of the Swiss and 70% of the German departments (ns) offered psychosomatic support. Models of counseling varied greatly between types of hospitals and both countries. Less than 15% of the medical doctors had a formation for psychosomatic counseling. CONCLUSION: Actual possibilities seem to be below the need for psychosomatic care. An adequate formation of medical doctors and considering the effects of psychosomatic care in the discussion on cost reduction for medical treatment would help to improve counseling structures.     

Quality of Life After TKA for Patients With Juvenile Rheumatoid Arthritis

Total knee arthroplasty frequently is required during early adulthood in patients with advanced juvenile rheumatoid arthritis. We queried patients on issues of importance to them, asked whether they were satisfied with surgical outcomes, and ascertained their postoperative status. We retrospectively reviewed 14 adult patients (22 knees) with severe juvenile rheumatoid arthritis who were treated with primary total knee arthroplasty between 1989 and 2001. All patients were evaluated by pain and stiffness visual analog scales, range of motion, the Patient-Specific Index, Hospital for Special Surgery knee score, WOMAC Osteoarthritis Index, EuroQuol in five dimensions, and SF-36 Health Survey. Preoperative scores were assessed by recall. Patients had a minimum followup of 2 years (mean, 8 years; range, 2-13 years). Quality of life improved after TKA as measured by the Patient-Specific Index. Eighteen of 22 patients rated themselves satisfied with the functional outcome of their surgery; all patients were satisfied with pain relief. Final SF-36, EuroQuol in five dimensions, and WOMAC scores were low compared with age-matched population norms. A mean postoperative flexion arc of 77 degrees (range, 30 degrees -130 degrees ) was observed. Total knee arthroplasty had a major positive impact on quality of life as reported by patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

Left ventricular architecture after valve replacement due to critical aortic stenosis: an approach to dis-/qualify the myth of valve prosthesis–patient mismatch?

Objectives: Left ventricular hypertrophy in patients with critical aortic stenosis (AS) is an adaptive process that compensates for high intracavitary pressure and reduces systolic wall stress followed by an increase in myocardial masses. In the present prospective clinical trial, we investigated long-term compensatory changes in left ventricular geometry and function after aortic valve replacement using mechanical bileaflet prostheses with the main emphasis on the small-sized aortic annulus and valve prosthesis–patient mismatch. Methods: A total of 58 patients with critical AS were assigned to the following groups according to the predictive value of prosthetic valve area index (VAI): group EXMIS: 29 patients (VAI≤0.99), expected mismatch; group NOMIS: 29 patients (VAI≤0.99), no mismatch. At controls T₀ (before operation/operation (OP), T₁ and T₂ (4 and 20 months after OP) the left ventricular geometry was recorded by means of Imatron^® electron beam tomography and the transprosthetic velocities were measured by echocardiography. Results: Statistical analysis showed a consistent reduction in the absolute (P=0.04) and indexed (P=0.04) left ventricular myocardial mass for both cohorts; furthermore, there was a significant difference between EXMIS and NOMIS patients concerning the factors, time and mass reduction (P=0.005), because of distinct baselines. A logistic regression report revealed preoperative cardiac output, absolute left ventricular myocardial mass, perfusion, body surface area and the native valve orifice area as predicting coefficients and factors for a minimum mass reduction of 25%. We explain a mathematical formula that turned out to be the most sensitive for correctly classified factors. Conclusions: The left ventricular geometry and transprosthetic velocities resulted in the same postoperative recovery for both EXMIS and NOMIS patients. The presented data showed that valve prosthesis–patient mismatch had no influence in several stepwise logistic regression models. We conclude that modern mechanical bileaflet prostheses allow both acceptable hemodynamics and recovery of left ventricular hypertrophy, even in small aortic annuli.     

Influence of preservation solution on human islet isolation outcome

BACKGROUND: The influence of the preservation solution used for in situ perfusion of the donor and pancreas storage on islet isolation has received little attention. METHODS: In this prospective controlled trial, we compared the outcome of human islet isolation from pancreata perfused with University of Wisconsin (UW) solution or Celsior, an alternative colloid-free extracellular solution. RESULTS: At the 1-year interim analysis, the viability and insulin secretion of islets isolated from donors perfused with UW (n=19) or Celsior (n=5) were identical. However, total islet recovery (IEQ) and isolation yield (IEQ/g) were 1.8-fold and 2.1-fold inferior in the Celsior group (P<0.05 vs. UW). Overall, 13 (68%) of islet preparations were effectively transplanted from the UW group vs. none from the Celsior group (P=0.01). The clinical study was discontinued and the causes of these differences were further explored in the pig (n=14). In contrast to UW, Celsior induced cell swelling and pancreas edema after only four hours of cold storage. These abnormalities were delayed when the donor was perfused with Solution de Conservation d'Organes et de Tissus (SCOT), an extracellular solution containing polyethylene glycol. CONCLUSIONS: Our results suggest that colloid-free preservation solutions might be suboptimal for pancreas perfusion and cold storage prior to islet isolation and transplantation. Because pancreata are now frequently recovered for islet transplantation, preliminary experimental and clinical data about islet isolation should be obtained prior to the routine implementation of new preservation solutions for abdominal perfusion during multiorgan recovery.     

Thyroid Artery Erosion by Esophageal Cancer: Management with Interventional Radiology

Management of upper gastrointestinal bleeding because of erosion of vessels by esophageal cancer may be challenging. We present herein the angiographic images of a 49-year-old patient who was admitted with massive bleeding from a tumor-eroded inferior thyroid artery. Attempts to control the bleeding by means of flexible endoscopy and insertion of a Sengstaken–Blakemore tube had failed. The diagnosis was impressively demonstrated by multislice computed tomography with intravenous contrast in the arterial phase and multiplanar reconstructions (computed tomography angiography) and by digital subtraction angiography. The bleeding was successfully treated with superselective catheterization and coiling of the eroded vessel.     

Ovarian metastases of appendiceal tumors with goblet cell carcinoidlike and signet ring cell patterns: a report of 30 cases

Synchronous and metachronous ovarian and appendiceal mucinous tumors are often the subject of diagnostic consultations in gynecologic pathology practices to address whether the tumors are independent neoplasms or related as primary and metastasis. Those with goblet cell carcinoidlike patterns have not been extensively evaluated in a large series. Clinicopathologic features of 30 cases were examined. All patients presented with signs or symptoms related to a pelvic/adnexal or abdominal mass. The ovarian tumors were bilateral in 25 of 28 cases with data on both ovaries and were typically large (mean/median: 14 cm, range: 4.5 to 24.0 cm). The appendices were often firm or thickened but usually did not have a discrete measurable tumor and were not notably enlarged; microscopically, transmural invasion was present in all of them. The ovarian and appendiceal tumors exhibited a variety of patterns of differentiation, including signet ring cell and glandular, with all displaying some goblet cell carcinoidlike patterns (nests, islands, cords, or cryptlike tubules with goblet cells); teratomatous elements were not identified in any ovarian tumors. Chromogranin was expressed in 7 of 19 ovarian tumors (mean/median: 6.3%/0%; range: 0% to 20%) and synaptophysin was expressed in 4 of 18 of these (mean/median: 7.8%/0%; range: 0% to 90%). Chromogranin was expressed in 6 of 16 appendiceal tumors (mean/median: 11.9%/0%; range: 0% to 70%) and synaptophysin was expressed in 6 of 15 of these (mean/median: 16.7%/0%; range: 0% to 90%). Follow-up was available for 25 patients: 17 died of disease at intervals ranging from 4 to 47 months (mean/median: 18/16) and 8 were alive with disease at 1 to 25 months (mean/median: 11/10); median survival was 19 months and the 1-year and 2-year survival rates were 63% and 34%, respectively. The clinicopathologic features of these ovarian tumors indicate they should be labeled as metastatic appendiceal adenocarcinomas rather than as goblet cell carcinoid tumors both to reflect their behavior and help distinguish them from the rare true primary ovarian goblet cell carcinoid tumors. As the ovarian tumors have appreciable components of signet ring cells they qualify as Krukenberg tumors. In cases in which the primary tumor is not already evident, their "goblet cell carcinoidlike" patterns should direct attention to the appendix as a possible source.