Non-traumatic renal arteriopelvic fistula

PURPOSE: In the present paper, we report on a 34-year-old female with macroscopic hematuria due to a nontraumatic renal arteriopelvic fistula (APF). The patient initially presented at another hospital with asymptomatic macroscopic hematuria. Following abdominal ultrasonography, computed tomography (CT) and laboratory data, no abnormal findings were seen. Therefore, the patient was referred to Teine Keijinkai Hospital for a more precise evaluation of the urinary tract and vascular abnormality. METHODS/RESULTS: Endoscopically, there was bleeding from the right ureteral orifice, so the patient was admitted for further examination. No abnormal findings were seen on urinary cytology and following an intravenous pyelogram. A selective right lower polar renal arteriogram revealed arterial extravasation directly into the pelvis before the venous phase, so APF of the kidney was diagnosed. The patient had no history of urinary tract trauma, so the APF was thought to be idiopathic. After transcatheter arterial embolization (TAE) with a gelatine sponge, macroscopic and microscopic hematuria disappeared and a low-density area was seen in the middle pole of the right kidney in an abdominal CT scan 4 days after TAE. This was thought to be renal infarction due to TAE. CONCLUSIONS: After discharge, the patient had no further hematuria.     

New method of measuring presampling MTF by fourier transform of square-wave chart image

We developed an easy method of measuring the presampling modulation transfer function (MTF) using the square wave chart in digital radiography. In this method, the presampling MTF is measured by Fourier transform of image data of the square wave chart. When Fourier analysis of the sampling data of a square wave is carried out, it is generally difficult to find the starting point and terminal point of the periodic data that should be extracted because of an insufficient number of data. To solve this problem, interpolated data were calculated by using a window function of the frequency domain. The aliasing error was avoided using a characteristic such that the square wave has discrete frequency components. The accuracy of this method was investigated by computer simulation study. Actual measurement of the presampling MTF by this method was also performed with a CR system. These studies indicated the effectiveness of our proposed method in terms of accuracy and ease of use.     

Four novel mutations in the thiazide-sensitive Na-Cl co-transporter gene in Japanese patients with Gitelman's syndrome.

BACKGROUND: Gitelman's syndrome (GS) is an autosomal recessive disorder resulting from inactivating mutations in the thiazide-sensitive Na-Cl co-transporter (NCCT) gene. To date, almost 90 mutations have been identified. It is possible that there is a population-specific distribution of mutations. In this study, we analysed mutations in the NCCT gene of seven Japanese patients with GS. METHODS: Peripheral blood mononuclear cells were isolated from patients with GS, their family members and healthy control subjects. A mutation analysis of the NCCT gene was performed completely by direct automated sequencing of polymerase chain reaction-amplified DNA products. In patients with a deletion or splice site mutation, we undertook cDNA sequence analysis. RESULTS: We identified nine mutations. Five of them [c.185C>T (Thr60Met), c.1712C>T (Ala569Val), c.1930C>T (Arg642Cys), c.2552T>A (Leu849His) and c.1932delC] have been reported in Japanese patients, but not in GS patients from other ethnic groups. The remaining four mutations [c.7A>T (Met1Leu), c.1181_1186+20del26, c.1811_1812delAT and IVS16+1G>A] were novel. In cDNA derived from a patient with c.1181_1186+20del26, a deletion of exon 9 and a frameshift at the start of exon 10 were observed. In cDNA derived from patients with IVS16+1G>A, an additional 96 bp insertion between exons 16 and 17 was observed. Six out of seven patients were compound heterozygotes, and the remaining one carried a single heterozygous mutation. CONCLUSIONS: We found four novel mutations in the NCCT gene in seven Japanese patients with GS. Moreover, our study suggests that the distribution of mutations in the NCCT gene in Japanese GS patients potentially differs from that in other populations.     

Endoscopic treatment or surgery for undifferentiated early gastric cancer?

BACKGROUND: Although almost all (96%) the surgical cases of undifferentiated intramucosal early gastric cancer (EGC) have been found not to have lymph node metastasis (LNM), local treatment by endoscopic mucosal resection (EMR) is not accepted as an alternative treatment to surgery for this type of EGC. If a subgroup of patients with undifferentiated EGC with negligible risk of LNM can be defined, unnecessary surgery can be avoided. This study was conducted to determine this subgroup among undifferentiated EGC patients in whom the risk of LNM can be highly ruled out in an attempt to identify candidates who can be treated by EMR. METHODS: Data from 175 patients surgically resected for undifferentiated EGC were retrospectively collected, and clinicopathological factors were multivariately analyzed to identify predictive factors for LNM. RESULTS: Multivariate logistic regression analysis identified two independent risk factors for LNM, namely, a large tumor (>/=20 mm, P = 0.011) and presence of lymphatic involvement (P = 0.0005). Using these two risk factors as the predictive factors, LNM was observed in 5.8% of patients who had neither of the two predictive factors, whereas 23.1% or 13.1% of patients with one or two predictive factors had LNM, respectively. In contrast, the LNM rate was calculated to be 60% in patients who had both factors. Lymph node metastasis was not found in any of 6 patients with small intramucosal lesions (<10 mm) without lymphatic involvement. CONCLUSIONS: An intramucosal undifferentiated EGC that is smaller than 10 mm without lymphatic involvement can safely be treated by EMR alone, given the negligible possibility of LNM. When histological examination of endoscopically resected specimens shows lymphatic involvement or unexpectedly larger tumor size than that determined at pre-EMR endoscopic diagnosis, an additional surgical procedure should be considered.     

Adjacent segment disease after anterior cervical interbody fusion

BACKGROUND CONTEXT: There have been many follow-up studies on anterior interbody fusion for cervical nerve root and spinal cord compression, and excellent neurological outcomes have been reported. However, postoperative degenerative changes at adjacent discs may lead to the development of new radiculopathy or myelopathy. In the previous reports, the incidence of symptomatic adjacent segment disease has ranged from 7% to 15%. PURPOSE: The present study was undertaken to investigate the incidence of symptomatic adjacent segment disease after anterior cervical interbody fusion (ACIF) and to identify the factors that are related to the development of this disease. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: A total of 112 patients were followed up clinically and radiologically for more than 2 years. OUTCOME MEASURES: Follow-up evaluation was primarily by means of clinical visits. The postoperative course of any symptoms, the findings of neurological examination and serial follow-up radiographs were performed in all patients. METHODS: The diagnosis of symptomatic adjacent segment disease was based on the presence of new radiculopathy or myelopathy symptoms referable to an adjacent level, and the presence of a compressive lesion at an adjacent level by magnetic resonance imaging or myelography. We evaluated the correlation between the incidence of symptomatic adjacent segment disease and the following clinical parameters (age at operation, sex, number of the levels fused) and radiological parameters (preoperative cervical spine alignment, preoperative range of motion of C2-C7 cervical spine, anteroposterior spinal canal diameter, preoperative existence of an adjacent segment degeneration on plain radiograph, myelography and magnetic resonance imaging [MRI]). RESULTS: Symptomatic adjacent segment disease developed in 19 of 112 patients (19%) followed. A Kaplan-Meier survival analysis was performed in order to follow the disease-free survival of the entire series of patients. The disease-free survival rates were 89% at 5 years, 84% at 10 years and 67% at 17 years. The incidences of indentation of dura matter on preoperative myelography or disc protrusion on MRI at the adjacent level were significantly higher in disease cases (p=.0087, .0299, respectively; chi-squared test). However, the other parameters did not show a statistically significant difference. There were seven cases (37%) who had failure of nonoperative treatment and additional operations were performed. CONCLUSIONS: The incidence of symptomatic adjacent segment disease after ACIF was higher when preoperative myelography or MRI revealed asymptomatic disc degeneration at that level regardless of the number of the levels fused, preoperative alignment, spinal canal diameter or fusion alignment.     

Inflammatory mechanisms contributing to pancreatic cancer development

OBJECTIVE: Pancreatic cancer is the most deadly of all gastrointestinal (GI) malignancies, yet relatively little is known regarding mechanisms of tumor development including the role of inflammation. SUMMARY BACKGROUND DATA: Chronic pancreatitis (CP) increases the risk of developing cancer by 10- to 20-fold; mediators of the chronic inflammatory process and the surrounding fibrotic stroma likely support a transformation to malignancy, yet the exact mechanisms remain undefined. The purpose of our present study was to determine potential inflammatory components in epithelial and stromal cells that may contribute to both CP and pancreatic cancers. METHODS: Specimens of normal pancreas, CP, and pancreatic cancer were examined using laser-capture microdissection (LCM), gene array, and immunohistochemistry. RESULTS: Gene array analysis from LCM-dissected tissues demonstrated: (i) increased expression of interleukin-8 (IL-8), an activator of the inflammatory factor nuclear factor-kappaB (NF-kappaB), and (ii) decreased expression of IkappaB (an inhibitor of NF-kappaB) in CP ductal cells compared with normal ducts. Compared with CP, cancers demonstrated: (i) increased expression of tumor related genes including S100A4, cyclin E1, and epidermal growth factor (EGF) receptor, and (ii) expression of matrix metalloproteinase 2, a pro-invasive factor for tumor cells, which was not present in the CP stroma. Increased staining of both the p50 NF-kappaB subunit and IKKalpha kinase (a protein that allows activation of NF-kappaB) was noted in CP and cancers. CONCLUSIONS: Our results demonstrate that similar inflammatory components and downstream effectors are present in CP and pancreatic cancers. Importantly, these findings suggest that a common pathway for pancreatic cancer development may be through a chronic inflammatory process including stroma formation. These findings may lead to novel strategies for pancreatic cancer prophylaxis based on inhibition of inflammatory mediators.     

Cross-sectional area of the posterior extensor muscles of the cervical spine in whiplash injury patients versus healthy volunteers--10 year follow-up MR study

IntroductionLong-term follow-up studies focusing on the posterior extensor muscles in patients suffering from whiplash injury are scarce. The purpose of this study was to elucidate the changes in the posterior extensor muscles 10 years after whiplash injury.MethodsTwenty-three patients who had suffered from whiplash injury in 1994–1996 and had undergone MRI using a 1.5-T superconductive imager participated in this follow-up study (13 males, 10 females, mean age 51.8 years, mean follow-up 11.5 years). In addition, 60 healthy volunteers who had undergone MRI in the same period were included as controls (36 males, 24 females, mean age 47.8 years, mean follow-up 11.1 years). All participants underwent follow-up MRI. The cross-sectional areas of the deep posterior muscles (CSA) including the multifidus, semispinalis cervicis, semispinalis capitis, and splenius capitis were digitally measured at C3-4, C4-5, and C5-6 using NIH image. The long-term changes in the CSA were compared between the two groups. In addition, correlations between the CSA and cervical spine-related symptoms were evaluated.ResultsThe mean total CSA per patient (the sum of the area from C3-4 to C5-6) was 4811.6 ± 878.4 mm² in the whiplash patients and 4494.9 ± 1032.7 mm² in the controls at the initial investigation (p = 0.20), and 5173.4 ± 946.1 mm² and 4713.0 ± 1065.3 mm² at the follow-up (p = 0.07). The mean change in CSA over time was 361.8 ± 804.9 mm² in the whiplash patients and 218.1 ± 520.7 mm² in the controls (p = 0.34). Ten whiplash patients (43.5%) had neck pain and 11 (47.8%) had shoulder stiffness. However, there was no difference in the change in CSA over time between the symptomatic and asymptomatic patients.ConclusionsThere was no significant difference in the change in CSA between whiplash patients and healthy volunteers after a 10-year follow-up period. In both groups, the cross-sectional area slightly increased at follow-up. In addition, there was no association between the change in CSA and clinical symptoms such as neck and shoulder pain. These results suggest that whiplash injury is not associated with symptomatic atrophy of the posterior cervical muscles over the long term.     

Adrenal pheochromocytoma with multiple neurofibromatosis on the trunk

We report a case of adrenal pheochromocytoma in a patient with neurofibromatosis type 1 (NF1). A 65-year-old female patient was admitted to our hospital for examination of a right adrenal mass. The adrenal tumor was incidentally discovered by abdominal computed tomography during examination for hypertension in another hospital. She had large multiple neurofibromatous lesions and café-au-lait spots on the trunk. We thought that it was difficult to make a skin incision on normal skin. Serum and urinary catecholamines were markedly increased. Magnetic resonance imaging revealed a solid round tumor 3 cm in diameter, located in the right adrenal gland. Laparoscopic right adrenalectomy was performed. Serum and urinary catecholamines returned to the normal range on post-operative day 10. Laparoscopic surgery may be a good option for NF1 patients with pheochromocytoma, especially those who had multiple neurofibromatosis on the trunk.     

Ruptured aneurysm of a posterior inferior cerebellar artery communicating artery. Case report and histological findings

A hypertensive 60-year-old man presented with a rare aneurysm arising from the posterior inferior cerebellar artery (PICA) communicating artery, manifesting as subarachnoid hemorrhage with intraventricular hemorrhage. Angiography showed a small aneurysm arising from a fine and tortuous artery interconnecting the bilateral vermian branches of distal PICAs. The right PICA was absent and its vermian territory was supplied by the left PICA through this communicating artery. The right anterior inferior cerebellar artery was also connected to the vermian branch of the right PICA. At surgery, a reddish and apparent fusiform aneurysm was noted at the top of the arterial loop under the cerebellar vermis. Microsurgical trapping and removal of the aneurysm was performed without complication. Histological examination demonstrated typical findings of a true aneurysm. Only four previous cases of aneurysm of the communicating artery between the bilateral distal PICAs have been reported. In all five reported cases including ours, the PICA communicating artery contributed to the collateral blood supply of the contralateral vermian territory based on vascular anomalies. Hemodynamic stress and congenital vulnerability may have caused this aneurysm. Trapping is suitable to treat this precarious aneurysm if other collateral vessels supply the contralateral vermian territory.     

Impaired expression of hepatic multidrug resistance protein 2 is associated with posthepatectomy hyperbilirubinemia in patients with biliary cancer

Background and aims Hyperbilirubinemia is a critical complication following hepatectomy for biliary cancer. Hepatic multidrug resistance protein 2 (MRP2), a bilirubin transporter, is shown to be down-regulated by acute biliary obstruction in rats. However, little is known about the effect of chronic obstruction by malignancy on the MRP2 expression in patients or the association of MRP2 expression with posthepatectomy hyperbilirubinemia.Materials and Methods The MRP2 expression before hepatectomy was determined by immunostaining and Western blotting in patients with biliary cancer. To directly determine the effect of chronic bile duct obstruction on the MRP2 expression, the expression levels were compared between the cholestatic and noncholestatic lobes in each of seven patients. In another 39 patients, the correlation of the MRP2 expression of the anticipated remnant liver with the posthepatectomy severe hyperbilirubinemia, defined as a serum total bilirubin concentration200 mol/l, was evaluated.Results The MRP2 staining in the cholestatic lobes was weak and not restricted to the canalicular membrane, unlike the noncholestatic lobes. The expression levels in the cholestatic lobes were 45% of those in the noncholestatic lobes. Postoperative maximum bilirubin levels were significantly correlated with MRP2 expression of the anticipated remnant liver. The MRP2 expression had been already impaired before hepatectomy in all patients who eventually developed severe hyperbilirubinemia.Conclusions Decreased MRP2 expression, caused by biliary obstruction due to cancer, is a possible risk factor for posthepatectomy severe hyperbilirubinemia.