Superficial elevated-type early gallbladder carcinoma treated by laparoscopic cholecystectomy

A 60-year-old woman was admitted to our department for detailed examination of a polypoid lesion of the gallbladder detected at the time of a mass survey by ultrasound. Endoscopic ultrasonography (EUS) demonstrated a broad-based mass lesion, about 10 mm in size, with an irregular surface, at the peritoneal side of the body of the gallbladder. The layer structure of the gallbladder wall had not been destroyed by the mass. Computed tomography showed no direct invasion of the liver or other evidence of metastasis. Type-IIa (superficial elevated-type) early gallbladder cancer was suspected and laparoscopic cholecystectomy was performed. Histologically, the tumor proved to be a papillo-tubular adenocarcinoma, 9×8 mm in size, confined to the mucosa and without lymphatic permeation, vascular involvement, perineural invasion, or other signs of metastasis. Laparoscopic cholecystectomy for gallbladder cancer can be indicated only when a lesion is a pedunculated protruded-type (type-Ip) cancer, or a broad-based cancer 10 mm or less in size located on the peritoneal side with no destruction of the layer structure of the wall demonstrated by EUS. This strategy is justified only with precise evaluation of the lesion by EUS.     

Left ventricular regional relaxation and its nonuniformity in hypertrophic nonobstructive cardiomyopathy

BACKGROUND. Regional nonuniformity has been suggested to be closely related to left ventricular (LV) relaxation in diseased heart. The purpose of the present study was to assess LV global and regional relaxation in patients with nonobstructive hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS. Left ventriculography was conducted simultaneously with pressure micromanometry in 10 normal control subjects and 11 patients with nonobstructive HCM. LV silhouettes in the right anterior oblique projection were divided into eight regions, and regional wall stress during isovolumic relaxation was computed for six regions from the midventricle to the apex. In HCM patients, isovolumic relaxation time (IRT) and the time constant of LV pressure decrease (Tp) were greater than in control subjects (IRT, 84 +/- 13 versus 66 +/- 6 msec; Tp, 51 +/- 8 versus 36 +/- 5 msec, respectively; p less than 0.01). In HCM patients, the (-)dP/dt upstroke pattern was convex-downward, and dP/dt(20/60), the ratio of dP/dt values 20 and 60 msec after peak (-)dP/dt, was less than in control subjects (1.46 +/- 0.16 versus 2.15 +/- 0.14, p less than 0.01). These findings suggest that there is impaired LV relaxation in HCM patients. End-systolic regional wall stress was lower, and the time constant of regional stress decrease (Tst) was prolonged for each region in HCM patients compared with control subjects. In the HCM group, Tst tended to be more prolonged in regions with increased wall thickness than in regions with normal wall thickness (60 +/- 15 versus 50 +/- 11 msec, p less than 0.01). The coefficient of variation for Tst values in six areas of the left ventricle was calculated in each subject and was greater in HCM patients than in control subjects (13 +/- 7% versus 7 +/- 3%, p less than 0.05), indicating regional nonuniformity in Tst during isovolumic relaxation in HCM patients. CONCLUSIONS. Significant correlations existed between the coefficients of variation for Tst and Tp (r = 0.80, p less than 0.01), IRT (r = 0.79, p less than 0.01), and dP/dt(20/60) (r = -0.67, p less than 0.05) in the HCM group. Thus, regional nonuniformity is closely related to the impairment of LV relaxation in HCM.     

Walking and sports participation and mortality from coronary heart disease and stroke.

OBJECTIVES: We aimed to examine the impact of exercise on mortality from cardiovascular disease (CVD) in Asian populations. BACKGROUND: Few data have been available in Asian countries, where job-related physical activity is higher than that in Western countries. METHODS: Between 1988 and 1990, 31,023 men and 42,242 women in Japan, ages 40 to 79 years with no history of stroke, coronary heart disease (CHD), or cancer, completed a self-administered questionnaire. Systematic mortality surveillance was performed through 1999, and 1,946 cardiovascular deaths were identified. We chose the second lowest categories of walking and sports participation as the reference to reduce a potential effect of ill health. RESULTS: Men and women who reported having physical activity in the highest category (i.e., walking > or =1 h/day or doing sports > or =5 h/week) had a 20% to 60% lower age-adjusted risk of mortality from CVD, compared with those in the second lowest physical activity category (i.e., walking 0.5 h/day, or sports participation for 1 to 2 h/week). Adjustment for known risk factors, exclusion of individuals who died within two years of baseline inquiry, or gender-specific analysis did not substantially alter these associations. The multivariate-adjusted hazard ratios (95% confidence interval) for the highest versus the second lowest categories of walking or sports participation were 0.71 (0.54 to 0.94) and 0.80 (0.48 to 1.31), respectively, for ischemic stroke (IS); 0.84 (0.64 to 1.09) and 0.51 (0.32 to 0.82), respectively, for CHD; and 0.84 (0.75 to 0.95) and 0.73 (0.60 to 0.90), respectively, for CVD. CONCLUSIONS: Physical activity through walking and sports participation might reduce the risk of mortality from IS and CHD.     

Hemodynamic changes associated with long-term antihypertensive therapy with new calcium antagonist

To evaluate the therapeutic efficacy of a new calcium antagonist, nicardipine in hypertension, the cardiovascular effects of chronic therapy were determined by echocardiography in 10 patients with uncomplicated mild to moderate hypertension. Significant declines were recorded in mean blood pressure (average; 11.7 +/- 0.8%) and total peripheral resistance (22.0 +/- 2.0%), accompanied by an increase in cardiac index (13.6 +/- 2.2%). In spite of the considerable degree of blood pressure reduction, heart rate and body weight were unchanged. The magnitude of the decline in total peripheral resistance was directly correlated to both the decrease in mean blood pressure (r = 0.701, p less than 0.02) and the increase in cardiac index (r = -0.953, p less than 0.01). These findings suggest that the hypotensive effect of this new calcium antagonist is due to peripheral vasodilation, and it appears to represent an effective adjunct for the treatment of mild to moderate hypertension.     

Temporary endosonography-guided biliary drainage for transgastrointestinal deployment of a self-expandable metallic stent

Endosonography-guided biliary drainage (ESBD) is now gaining acceptance as a useful alternative for the management of obstructive jaundice.(1) At present, ESBD is used mainly to establish an anastomosis between the biliary tree and the duodenum, stomach, jejunum, or esophagus by placing a stent so as to bridge the bile duct and alimentary tract. We herein report a new application of ESBD, that is, its temporary use for gaining access to the bile duct in order to deploy a self-expandable metallic stent (SEMS) via the transhepatic route. In a patient with pylorus stenosis due to advanced gastric cancer with extrahepatic bile duct obstruction caused by nodal metastasis, a plastic stent was placed temporarily by ESBD to bridge the esophagus and the left hepatic duct. Ten days later, the stent was retrieved, leaving a guidewire in the bile duct, and a delivery unit of a SEMS was introduced into the bile duct over the guidewire via the sinus tract. The SEMS was then successfully deployed through the stenosis. No stent was left in the sinus tract. This procedure yields a mature fistula through which a delivery unit can be safely introduced into the bile duct followed by uneventful deployment of a SEMS.     

Clinical Effectiveness of Tolvaptan in Patients with Acute Decompensated Heart Failure and Renal Failure: Design and Rationale of the AQUAMARINE Study

Purpose

Over half of all admitted acute decompensated heart failure (ADHF) patients have renal failure. Although diuretics represent the mainstay of treatment strategy even in this population, there are unmet needs for safer and more effective treatment. Tolvaptan is a vasopressin-2 receptor antagonist, and we hypothesized that adding tolvaptan to standard diuretic therapy would be more effective in ADHF patients with renal function impairment.

Methods

The Answering question on tolvaptan’s efficacy for patients with acute decompensated heart failure and renal failure (AQUAMARINE) is a multicenter, randomized controlled clinical trial, which will enroll 220 patients from 17 hospitals in Japan. ADHF patients whose estimated glomerular filtration rate is above 15 and below 60 mL/min/1.72 m² will be randomly assigned within 6 h after admission to usual care with furosemide or tolvaptan add-on therapy. Primary endpoint is achieved urine output within 48 h. Secondary endpoints include dyspnea relief measured by 7-points Likert scale, incidence of worsening renal function, dose of furosemide used within 48 h, and changes of brain natriuretic peptide.

Conclusion

This study is the first multicenter study in Japan to evaluate clinical effectiveness of tolvaptan add-on therapy in ADHF patients with renal failure. The results of this study address the treatment strategy of this high-risk population (UMIN Clinical Trial Registry Number: UMIN000007109).