A case of cardiac sarcoidosis with advanced atrioventricular block. Failure of endomyocardial biopsy diagnosis and success in detecting

 We present a case of cardiac sarcoidosis with advanced atrioventricular (AV) block in a 45-year-old female patient. Although endomyocardial biopsy and other diagnostic findings were inconclusive, gastrocnemial muscle biopsy indicated a definitive diagnosis of sarcoidosis. Whole-body gallium-67 scintigraphy was useful to confirm the suspicion of the presence of sarcoidosis. Thereafter, magnetic resonance imaging (MRI) was successful in detecting the space-occupying lesion in the skeletal muscle, leading to a positive diagnosis of sarcoidosis. It is concluded that the presence of myocardial disease, such as cardiac sarcoidosis, should be considered when advanced AV block is encountered. Even if endomyocardial biopsy and other conventional diagnostic approaches are inconclusive, the possibility of cardiac involvement in sarcoidosis cannot be denied. This case report stresses the importance of more advanced diagnostic approaches, such as whole-body gallium scanning and MRI, in clarifying the etiology of AV block. Establishing the diagnosis of cardiac sarcoidosis is important in determining whether or not to begin effective long-term treatment with corticosteroids. Received: February 2, 2002 / Accepted: October 12, 2002 Correspondence to M. Sekiguchi     

Reverse redistribution phenomenon on rest (99m)Tc-tetrofosmin myocardial single photon emission computed tomography involves impaired left ventricular contraction in patients with acute myocardial infarction.

The purpose of this study was to investigate the clinical significance of the reverse redistribution (RR) phenomenon on technetium-99m ((99m)Tc)-tetrofosmin myocardial single photon emission computed tomography (SPECT) performed at rest. Twenty-five patients underwent myocardial SPECT 3 weeks after the onset of acute myocardial infarction. Myocardial images were acquired at 40 min (early) and 4 h (delayed) after the injection of 740 MBq of (99m)Tc-tetrofosmin. The regional myocardial uptake of the tracer in 26 segments of the left ventricular (LV) wall was visually scored from 0 (no activity) to 3 (normal activity), and then the RR was defined as a decrease of more than 1 point in the activity score on the delayed image compared with that on the early image. Regions with an activity score of 3 on both the early and delayed images were defined as normal, and those with a score of 0 or 1 on the early image were considered to have a fixed defect. The regional myocardial (99m)Tc-tetrofosmin uptake and washout rate were also quantitatively assessed in each region. In addition, exercise stress electrocardiograph-gated SPECT with (99m)Tc-tetrofosmin was performed within 1 week of the rest study, and the percent count increase (%CI) during myocardial contraction in each corresponding region was studied. RR was observed in 18 of the 25 patients. The regional washout rate of (99m)Tc-tetrofosmin was significantly higher in the RR regions (45.0+/-3.8%) than in either the normal regions (36.4+/-4.1%, p<0.001) or in those with a fixed defect (39.7+/-3.9%, p<0.001). The %CI in the RR regions (10.4+/-10.4%) was significantly less than that in the normal regions (23.5+/-10.1%, p<0.001); however, no significant difference was found between the RR regions and those with a fixed defect (8.0+/-7.2%). In patients with acute myocardial infarction, the regions showing the RR phenomenon on (99m)Tc-tetrofosmin SPECT have severely impaired LV wall contraction after exercise.     

Comparison of adverse effects of proton and X-ray chemoradiotherapy for esophageal cancer using an adaptive dose–volume histogram analysis

Cardiopulmonary late toxicity is of concern in concurrent chemoradiotherapy (CCRT) for esophageal cancer. The aim of this study was to examine the benefit of proton beam therapy (PBT) using clinical data and adaptive dose–volume histogram (DVH) analysis. The subjects were 44 patients with esophageal cancer who underwent definitive CCRT using X-rays (n = 19) or protons (n = 25). Experimental recalculation using protons was performed for the patient actually treated with X-rays, and vice versa. Target coverage and dose constraints of normal tissues were conserved. Lung V5–V20, mean lung dose (MLD), and heart V30–V50 were compared for risk organ doses between experimental plans and actual treatment plans. Potential toxicity was estimated using protons in patients actually treated with X-rays, and vice versa. Pulmonary events of Grade ≥2 occurred in 8/44 cases (18%), and cardiac events were seen in 11 cases (25%). Risk organ doses in patients with events of Grade ≥2 were significantly higher than for those with events of Grade ≤1. Risk organ doses were lower in proton plans compared with X-ray plans. All patients suffering toxicity who were treated with X-rays (n = 13) had reduced predicted doses in lung and heart using protons, while doses in all patients treated with protons (n = 24) with toxicity of Grade ≤1 had worsened predicted toxicity with X-rays. Analysis of normal tissue complication probability showed a potential reduction in toxicity by using proton beams. Irradiation dose, volume and adverse effects on the heart and lung can be reduced using protons. Thus, PBT is a promising treatment modality for the management of esophageal cancer.     

Final results from a multicenter prospective study (?JROSG 05–5) on postoperative radiotherapy for patients with ductal carcinoma in situ with an involved surgical margin or close margin widths of 1 mm or less

This multicenter prospective study ( Japanese Radiation Oncology Study Group: JROSG 05-5) aimed to evaluate the effectiveness of postoperative radiotherapy (PORT) in patients with ductal carcinoma in situ (DCIS) with an involved surgical margin or close margin widths of ≤1 mm or less. PORT consisted of whole-breast irradiation (50 Gy in 25 fractions) followed by boost irradiation (10 Gy in 5 fractions). Eligibility criteria were as follows: (i) DCIS without an invasive carcinoma component, (ii) age between 20 and 80 years old, (iii) involved margin or close margin widths of ≤1 mm, (iv) refusal of re-resection, (v) performance status of 0–2, and (vi) written informed consent. The primary endpoint was ipsilateral breast tumor recurrence (IBTR), and secondary endpoints were overall survival (OS), relapse-free survival (RFS), recurrence patterns, and adverse events. A total of 37 patients from 12 institutions were enrolled from January 2007 to May 2009. The median follow-up time was 62 months (range, 28–85 months). The median pathological tumor size was 2.5 cm (range, 0.3–8.5 cm). Of the 37 patients, 21 had involved margins, and 16 had close margins. The 5-year IBTR, OS and RFS rates were 6% (95% confidence interval [CI]: 2–21), 97% (95% CI: 83–99) and 91% (95% CI: 77–97), respectively. Two patients developed local recurrence at the original site after 39 and 58 months. No severe adverse events were found. Our study suggests that this PORT regimen could be a treatment option for patients with DCIS with involved margin or close margin who don''t desire re-resection.     

Association between trunk pain and lower extremity pain among youth soccer players: a cross-sectional study

Background

Soccer is a high-intensity sport with a high injury rate. Among youth soccer players, lower extremity pain is a major problem that could be associated with trunk function. This study investigated the association between lower extremity pain and trunk pain among youth soccer players.

Methods

A cross-sectional study involving youth soccer players participating in the Miyagi Amateur Sports Association was conducted using a self-reported questionnaire. A multiple logistic regression analysis was used to examine the association between trunk pain and lower extremity pain. Covariates were sex, age, body mass index, height increase, number of days of training per week, practice time per day on weekdays or weekends, competition levels, frequency of participation in games, and previous injuries.

Results

The final study population comprised 1139 youth soccer players (age, 6–15 years; male, 94.2%). Lower extremity pain with concomitant trunk pain occurred in 61.8% (42/68). Trunk pain was significantly associated with lower extremity pain (adjusted odds ratio [OR], 6.82; 95% confidence interval [CI], 3.99–11.67). Back pain and hip pain were significantly associated with knee pain (adjusted OR [95% CI]: 7.63 [3.70–15.76] and 3.84 [1.89–7.83], respectively), ankle pain (adjusted OR [95% CI]: 9.03 [4.42–18.44] and 5.43 [2.77–10.62], respectively), and both knee and ankle pain (adjusted OR [95% CI]: 13.67 [6.01–31.09] and 5.98 [2.56–13.97], respectively).

Conclusions

Trunk pain was associated with lower extremity pain among youth soccer players. Clinicians and coaches should consider comorbidities while treating those players.

     

Amino acid substitutions of hepatitis C virus core protein are not associated with intracellular antiviral response to interferon‐α in vitro

Background: Studies on patients with hepatitis C virus (HCV) of genotype 1b have suggested that amino acids (aa) 70 and/or 91 of the HCV core protein affect the outcome of interferon (IFN)‐α and ribavirin (RBV) therapy, although there are no clear supporting data in vitro. Aims: This study was designed to determine the differences among the antiviral activities of HCV core proteins with various substitutions at aa70 and/or aa91. Methods: The retroviral vectors expressing the HCV core proteins with substitutions of arginine/leucine, arginine/methionine, glutamine/leucine or glutamine/methionine at aa70/aa91 were transiently transfected or stably transducted into an immortalized hepatocyte line (PH5CH8), hepatoma cell lines and an HCV‐RNA replicating cell line (sOR) to evaluate antiviral responses to IFN‐α or IFN‐α/RBV. Sequence analysis was performed using genome‐length HCV‐RNA replicating cells (OR6 and AH1) to evaluate HCV core mutations during IFN‐α treatment. Results: The promoter activity levels of IFN‐stimulated genes in the transiently transfected cells or the mRNA levels of 2′‐5′‐oligoadenylate synthetase in the stably transducted PH5CH8 cells were not associated with the HCV core aa70 and/or aa91 substitutions during IFN‐α treatment. Antiviral responses to IFN‐α or IFN‐α/RBV treatment were enhanced in sOR cells stably transducted with the HCV core, although there were no differences in antiviral responses among the cells expressing different core types. Sequence analysis showed no aa mutations after IFN‐α treatment. Conclusions: Antiviral activities were enhanced by HCV core transduction, but they were not associated with the HCV core aa70 and/or aa91 substitutions by in vitro analysis.     

Arterial embolization for iatrogenic life-threatening bleeding from subcutaneous hypervascular tumor in prone position

Performing angiography in the prone position is a difficult technique; however it is useful in some emergency situation. We experienced a 60 years old male who was performed lipema excision on his back in his family doctor＇s clinic. Since massive arterial bleeding could not be controlled with manual astriction, he transferred to our hospital in prone position with hemodynamic instability. Operating field was not kept because of massive bleeding; therefore surgical treatment was impossible. We planed emergency arterial embolization （AE） in prone position. Hence we chose the left radial artery for vascular access. The left subclavicle arteriography showed many major and minor feeding arteries from left subclavicular and axillary arteries and a massive extravasation of the contrast medium. Three major feeding arteries were performed AE with gelatin sponge and steel coils, After AE, massive bleeding was controlled. He could discharge from our hospital on the 5th hospital day without any complication. Arterial embolization for lifethreatening bleeding from subcutaneous hypervascular tumor in the prone position is first report to our knowledge, and it is extremely rare. However we thought that this technique is useful for patients who could not turn in the supine position, e.g. massive bleeding during renal biopsy and penetrating trauma from back.     

Kif26b,a kinesin family gene,regulates adhesion of the embryonic kidney mesenchyme

The kidney develops through reciprocal interactions between two precursor tissues: the metanephric mesenchyme and the ureteric bud. We previously demonstrated that the zinc finger protein Sall1 is essential for ureteric bud attraction toward the mesenchyme. Here, we show that Kif26b, a kinesin family gene, is a downstream target of Sall1 and that disruption of this gene causes kidney agenesis because of impaired ureteric bud attraction. In the Kif26b-null metanephros, compact adhesion between mesenchymal cells adjacent to the ureteric buds and the polarized distribution of integrin α8 were impaired, resulting in failed maintenance of Gdnf, a critical ureteric bud attractant. Overexpression of Kif26b in vitro caused increased cell adhesion through interactions with nonmuscle myosin. Thus, Kif26b is essential for kidney development because it regulates the adhesion of mesenchymal cells in contact with ureteric buds.