Laparoscopic repair of late-presenting Bochdalek hernia in 2 infants

Laparoscopic repair was performed on 2 infants with late-presenting Bochdalek hernia. Intraoperatively, the entire small intestine was herniated in 1 case and the stomach, small intestine, and part of the colon and spleen were herniated in the other case. Laparoscopic repair of Bochdalek hernia was successfully completed in both the cases. On the basis of our experience, 4 points seem important in laparoscopic surgery for Bochdalek hernia: (1) avoiding damage to the spleen while reducing organs back into the abdominal cavity; (2) ensuring visualization of diaphragmatic defect after reducing the spleen and intestinal tract; (3) ensuring sufficient width to suture the dorsal side of the diaphragm; and (4) identifying intestinal malrotation. We believe that the fourth point represents an advantage of a laparoscopic approach, which seems superior to the thoracoscopic approach and could represent a useful therapy for Bochdalek hernia in infants and older patients.     

Detection of lung nodules on digital chest radiographs: potential usefulness of a new contralateral subtraction technique

PURPOSE: To evaluate the potential usefulness of a contralateral subtraction technique developed for radiologists' performance in the detection of subtle lung nodules on chest radiographs. MATERIALS AND METHODS: Fifty chest radiographs (25 normal and 25 abnormal with a subtle lung nodule) that were digitized with a 0.175-mm pixel size and 4,096 gray levels were used. Twelve radiologists (10 attending and two residents) participated in observer tests and read both original and contralateral subtraction images with a sequential testing method. Radiologists' performance was evaluated by means of receiver operating characteristic analysis with use of a continuous rating scale. The beneficial and detrimental effects of the contralateral subtraction technique on the radiologists' performance were also evaluated. RESULTS: The area under the receiver operating characteristic curve values obtained without and with contralateral subtraction images were 0.926 and 0.962, respectively. Results indicated that the contralateral subtraction images significantly (P <.05) improved diagnostic accuracy, particularly for radiologists with limited experience. CONCLUSION: The contralateral subtraction technique can assist radiologists in the correct identification of subtle lung nodules on chest radiographs.     

Linkage guide for rotational alignment during total knee arthroplasty

A linkage guide was devised for use in conjunction with knee arthroplasty instruments to achieve proper component rotation. The femoral component was rotationally aligned to the surgical epicondylar axis using one guide. The other guides were used after all bone surfaces were cut and soft tissue balancing was completed. A Kirschner wire was guided into the proximal tibial aspect parallel to the sagittal plane of the femoral component with the patella in its normal position and the knee in full extension. The wire was used as a reference to determine tibial component rotation. The relative rotational alignment of 21 knees in 19 patients who had undergone cruciate-retaining total knee arthroplasty utilizing this guide was assessed using the modified Eckhoff method. The results of radiographic analysis were compared with those in a control group of 25 knees where the guide was not employed. The external rotation of the femoral component relative to the tibial component was 1.3° ± 2.0° (mean ± SD) in the guided group and 1.1° ± 4.4° in the control group. The relative rotational angle was significantly more consistent using the guide. Implant malrotation can be reduced using our technique.     

Results of a multicenter prospective clinical study in Japan for evaluating efficacy and safety of desensitization protocol based on rituximab in ABO-incompatible kidney transplantation

Background

Deceased organ donations are rare in Japan, with most kidney transplants performed from a limited number of living donors. Researchers have thus developed highly successful ABO-incompatible transplantation procedures, emphasizing preoperative desensitization and postoperative immunosuppression. A recent open-label, single-arm, multicenter clinical study prospectively examined the efficacy and safety of rituximab/mycophenolate mofetil desensitization in ABO-incompatible kidney transplantation without splenectomy.

Methods

Mycophenolate mofetil and low dose steroid were started 28 days pretransplant, followed by two doses of rituximab 375 mg/m² at day ?14 and day ?1, and postoperative immunosuppression with tacrolimus or ciclosporin and basiliximab. The primary endpoint was the non-occurrence rate of acute antibody-mediated rejection. Patient survival and graft survival were monitored for 1 year posttransplant.

Results

Eighteen patients received rituximab and underwent ABO-incompatible kidney transplantation. CD19-positive peripheral B cell count decreased rapidly after the first rituximab infusion and recovered gradually after week 36. The desensitization protocol was tolerable, and most rituximab-related infusion reactions were mild. No anti-A/B antibody-mediated rejection occurred with this series. One patient developed anti-HLA antibody-mediated rejection (Banff 07 type II) on day 2, which was successfully managed. Patient and graft survival were both 100 % after 1 year.

Conclusion

Our desensitization protocol was confirmed to be clinically effective and with acceptable toxicities for ABO-I-KTx (University Hospital Medical Information Network Registration Number: UMIN000006635).

     

The Role of Shoulder Maximum External Rotation During Throwing for Elbow Injury Prevention in Baseball Players

The objective of the present study was to examine whether the passive range of shoulder external rotation (ER), the maximum shoulder external rotation angle (MER) during throwing, and the ratio of MER to ER are related to the incidence of the elbow injury. A mixed design with one between-factor (a history of the elbow injury) and two within-factors (ER and MER) was used to analyze the difference between baseball players with and without a history of medial elbow pain. Twenty high school baseball players who had experienced the medial elbow pain within the previous month but who were not experiencing the pain on the day of the experiment were recruited (elbow-injured group). Another twenty baseball players who had never experienced the medial elbow pain were also used for testing (control group). MER during throwing, ER, and the ratio of MER to ER were obtained in both of the group. A Mann-Whitney test was used for the group comparison (p < 0.05). The ratio of MER to ER was significantly greater in the elbow-injured group (1.52 ± 0.19) than that in the control group (1.33 ± 0.23) (p = 0.008). On the other hand, there was no statistical significance in MER and ER between two groups. The findings of the study indicate that MER/ER relation could be associated with the incidence of the elbow injury in baseball players.

Key points

• It is accepted that the greatest elbow valgus stress appears at the position of shoulder maximum external rotation (MER) in the acceleration phase of the throwing movement. As a consequence, shoulders with restricted range of motion of external rotation (ER) compensate with a valgus stress on their elbow joints.
• In this study, we evaluated the relation between MER and ER of shoulder in players with/without elbow injuries.
• The result of this study demonstrated that the elbow injured group showed significantly greater MER/ER relation than the control group.
• The current finding suggests that great MER combined with the ROM restriction may be one of the risk factors to cause medial elbow pain in baseball players.

Key words: Throwing, shoulder, maximum external rotation, elbow valgus stress, prevention.     

RNA interference for noggin enhances the biological activity of bone morphogenetic proteins in vivo and in vitro

Noggin is a major extracellular antagonist to bone morphogenetic proteins (BMPs) which binds to BMPs and blocks binding of them to BMP-specific receptors and negatively regulates BMP-induced osteoblastic differentiation. In this study, we investigated the effect of noggin silencing by transfection of small interfering RNA (siRNA) on BMP-induced osteoblastic differentiation in vitro and ectopic bone formation in vivo induced by recombinant human BMP-2 (rhBMP-2). Noggin mRNA expression was up-regulated in response to rhBMP-2 in C2C12 cells, a myoblastic cell line, in dose- and time-dependent fashion as determined by real-time RT-PCR assay. Silencing of noggin expression by transfection of noggin siRNA suppressed BMP-stimulated noggin expression, resulting in acceleration of BMP-induced osteoblastic differentiation. For in vivo noggin silencing, siRNA was injected locally into back muscles and transfected into local cells by electroporation, where rhBMP-2-retaining (5 μg) collagen disks had been surgically placed. The implants were harvested at 2 weeks after surgery from experimental and control group mice and analyzed by radiological and histological methods. As a result, bone mineral content of ossicles ectopically induced by rhBMP-2 was significantly increased by silencing of noggin. Our findings suggest that silencing of noggin enhances the osteoblastic differentiation of BMP-responding cells in vitro and new bone formation induced by rhBMP-2 in vivo by eliminating negative regulation of the effects of BMP. RNA interference might be useful for intensifying the effects of BMP in promoting new bone (callus) formation in repair of damaged bone.     

Severe exacerbation of hepatitis after short-term corticosteroid therapy in a patients with "latent" chronic hepatitis B

We present a case of severe exacerbation of hepatitis after short-term corticosteroid therapy for chronic inflammatory demyelinating polyneuropathy (CIPD) with "latent" chronic hepatitis B showing no HBV-related antigens and antibodies. After corticosteroid pulse therapy for CIPD, the patient had severe exacerbation of hepatitis twice. Although she did not show any hepatitis B virus (HBV)-related antigens or antibodies, sequences of HBV were detected in serum and liver by a nested polymerase chain reaction. A sequence analysis of HBV at the second exacerbation showed that the G-to-A point mutation at nucleotide 1896 that converted codon 28 from tryptophan (TGG) to a stop codon (TAG) in the precore region resulted in amino acid change, which has been frequently observed in fulminant hepatitis and severe hepatitis in Japan.     

Hemodynamic effects of inhaled nitric oxide using pulse delivery and continuous delivery systems in pulmonary hypertension

OBJECTIVE: Inhaled nitric oxide (NO) has been used for pulmonary vasodilation therapy in patients with pulmonary hypertension. Inhaled NO for awake and ambulatory patients, however, is unusual because it requires intubation or a tightly fitting facemask, and a large-scale delivery system for the safe management of toxic nitrogen oxides. We undertook this study to investigate the possibility of using inhaled NO therapy for awake and ambulatory patients with pulmonary hypertension. METHODS: Patients with pulmonary hypertension underwent cardiac catheterization and hemodynamic variables were measured at the baseline, after inhaled NO using our pulse delivery system, which involved a nasal cannula and a pulse device, and after inhaled NO using a continuous delivery system. PATIENTS OR MATERIALS: We studied seventeen patients with precapillary pulmonary hypertension (4 men and 13 women; age, 41+/-3, ranging from 19 to 61). RESULTS: Cardiac output was increased significantly by each system. Pulmonary vascular resistance was decreased significantly by each system. There was no significant change in mean pulmonary artery pressure, mean systemic artery pressure, or systemic vascular resistance. The concentrations of NO and nitrogen dioxide (NO2) in the expiratory gas using the pulse delivery system were 0.0 ppm as long as the pulse device was synchronized with the patient's respiratory cycle. CONCLUSION: Inhaled NO using our pulse delivery system changed the hemodynamic variables similarly to those when using the continuous delivery system. The concentrations of NO and NO2 in the expiratory gas using the pulse delivery system were within safe limits.     

Primary liver cancer

Liver cancer, whether primary or secondary, is one of the most difficult to treat among malignant solid tumors, with a miserable prognosis. In view of the relative lack of exciting progress in the management of metastatic liver cancer in recent years this lecture necessarily concerns primary liver cancer, particularly hepatocellular carcinoma (HCC). Time permits coverage of only several important aspects of general interest and recent advances in the study of HCC.