Reconstruction of the hepatic artery with the middle colic artery is feasible in distal pancreatectomy with celiac axis resection: A case report

Despite the advance of diagnostic modalities, carcinoma in the body and tail of the pancreas are commonly presented at a late stage. With unresectable lesions, long-term survival is extremely rare, and surgery remains the only curative option for pancreatic cancer. An aggressive approach by applying extended distal pancreatectomy with the resection of the celiac axis may increase the resectability and analgesic effect but great care must be taken with the arterial blood supply to the liver and stomach. Sometimes, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and leads to fatal complications. Therefore, knowledge of any alternative restoration of the compromised collateral flow before surgery is essential. The present case report shows a patient with a pancreatic body cancer in whom the splenic, celiac, and common hepatic arteries were involved with the tumor, which extended almost to the root of the gastroduodenal artery. We modified the procedure by reanastomosis between the proper hepatic artery and middle colic artery without vascular graft. The postoperative course was uneventful, and the patient was discharged on post-operative day 19. The patient was immediately free of epigastric and back pain.     

Urinary incontinence after robot‐assisted radical prostatectomy: Pathophysiology and intraoperative techniques to improve surgical outcome

Robot‐assisted radical prostatectomy has been shown to have comparable and possibly improved postoperative continent rates compared with retropubic and laparoscopic radical prostatectomy. However, postoperative urinary incontinence has remained one of the most bothersome postoperative complications. The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. Therefore, improved knowledge of the normal structure in the pelvis should lead to a greater understanding of the pathophysiology of urinary incontinence, and further development of intraoperative techniques to improve the outcomes of urinary continence. It might be necessary to carry out three steps to realize improvement of the early return of urinary continence after robot‐assisted radical prostatectomy: (i) preservation (bladder neck, neurovascular bundle, puboprostatic ligament, pubovesical complex, and/or urethral length, etc.); (ii) reconstruction (posterior and/or anterior reconstruction, and/or reattachment of the arcus tendineus to the bladder neck, etc.); and (iii) reinforcement (bladder neck plication and/or sling suspension, etc.). On the basis of these steps, further modifications during robot‐assisted radical prostatectomy should be developed to improve urinary continence and quality of life after robot‐assisted radical prostatectomy.     

One and a half ventricle repair for Ebstein’s anomaly

The surgical strategy for patients having Ebstein’s anomaly and hypoplastic right ventricle is controversial. An 11-year-old boy patient having such condition, with estimated end-diastolic volume index of the atrialized and functional right ventricle being 70% of normally expected values, underwent biventricular repair. Immediately after the surgery, however, he developed right heart failure with the central venous pressure of 11 mmHg. He consequently underwent additional bidirectional cavopulmonary anastomosis, thereby converting the biventricular repair into one and a half ventricle repair. He recovered uneventfully and is doing well 2 years after the surgery.     

Tissue factor antisense oligonucleotides prevent renal ischemia-reperfusion injury

BACKGROUND: Tissue factor (TF) expression is induced on macrophages and endothelial cells during the immune response. We designed an antisense (AS) phosphorothioate oligodeoxynucleotide (ODN) to specifically inhibit the expression of rat TF to study the effects of the AS ODN on renal ischemia-reperfusion injury in the rat. METHOD: AS-1 ODN for TF was delivered intravenously to inhibit the expression of TF in endothelial cells. After 8 hr, the right kidney was harvested and the left renal artery and vein were clamped. The kidney was reperfused after 90 min of ischemia, and rats were killed at 0, 1.5, 5, 12, and 24 hr after reperfusion. TF expression was analyzed by immunohistochemical staining using monoclonal antibody. RESULTS: In the untreated ischemic group, 0 of 20 rats survived beyond day 3. However, treatment with AS-1/TF led to 12 of 20 rats surviving beyond day 4. TF was detected on distal tubular epithelial cells, endothelial cells, and blood vessels but not on necrotic and proximal tubular epithelial cells. The necrotic area extended and encompassed nearly all of the ischemic kidney within 12 hr after reperfusion. The necrotic area and the grade of TF staining were more significantly reduced in the AS-1/TF-treated group than in the control group. Furthermore, fluorescein isothiocyanate-labeled AS-1/TF was significantly intense in tubular epithelial cells 8 hr after intravenous administration. CONCLUSIONS: The results indicate that AS-1/TF inhibited the ischemia-reperfusion injury of the kidney. Microcirculatory incompetence resulting from microthrombus may cause the formation and development of necrosis.     

A nonerythropoietic derivative of erythropoietin inhibits tubulointerstitial fibrosis in remnant kidney

Background

The tissue-protective effects of erythropoietin (EPO) have been extensively investigated, and EPO administration can raise the hemoglobin (Hb) concentration. Recently, we reported that carbamylated erythropoietin (CEPO) protected kidneys from ischemia-reperfusion injury as well as EPO.

Methods

To investigate the clinical applications of CEPO, we next evaluated the long-term therapeutic effect of CEPO using a tubulointerstitial model rat. We randomized remnant kidney model rats to receive saline, EPO, or CEPO for 8?weeks.

Results

CEPO- and EPO-treated rats had improved serum creatinine levels compared with saline-treated remnant kidney model rats, although the Hb level was significantly increased in EPO-treated rats. Two-photon microscopy revealed that EPO/CEPO significantly ameliorated tubular epithelial cell damage assessed by endocytosis. In addition, CEPO or EPO protected endothelial cells with a sustained blood flow rate. EPO or CEPO suppressed the number of TUNEL-positive apoptotic cells with weak ??SMA staining. Furthermore, PCR analysis demonstrated that TGF-?? and type I collagen expression was attenuated in EPO- or CEPO-treated rats, accompanied by a significant decrease in interstitial fibrosis.

Conclusion

We established a long-term therapeutic approach to protect tubulointerstitial injury with CEPO, and thus, the therapeutic value of this approach warrants further attention and preclinical studies.     

A screening model for low bone mass in elderly Japanese men using quantitative ultrasound measurements: Fujiwara-Kyo Study

Screening for low bone mass is important to prevent fragility fractures in men as well as women, although men show a much lower prevalence of osteoporosis than women. The purpose of this study was to establish a screening model for low bone mineral density (BMD) using a quantitative ultrasound parameter and easily obtained objective indices for elderly Japanese men. We examined 1633 men (65-84 yr old) who were subjects of the Fujiwara-Kyo Study. Speed of sound (SOS) at the calcaneus was determined, and BMD was measured by dual-energy X-ray absorptiometry at the lumbar spine (LS), total hip (TH), and femoral neck (FN). Low BMD was defined as >1 standard deviation below the young adult mean, in accordance with World Health Organization criteria. We performed receiver operating characteristic (ROC) analysis to identify a better screening model incorporating SOS and determined the optimal cutoff value using Youden index. Prevalences of low BMD at the 3 skeletal sites were 27.8% (LS), 33.5% (TH), 48.6% (FN), and 43.3% at either LS or TH. The greatest area under the ROC curve (0.806, 95% confidence interval: 0.785-0.828) and smallest Akaike's information criterion were obtained in the multivariate model incorporating SOS, age, height, and weight for predicting low BMD at all skeletal sites. This model predicted low BMD at TH with the sensitivity of 0.726 and specificity of 0.739, whereas a similar model predicted low BMD at LS with much lower validity. We conclude that the multivariate model for TH could be used to screen for low BMD in elderly Japanese men.     

Evaluation of primary brain tumors with FLT-PET: usefulness and limitations

PURPOSE OF THE REPORT: The purpose of this report was to investigate the potential of positron emission tomography using F-18 fluorodeoxythymidine (FLT-PET) in evaluating primary brain tumors. MATERIALS AND METHODS: FLT-PET was performed in 25 patients with primary brain tumors. FLT uptake in the lesion was semiquantitatively evaluated by measuring the maximal standardized uptake value (SUVmax) and the tumor-to-normal tissue ratio (TNR). SUVmax and TNR were compared with the histologic grade and the expression of the proliferation marker (Ki-67). RESULTS: FLT uptake in normal brain parenchyma was very low, resulting in the visualization of brain tumors with high contrast. Both SUVmax and TNR significantly correlated with the malignant grade of brain gliomas, in which high SUVmax/TNR was obtained for high-grade gliomas. Patients with primary lymphoma also showed SUVmax/TNR equivalent to glioblastoma. There was a positive correlation between SUVmax/TNR and the Ki-67 index. In contrast, spuriously high SUVmax and TNR were obtained in 3 of 6 patients with suspected recurrent tumors (2 patients with recurrent grade 2 glioma and one patient with postoperative granuloma), all of which showed lesion enhancement on MRI after Gd administration. CONCLUSIONS: FLT-PET can be used to evaluate the malignant grade and proliferation activity of primary brain tumors, especially malignant brain tumors. However, the presence of benign lesions showing blood-brain barrier disruption cannot be distinguished from malignant tumors and needs to be carefully evaluated.     

Changes in muscle temperature induced by 434 MHz microwave hyperthermia

Objective

To investigate the changes in temperature of human muscle during microwave hyperthermia.

Methods

Skin surface and muscle temperatures were measured in 11 healthy adult men (mean (SD) age 24.3 (2.2) years; height 174.2 (6.1) cm; weight 70.0 (5.3) kg) during a 30 min exposure of the thigh to 434 MHz microwave hyperthermia. Skin temperature was maintained at the pilot temperature of 40°C, and the temperature of the water in the bolus was 38°C. The peak power output was set at 60 W and controlled automatically to maintain the pilot temperature. The temperature was measured in the vastus lateralis muscle at an average muscle depth of 2.0 (0.2) cm, using a 23 G Teflon‐shielded thermocouple. Biopsy specimens were obtained for light microscopy from three subjects. A muscle‐equivalent phantom was used to evaluate the vertical heating pattern.

Results

Both skin and muscle temperatures increased from baseline, and muscle temperature was higher than skin temperature (skin temperature 39.2 (0.5)°C, temperature rise 5.0 (1.5)°C; muscle temperature 43.7 (0.8)°C, temperature rise 8.9 (1.4)°C). At the end of the hyperthermia treatment, muscle temperature decreased to 39.8 (0.9)°C, but was still 4.8 (1.5)°C higher than the baseline. No signs of muscle damage were observed on the basis of the blood creatine kinase activity and histological sections.

Conclusions

The results show that the 434 MHz microwave hyperthermia treatment increased and maintained muscle temperature locally by 6.3–11.4°C without muscle damage. These findings suggest that the microwave hyperthermia system provides effective and safe treatment.For many years, heat treatment has been used as a therapy for muscle tissue injured in sports. There are several heating modalities, including silicon gel hot packs, whirlpools, paraffin baths, ultrasound and electromagnetic waves.¹ Most of these modalities are classified as superficial heating, and primarily cause a temperature increase in structures up to 1 cm below the skin surface. Ultrasound and electromagnetic waves (eg, radiofrequency and microwaves) are used for deep heating at tissue depths of 3–5 cm.²To gain therapeutic benefit, the target tissue depth and temperature should be considered when choosing the appropriate thermal modality. When deep skeletal muscle (over a small region) is targeted for heat treatment, both ultrasound and microwaves are used clinically because both modalities are thought to effectively heat the target tissue. Garrett et al³ evaluated the changes in gastrocnemius muscle temperature induced by short‐wave diathermy, and found that 20 min of microwave exposure induced an increase of 4.6°C in muscle temperature. Another study reported that ultrasound produced a mean temperature rise of 3.5°C in the gastrocnemius–soleus complex.⁴ A few comparative studies have examined the use of heat modalities on living tissue, such as muscle, and reported that electromagnetic waves are more effective than ultrasound.^3,5 In general, the therapeutic range for sports medicine is assumed to be from 41°C to 45°C.⁶ However, the increase in temperature may depend on the thermal modality.Recently, 434 MHz hyperthermia has been introduced in physical medicine and rehabilitation. Hyperthermia treatment with this equipment was reported to be a highly innovative and reliable modality for treating acute muscle injuries in sports.^5,7,8 These reports mentioned that 434 MHz hyperthermia treatment significantly reduces the pressure pain and pain on active contraction, but they did not determine muscle temperature during treatment. To our knowledge, only one report⁹ has measured the changes in temperature, and it used a phantom. The therapeutic benefits of hyperthermia treatment are related to the target‐tissue temperature and changes in temperature; so the change in temperature with treatment should be measured to assess the therapeutic benefits. Measuring the temperature can also provide evidence for the safety of the treatment. Nevertheless, the changes in human muscle temperature have not been reported because it is difficult to measure muscle temperature in a clinical setting. Therefore, we investigated the changes in the temperature of human muscle induced by a 434 MHz microwave hyperthermia system to provide evidence for its clinical effectiveness and safety.     

A questionnaire about radiation safety management of the draining-water system at nuclear medicine facilities

We conducted a questionnaire survey about radiation-safety management condition in Japanese nuclear medicine facilities to make materials of proposition for more reasonable management of medical radioactive waste. We distributed a questionnaire to institutions equipped with Nuclear Medicine facilities. Of 1,125 institutions, 642 institutes (52.8%) returned effective answers. The questionnaire covered the following areas: 1) scale of an institution, 2) presence of enforcement of radiotherapy, 3) system of a tank, 4) size and number of each tank, 5) a form of draining-water system, 6) a displacement in a radioactive rays management area, 7) a measurement method of the concentration of medical radioactive waste in draining water system, 8) planned and used quantity of radioisotopes for medical examination and treatment, 9) an average displacement of hospital for one month. In most institutions, a ratio of dose limitation of radioisotope in draining-water system was less than 1.0, defined as an upper limitation in ordinance. In 499 hospitals without facilities of hospitalization for unsealed radioisotope therapy, 473 hospitals reported that sum of ratios of dose limits in a draining-water system was less than 1.0. It was calculated by used dose of radioisotope and monthly displacement from hospital, on the premise that all used radioisotope entered in the general draining-water system. When a drainage including radioactivity from a controlled area join with that from other area before it flows out of a institution, it may be diluted and its radioactive concentration should be less than its upper limitation defined in the rule. Especially, in all institutions with a monthly displacement of more than 25,000 m3, the sum of ratio of the concentration of each radionuclide to the concentration limit dose calculated by used dose of radioisotope, indicated less than 1.0.     

Estrogen Deficiency Accelerates Autoimmune Exocrinopathy in Murine Sjögren’s Syndrome through Fas-Mediated Apoptosis

Estrogenic action has been suggested to be responsible for the strong female preponderance of autoimmune diseases, but the role of estrogens in the female has not been well characterized. We evaluated the effects of estrogen deficiency in a murine model for autoimmune exocrinopathy of Sj?gren's syndrome (SS). Severe destructive autoimmune lesions developed in the salivary and lacrimal glands in estrogen-deficient mice, and these lesions were recovered by estrogen administration. We detected an intense estrogen receptor in splenic CD8(+) T cells compared with that in CD4(+) T cells, and concanavalin-A-stimulated blastogenesis of splenic CD8(+) T cells with estrogens was much higher than that of CD4(+) T cells. We found a significant increase in serum autoantibody production against the organ-specific autoantigen alpha-fodrin. Moreover, an increased proportion of TUNEL+ apoptotic epithelial duct cells was observed in estrogen-deficient mice. It was demonstrated that Fas-mediated apoptosis in cultured salivary gland cells was clearly inhibited by estrogens in vitro. These results indicate that dysfunction of regulatory T cells by estrogen deficiency may play a crucial role on acceleration of organ-specific autoimmune lesions, and estrogenic action further influences target epithelial cells through Fas-mediated apoptosis in a murine model for SS.