Multi-centric pancreatic cancer without PanIN lesion

The patient was a 67-year-old man under follow-up after gastric cancer surgery. An abdominal CT scan performed 1 year earlier had shown an approximately 14-mm hypovascular mass in the pancreatic body; however, he did not consent to treatment and was followed up for 1 year. A blood workup showed that the fasting blood glucose level, which had been within normal limits, was elevated to 174 mg/dl (normal, 70–109 mg/dl), and the HbA1c level was 12.0% (normal, 4.3–5.8%). Abdominal CT revealed an approximately 20-mm mass in the pancreatic body and an approximately 12-mm mass in the pancreatic tail, and magnetic resonance imaging cholangiopancreatography (MRCP) showed discontinuity of the main pancreatic duct (MPD). Since these findings led to the suspicion of invasive ductal carcinoma (IDC) of the pancreas developing in the pancreatic body and tail, we performed distal pancreatectomy with splenectomy. Histologically, IDCs were observed in the pancreatic body and tail. However, PanIN was not observed in the MPD between the two carcinomas. They were diagnosed as independent invasive ductal carcinomas of the pancreas.     

A case report of a patient repeatedly infected with Ancylostoma duodenale, probably from himself through his artificial anus, and resistant against a single dose of pyrantel pamoate

A 88 year old Japanese male was repeatedly infected with Ancyclostoma duodenale. He underwent an artificial anus operation about 55 years ago. He appeared to be infected with hookworm earlier than in 1977 and developed severe anemia. Though he was treated with pyrantel pamoate and mebendazole several times, reinfections developed in each time. A possible origin for his reinfections was his own feces defecated through his artificial anus. Unsanitary handling of the anus and the feces exposed himself to oral or percutaneous infection. Besides, a single dose of pyrantel pamoate, usually very effective against Ancylostoma duodenale, was not so effective in this patient. Therefore, we prescribed multiple doses of pyrantel pamoate, and followed by a single dose of mebendazole. However, reinfections still persisted because of his unsanitary behavior.     

Technique of endoscopic ultrasonography‐guided pancreatic duct intervention (with videos)

To date, several endoscopic ultrasonography (EUS)‐guided interventions have been reported. Of these interventions, EUS‐guided pancreatic duct (PD) intervention seems to be the most difficult and challenging procedure to accomplish. We provide suggestions for EUS‐guided PD intervention, which includes PD stenting and the rendezvous technique following EUS‐guided pancreatography. PD stenting is performed between the PD and the gastrointestinal tract (stomach, duodenum, or jejunum). The rendezvous technique is performed using a guidewire across the papilla or anastomotic site for retrograde stent insertion. EUS‐guided PD intervention is still challenging because it is not established yet. Thus, although EUS‐guided PD intervention seems to be promising, it should be performed in selected patients such as those of failed standard endoscopic retrograde cholangiopancreatography.     

Meal Ingestion and Hemodynamic Interactions Regarding Renal Blood Flow on Duplex Sonography: Potential Diagnostic Implications

Splanchnic blood flow changes dramatically after meal ingestion. The present study evaluated physiologic interactions between meal ingestion and hemodynamics with respect to renal blood flow on duplex sonography, assessing the possible influence on Doppler parameters used as diagnostic criteria for renal artery stenosis. Subjects comprised 26 healthy young men (mean age: 22 ± 2 y). Sonographic measurements were made shortly after breakfast and every 1 h thereafter and were compared with values measured before the meal. Peak systolic velocity in the renal artery was elevated post-prandially, peaking at 1 h (90 ± 12 cm/s), compared with pre-prandially (73 ± 10 cm/s, p < 0.01). Similarly, acceleration time at the intra-renal segmental artery shortened to a minimum at 1 h (45 ± 5 ms) compared with baseline (51 ± 6 ms, p < 0.01). The present study indicates that renal blood flow is altered for a few hours after meal ingestion. Attention should be paid to the interpretation of data measured after meals on duplex sonography for diagnosis of renal artery stenosis.     

Ventilator-associated pneumonia in critically ill stroke patients: frequency, risk factors, and outcomes

Purpose

Our main objective was to assess incidence, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients.

Materials and Methods

After obtaining approval from the Human Studies Committee, we reviewed the electronic records from our intensive care unit database of 111 stroke patients on mechanical ventilation for more than 48 hours. Thirty-six risk factors related to disease and general health status, and 8 related to care—all assigned a priori—were collected and analyzed. Selected factors with univariate statistical significance (P < .05) were then analyzed with multivariate logistic regression.

Results

Thirty-one patients developed pneumonia (28%). Methicillin-resistant Staphylococcus aureus (n = 12) and methicillin-sensitive S aureus (n = 7) were the most common pathogenic bacteria. Chronic lung disease, neurological status at admission as assessed by the National Institutes of Health Stroke Scale, and hemorrhagic transformation were the independent risk factors contributing to VAP. Worsening oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) and proton pump inhibitor use for ulcer prophylaxis were other potentially important factors.

Conclusions

Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit stay gets significantly prolonged by VAP, but it does not affect mortality.     

Prediction of cognitive function by arterial stiffness in the very elderly.

BACKGROUND: Cognitive function is impaired in elderly subjects, so the aim of the present study was to determine the role of arterial stiffness on cognitive function. METHODS AND RESULTS: Cognitive function and arterial stiffness were assessed by the Mini-Mental State Examination (MMSE) and measurement of the brachial-ankle pulse wave velocity (PWV), respectively. The cross-sectional association of the MMSE score and PWV was studied in 203 subjects (87 men, 116 women), all of whom were 85 years old. Sex distribution, systolic and diastolic blood pressures did not differ between the normal (MMSE score >or=24, n=128) and impaired MMSE groups (MMSE score <24, n=75). In contrast, the PWV was significantly increased in the impaired MMSE group than in the normal MMSE group (25.0+/-0.8 vs 22.9+/-0.5 m/s, p<0.05). In multiple regression analysis, the PWV was also independently and significantly associated with the MMSE score. CONCLUSIONS: These results suggest that cognitive function could be predicted by arterial stiffness, as assessed by the PWV, in the very old. Preventing atherosclerosis may play an important role in preserving normal cognitive function until very old age.     

Primary aldosteronism due to unilateral adrenal microadenoma in an elderly patient: efficacy of selective adrenal venous sampling

We encountered a case of drug-resistant hypertension and hypokalemia. Laboratory data suggested primary aldosteronism (PA). Computed tomography imaging appeared normal for a long duration with a left-sided nodule appearing far later; adrenal scintigraphy was first normal, and the second test showed right-sided uptake. However, a repeat selective adrenal venous sampling (SAVS) indicated a left-sided lateralization of the hypersecretion of aldosterone. Left adrenectomy was performed, and his clinical symptoms improved. The histopathological findings demonstrated the aldosterone-producing microadenoma with secondary micronodules. In conclusion, SAVS should be performed to determine the laterality of PA with obscure CT imaging.     

Pancreatic head resection with segmental duodenectomy for pancreatic neoplasms

Background/purpose

We have experienced 67 cases of pancreatic head resection with segmental duodenectomy (PHRSD) for benign or low-grade malignant tumor of the pancreatic head region. Here we introduce our operative technique for these 67 cases.

Methods

Pancreatic head resection is performed with segmental duodenectomy including minor and major papilla. By conserving the right gastric artery and the gastroduodenal artery, 5–7 cm of the first portion of the duodenum is preserved with good arterial circulation. In addition, by conserving the anterior inferior pancreatoduodenal artery, the third portion and anal side or the second portion of the duodenum are preserved with good arterial circulation. Cholecystectomy is performed. The procedure is completed by resection of the pancreatic head with 3–4 cm of segmental duodenectomy including minor and major papilla. Reconstruction of the alimentary tract is performed with pancreatogastrostomy, end-to-end duodenoduodenostomy and end-to-side choledochoduodenostomy.

Results

In 67 cases with diseases of the pancreatic head region, chiefly intraductal papillary mucinous neoplasms, this procedure was successfully performed without operative or hospital death. Postoperative quality of life was quite satisfactory.

Conclusion

Total resection of the pancreatic head can be performed safely and effectively by this procedure.     

Relationship between the subendocardial viability ratio and risk factors for ischemic heart disease]

Ischemic heart disease is one of the major causes of sudden death in Japanese workers. Hypercholesteremia, hypertension, obesity, and the smoking habit are considered to be risk factors for cardiovascular events. Generally the subendocardium is thought to be more sensitive to a shortage of blood supply than the subepicardium. Buckberg et al. have demonstrated that the ratio of the area of the diastolic phase (diastolic pressure time index: DPTI) to that of the systolic phase (time tension index: TTI) in the central aortic profile has a close correlation with the blood supply to the subendocardium. This ratio was designated as the subendocardial viability ratio: SEVR (DPTI/TTI). We examined the relationships between the SEVR, as measured by SphygmoCor (AtCor Medical Ltd.), and the data from the health examination of 178 males working for a steel company. A significantly low SEVR was observed in people with the smoking habit, a high pulse rate, obesity, abnormality of blood fat components, or hyperglycemia. Employees in the normal SEVR group (SEVR: 140% or more) n = 120 and low SEVR group (SEVR: 139% or less) n = 58 were compared. The results suggested that employees with low SEVR were older and had a higher BMI, higher pulse rate, higher total cholesterol, higher triglyceride, and higher fasting plasma glucose. They also had lower HDL-cholesterol. In the low SEVR group, the percentage of employees with hyperlipidemia or hyperglucosemia was significantly higher than that in the normal SEVR group. Results of stepwise regression analysis indicated that the pulse rate and age were significant and independent predictive factors for SEVR. These data on SEVR calculated from the wave pattern of the central artery are considered to be useful parameters for evaluating the risk of myocardial ischemia and for guiding health promotion.