Age‐ and sex‐associated morphological variations of metatarsal torsional patterns in humans

It has been demonstrated that the torsional patterns of the metatarsal heads are associated with the presence or absence of the medial longitudinal arch in hominoid feet. The relatively untwisted second metatarsal is unique in humans, but that of the African apes is much more inverted, suggesting that the torsion of the second metatarsal might represent the overall shape and flatness of the foot. Some clinical studies have recently argued that the onset of foot pathologies such as hallux valgus might be related to the torsional pattern of the metatarsals. However, to date, no studies have systematically investigated the morphological variations of the torsional patterns of human metatarsals. In this study, therefore, the aim was to clarify the age‐ and sex‐associated variations in the torsional patterns of human metatarsals using three‐dimensional computed tomography. The torsion angles of the five metatarsals were calculated by defining the dorsopalmar vector of the metatarsal base and the vector corresponding to the rotational axis of the metatarsal head. The present result demonstrated that the second metatarsals of females were significantly more inverted with increasing age. Flat foot is known to be most common in elderly women. Whether there is a cause–effect relationship between second metatarsal torsion and flattening of the medial longitudinal arch has yet to be answered, but this study suggested that torsion of the second metatarsal might possibly be used as an indicator for the early diagnosis of flat foot and associated foot pathologies. Clin. Anat. 30:1058–1063, 2017. © 2017 Wiley Periodicals, Inc.     

Polymerase chain reaction screening of immunoglobulin heavy chain and T cell receptor γ gene rearrangements: A practical approach to molecular DNA analysis of non-Hodgkin's lymphoma in a surgical pathology laboratory

Characterization of the clonality of non-Hodgkin's lymphoma (NHL) by the rearranged segments of immunoglobulin heavy chain (Ig(H)) or T cell receptor (TCR) genes is not only useful in the confirmation of the diagnosis but also for the future assessment of how a secondary lymphoma, such as a recurrence or another primary lymphoma, occurs. As a practical approach to obtaining and registering this information in a surgical pathology laboratory, FR3 and FR1 regions of Ig(H) gene and TCRgamma gene were concurrently amplified by polymerase chain reaction (PCR) using each pair of consensus primers and the same PCR protocol. Examined samples consisted of 134 primary NHL (phenotypically, 108 B cell and 26 T cell NHL), 19 reactive lymphadenopathies, as well as five secondary lymphomas whose primary lesions were included in this study. Among the primary NHL, the combined PCR analysis disclosed the clonality in 103 of 134 NHL (77%), by FR3 PCR in 77 B cell and two T cell NHL, by FR1 PCR in 59 B cell and one T cell NHL, and by TCRgamma PCR in 11 B cell and 17 of 26 T cell NHL, but in none of the reactive lymphadenopathies. Among the secondary lymphomas, the same pattern of PCR analysis was obtained in two cases (the durations between first and second lymphomas; 6 and 10 months), which suggested recurrence. In contrast, different results were obtained in three cases (17-37 months), which indicated another primary or emergence of the subclones. The results of Southern blot analysis were concordant with the PCR results of the first and the secondary lymphomas. Although the combined PCR analysis cannot replace Southern blot hybridization because of its lower detection rate, it can select those cases suitable for further Southern blot analysis thus reducing the number of unnecessary examinations by nearly 75%. This approach may also be useful in the comparative evaluation of primary and secondary lymphomas.     

Physiologic Effect of Stent Therapy for Inferior Vena Cava Obstruction Due to Malignant Liver Tumor

Purpose To understand systemic the influence of stent therapy for inferior vena cava (IVC) obstruction due to advanced liver tumor. Methods Seven patients with symptomatic IVC obstruction due to advanced primary (n = 4) or secondary (n = 3) liver tumor were subjected to stent therapy. Enrollment criteria included high IVC pressure over 15 mmHg and the presence of edema and ascites. Z-stents were deployed using coaxial sheath technique via femoral venous puncture. Physiologic and hematobiochemical parameters were analyzed. Results All procedures were successful, and the stents remained patent until patient death. Promptly after stent placement, the IVC flow recovered, and the venous blood pressure in the IVC below the obstruction level showed a significant decrease from 20.8 ± 1.2 mmHg (mean ± SE) to 10.7 ± 0.7 mmHg (p < 0.01). Transient mild increase of right atrial pressure was observed in 1 patient. During the following week prominent diuresis was observed in all patients. Mean urine output volume in the 3 days before the stent therapy was 0.81 ± 0.09 l/day compared with 2.1 ± 0.2 l/day (p < 0.01) in the 3 days after. The edema and ascites decreased in all patients. The caval pressure change correlated well (r > 0.6) with the urine volume increase, and with the decreased volume of edema and ascites. The urine volume increase correlated well with the decrement of edema, but not with that of ascites. Improvements for various durations in the levels of blood urea nitrogen, serum creatinine, lactate dehydrogenase, fibrinogen, and platelet count were found (p < 0.05). These hematobiochemical changes were well correlated with each other and with the decrement of ascites. Two patients showed a low blood sodium level of 128.5 mEq/l after intensive natriuresis, and one of them died on day 21 with hepatic failure, which was interpreted as maladaptation aggravation. The mean survival time was 94.1 ± 34.1 days (mean ± SD), ranging from 21 to 140 days after stent treatment. Conclusion The stent therapy for IVC obstruction due to malignant liver tumors was followed by a series of physiologic and hematobiochemical consequences, most of them favorable but some possibly unfavorable. Rational interpretations and predictions of sequelae based on physiologic science including cardiology, hepatology, and nephrology would facilitate the best management of stent therapy for malignant IVC obstruction.     

Interfractional fluctuation of rectal dose in high dose rate brachytherapy for prostate cancer

Purpose The aim of the study was to explore the cause of the difference in the maximal rectal dose between the first and second high dose rate (HDR) brachytherapy applications by comparing the thickness of the anterior rectal wall. Materials and methods The rectal dose and the thickness of the anterior rectal wall were analyzed in 26 patients with prostate cancer. After undergoing external beam radiation treatment with a total isocenter dose of 50 Gy, they were treated with HDR brachytherapy of 7.5 Gy/fraction, two fractions daily. The interval between the first HDR brachytherapy session and the second was 5 h. The rectal doses were directly surveyed during irradiation of the HDR brachytherapy. Thickening of the anterior rectal wall was measured at the same level by axial computed tomography scans obtained before the first and second HDR brachytherapy applications. Results The maximal surveyed rectal doses during the first and second HDR brachytherapy applications were 188 ± 51 cGy and 220 ± 35 cGy, respectively (P < 0.01). The fluctuation ratio exceeded 1 in each case. The thickness of the anterior rectal wall before the first and second HDR brachytherapy applications was 18.78 ± 4.34 mm and 14.95 ± 4.09 mm (P < 0.01), respectively. The fluctuation difference exceeded 0 in each case. Conclusion The different rectal dose is attributable to thinning of the anterior rectal wall. The total rectal dose is within the range of doses at risk of exerting a toxic effect on the rectum.     

Evaluation of Dynamic Carpal Arch Stability following Carpal Tunnel Release Using Four-Dimensional Computed Tomography

Introduction  This study aimed to assess the carpal arch dynamics during active finger and wrist motion following carpal tunnel release using four-dimensional computed tomography (4D-CT). Materials and Methods  Four patients who diagnosed with bilateral carpal tunnel syndrome and underwent unilateral carpal tunnel release were prospectively included. 4D-CT of the bilateral wrists during active finger and wrist motion was performed for 10 seconds at five frames per second. The distances between the tip of tuberosity of the scaphoid and the volar ridge of the pisiform (S–P distance) and volar ridge of trapezium and the tip of hook of hamate (T–H distance) were measured at each position and the values of S–P and T–H distances were compared between the postoperative and contralateral wrists. Results  During finger motion, the S–P and T–H distances were not different at any position between the postoperative side and contralateral side. Conversely, S–P and T–H distances gradually increased in the postoperative wrists. The differences between the sides of S–P distance were significant, with >0 degrees of wrist extension, and differences of T–H distance were significant with >15 degrees of wrist extension. Conclusion  This study demonstrated the carpal arch dynamics using 4D-CT and revealed that the carpal arch was widened with the wrist in extension after carpal tunnel release. This study suggests that the transverse carpal ligament plays an important role in maintaining carpal arch stability.     

Surface appearance of the vertebrobasilar artery revealed on basiparallel anatomic scanning (BPAS)-MR imaging: its role for brain MR examination

PURPOSE: Basiparallel anatomic scanning (BPAS)-MR imaging is a simple MR imaging technique that we designed for visualization of the surface appearance of the vertebrobasilar artery within the cistern. It can clearly show the outer contour of occluded arteries or thrombosed aneurysms. By comparing BPAS-MR imaging with 3D time-of-flight (TOF) MR angiography (MRA), we can precisely evaluate the vertebrobasilar artery condition. The purpose of this study is to determine the value of BPAS-MR imaging for brain MR examination. MATERIALS AND METHODS: We obtained BPAS-MR imaging, in addition to 3D TOF MRA, for 385 consecutive patients who underwent brain MR imaging and MRA in our hospital between April 1 and August 31, 2003. Their complaints varied from mild head symptoms to severe neurologic illness. Comparing BPAS-MR imaging with MRA, we revealed the character of BPAS-MR imaging and determined the role and value of displaying vascular outer contour. RESULTS: Although the cases did not represent a restricted group of vertebrobasilar diseases, BPAS-MR imaging contributed to accurate evaluation of the vertebrobasilar artery in 90 of our 385 patients (23.4%). Of particular note, 16.1% of our patients could not be evaluated accurately by MRA only. BPAS-MR imaging was useful to confirm hypoplastic or occluded vertebral arteries and to reveal the whole appearance of large or partially thrombosed aneurysms of the vertebrobasilar system. CONCLUSION: The combination of the BPAS-MR imaging and the 3D TOF MRA was necessary for accurate diagnosis in 16.1% of our ordinary patients. We should evaluate not only MRA but also the vascular outer contour revealed on BPAS-MR imaging, though its application is limited to the vertebrobasilar system and the screening use.     

Optimal Covering Material for Stent-Grafts Placed in the Portal Vein in a Canine Model

Purpose We evaluated the suitability of Dacron, polytetrafluoroethylene (PTFE), and small intestinal submucosa (SIS) as a covering material for stent-grafts placed in the portal vein as compared with a bare stent. Methods Using 24 beagle dogs, either bare stents or stent-grafts covered with Dacron, PTFE, or SIS were placed in the main trunk of the portal vein in 6 animals each. Portography was performed immediately after stent placement, and at 2, 4, and 12 weeks thereafter. Next, the extracted stents or stent-grafts were examined histopathologically. Neointimal thickness adjacent to the stent wire and at the midportion between the stent wires was compared among the groups. Then, the neointimal thickness at the sub- and supragraft sites was compared between each stent-graft group. Serial changes in the histologic features of the thickened neointima were also investigated. Results No significant difference was noted in the mean stenotic ratio of the portal vein diameter between the bare stent and PTFE groups, whereas it was significantly higher in the Dacron and SIS groups compared with the bare stent group. In neither of the studies on neointimal thickness adjacent to the stent wire and at the midportion between the stent wires were any significant differences noted between the neointimal thickness of the bare stent group and the sum of the neointimal thickness of the PTFE group, whereas the sum of the neointimal thickness of the Dacron and SIS groups was significantly greater than that of the bare stent group at both sites. In the comparison of the supragraft neointimal thickness, the SIS group showed significantly greater thickness than the PTFE group, while the difference between the Dacron and PTFE groups was not significant. In the comparison of the subgraft neointimal thickness, the Dacron and SIS groups showed significantly greater thickness than the PTFE group. Conclusion The present results indicate that of the three covering materials examined here, PTFE is the most suitable material for grafts placed in the portal vein.     

Prospective comparison of transcatheter arterial chemoembolization with Lipiodol-epirubicin and Lipiodol-cisplatin for treatment of recurrent hepatocellular carcinoma

Purpose

The aim of this study was to compare the safety and short-term efficacy of transcatheter arterial chemoembolization (TACE) using cisplatin-Lipiodol suspension (CP/Lp) with that using epirubicin-Lipiodol emulsion (EP/Lp) in patients with recurrent hepatocellular carcinoma (HCC).

Materials and methods

A total of 28 HCC patients were enrolled prospectively and assigned to the CP/Lp group or EP/Lp group. Adverse effects related to TACE were graded; and the treatment effect (TE) on HCC nodules at 3 months and overall tumor response at 6 months were assessed as the endpoint.

Results

No significant difference was observed between the groups regarding the frequency of adverse effects of grade 3 or less. The TE rates for 100% necrosis plus >50% necrosis in 62 HCC nodules in the CP/Lp group and 75 HCC nodules in the EP/Lp group were 72.6% and 66.7%, respectively (P = 0.894). Overall tumor response revealed that six patients (50.0%) in the CP/Lp group and six patients (37.5%) in the EP/Lp group had a partial response plus a complete response, with no significant difference (P = 0.615). TACE-free control curves for both groups revealed no significant difference (P = 0.513).

Conclusion

No significant difference was found with regard to adverse effects, the treatment effect on HCC nodules, or overall tumor response between the CP/Lp and EP/Lp groups.     

Stride length of elderly patients with lumbar spinal stenosis: Multi-center study using the Two-Step test

BackgroundShort stride length is one of clinical symptoms associated with lumbar spinal stenosis (LSS). Short stride is a risk factor for falls; therefore, identification of factors associated with short stride is critical for fall prevention in LSS patients. Although the Two-Step test can conveniently assess maximal stride length, it has not become widely used; therefore, its data are limited. We identified the potential factors associated with short stride of elderly LSS patients using Two-Step test.MethodsClinical data of patients aged >65 years who planned to undergo surgery for LSS were prospectively collected at multiple institutions. Patients were assessed with the Two-Step test and Timed Up-and-Go Test prior to surgery; 357 consecutive patients were enrolled. We determined the cut-off value of the Two-Step test score for short stride, referring to the Timed Up-and-Go Test score of 13.5 s, used to indicate high risk of falls in elderly individuals. Logistic regression model was constructed to identify factors associated with short stride.ResultsThe Two-Step test score showed moderate-to-strong inverse correlation with that of Timed Up-and-Go Test (r = ?0.65, p < 0.001). Using the tentative Two-Step test cut-off value (0.93) for short stride, multivariable analysis showed that age ≥80 years (OR = 2.3, 95% CI:1.1–4.8), a score of <60 for lumbar function in Japanese Orthopedic Association Back Pain Evaluation Questionnaire (OR = 2.7, 95% CI:1.5–4.7), motor deficit (OR = 2.7, 95% CI:1.2–6.1), and sagittal vertical axis ≥50 mm (OR = 2.1, 95% CI:1.2–3.5) were factors significantly associated with short stride in elderly patients with LSS.ConclusionsUsing the Two-Step test, we found that 80 years old and over, lumbar dysfunction, motor deficit of the lower extremities, and forward-bent posture were associated with short stride in LSS patients. Therefore, elderly LSS patients with these conditions may have a higher risk for falls.