A Case of Cushing’s Syndrome with Multiple Adrenocortical Adenomas Composed of Compact Cells and Clear Cells

A 58-year-old woman was referred to our hospital for Cushingoid features and diagnosed as adrenal Cushing’s syndrome due to a right adrenocortical mass (60?×?55 mm). The mass was composed of three different tumors; the first one was homogeneously lipid-poor neoplasm measuring 20?×?13 mm located at the most dorsal region, the second one was heterogeneous and lipid-rich tumor containing multiple foci of calcification measuring 50?×?32 mm located at the central region, and the last one was heterogeneous harboring dilated and tortuous vessels and lipid-poor one measuring 35?×?18 mm at the most ventral region of the adrenal gland. A right adrenalectomy was subsequently performed by open surgery. Macroscopic and microscopic analyses revealed that all three tumors were adrenocortical adenomas; the first one represents a pigmented adrenocortical adenoma, the second one adrenocortical adenoma associated with degeneration, and the third one adrenocortical adenoma harboring extensive degeneration. Immunohistochemical analysis of the steroidogenic enzymes also revealed that all of the tumors had the capacity of synthesizing cortisol. This is a very rare case of Cushing’s syndrome caused by multiple adrenocortical adenomas including a pigmented adenoma. Immunohistochemical analysis of steroidogenic enzymes contributed to understanding of steroidogenesis in each of these three different adrenocortical adenomas in this case.     

Infantile hemangiopericytoma of the tongue—Efficacy of ex utero intrapartum treatment procedure and combined-modality therapy

Here we present an extremely rare case of giant infantile hemangiopericytoma (HPC) of the tongue diagnosed prenatally by fetal ultrasonography and MR imaging. Due to airway stenosis, the patient was delivered by the ex utero intrapartum treatment (EXIT) procedure at 36 weeks of pregnancy. Initial diagnosis was infantile hemangioma based on physical examination, diagnostic imaging and the high incidence of hemangioma. The tumor was resistant to conservative treatments. Due to severe tumor hemorrhage, the nutrient vessel was embolized by endovascular treatment on the 73th day after birth. Two days after embolization, a hemiglossectomy was performed. Histological analysis after surgery diagnosed infantile HPC with microscopically positive stumps. After receiving adjuvant chemotherapy, the patient has had no recurrence after 53 months with normal speech and swallowing function resulting in normal growth. Our findings support that infantile HPC is one of the differential diagnosis of infantile hemangioma. The EXIT procedure could be effective for infants with upper respiratory stenosis by head and neck tumor diagnosed prenatally. Though complete resection is required for infantile HPC, our report suggests that a conservative surgical approach followed by adjuvant chemotherapy should be used for giant head and neck infantile HPC.     

Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients

The aim of this study was to clarify the relationship of nursing autonomy and other factors related to attitudes toward caring for dying patients. A cross-sectional survey of nurses was conducted in November 2003 using a self-administered questionnaire. We collected demographic data from 178 (75%) participants and used the Frommelt Attitude Toward Care of the Dying scale, Form B, Japanese version (FATCOD-Form B-J), the Pankratz Nursing Questionnaire (PNQ), and the Death Attitude Inventory (DAI). FATCOD-Form B-J measures nurse's attitude toward caring for dying patients. It includes two subscales: positive attitude toward caring for the dying patient and perception of patient- and family-centered care. The PNQ measures nursing autonomy of individual nurses and has three subscales: nursing autonomy and advocacy, patients' rights, and rejection of traditional role limitations. The DAI measures attitudes toward death in context of Japanese cultural characteristics. It includes seven subscales: afterlife beliefs, death anxiety, death relief, death avoidance, life purpose, death concern, and supernatural beliefs. We investigated the factors associated with the FATCOD-Form B-J. Support of a mentor regarding end-of-life issues (beta = .19, P = .001), death avoidance domain of the DAI (beta = -.14, P = 0.03), life purpose domain of the DAI (beta = .23, P = .001), and rejection of traditional role limitations domain of the PNQ (beta = .51, P = .001) were selected as significant independent variables by multivariate analysis to evaluate nurses' positive attitudes toward caring for dying patients. Death anxiety domain of the DAI (beta = -.17, P = .02), patients' rights domain of the PNQ (beta =.46, P = .001), and rejection of traditional role limitations domain of the PNQ (beta = .34, P = .001) were selected as significant independent variables by multivariate analysis to evaluate the nurses' perception of patient-and family-centered care. In conclusion, nursing autonomy plays an important role in the attitudes of Japanese nurses who care for dying patients. Educational and administrative efforts to strengthen nursing autonomy are necessary.     

Immunohistochemical characterization of glomerular PDGF B-chain and PDGF beta-receptor expression in diabetic rats

Platelet-derived growth factor (PDGF) was found to contribute to the pathophysiological process in the development and progression of glomerulosclerosis characterized by mesangial cell proliferation and accumulation of extracellular matrix. To examine the role of PDGF in the development of diabetic nephropathy, we conducted immunohistochemical analysis for PDGF B-chain (PDGF-B) and PDGF beta-receptor (PDGFR-beta) in the glomeruli of streptozotocin-induced diabetic rats. At 2, 4, and 12 weeks after the onset of diabetes, the expression of PDGF-B in glomeruli of diabetic rats was increased significantly as compared to control or diabetic rats treated with insulin. Similar changes were observed on PDGFR-beta immunostaining. The immunostaining of mirror sections revealed the existence of PDGF-B or PDGFR-beta not only in mesangial cells but also in visceral epithelial cells. Glomerular volume was significantly increased in diabetes. This early glomerular abnormality was prevented by an inhibition of PDGF system with trapidil as well as by the treatment of insulin. Our results suggest that the activation of the PDGF system in glomerular cells might play an important role in the development of early glomerular lesion in diabetes.     

The immunobiological properties expressed in vitro and in vivo of Salmonella enteritidis-induced murine T cell lines

Splenic T lymphocytes from two strains of mice, BALB/c and B10.BR, infected with an attenuated strain of Salmonella enteritidis were cloned by the double-layer soft agar technique in the presence of interleukin 2 (IL 2), formalin-killed S. enteritidis (FKS) and syngeneic feeder cells. One Salmonella-reactive T cell line was established from each strain of mice. Both T cell lines bore Thy-1+, Lyt-1+ and L3T4+ surface markers as demonstrated by cytofluorography. Biological properties of the T cell lines were studied with respect to their ability to proliferate and produce lymphokines such as IL 2 and gamma-interferon (IFN-gamma) in response to Salmonella antigens, and to transfer adoptively protection against infection and delayed-type hypersensitivity (DTH). As the result of the present study, the T cell lines were proliferated specifically against several Salmonella and other bacteria, which belong to species of Enterobacteriaceae. Their proliferation required the presence of the specific antigen(s) and the compatibility in the I-A region of the H-2 complex between the T cell lines and feeder cells. The T cell lines could be proliferated with resultant production of IL 2 and IFN-gamma by in vitro culture in the presence of syngeneic feeder cells and Salmonella antigens. The protective activity assessed by the number of recoverable bacteria in spleens and livers after challenge with virulent S. enteritidis and DTH reactions to Salmonella antigen were exhibited by the T cell lines when transferred adoptively to naive syngeneic mice. These results suggested that different biological functions of cell-mediated immunity to Salmonella could be mediated by a single phenotype of T cell population.     

Endovascular treatment of chronic mesenteric ischemia

Endovascular procedure is frequently used as an alternative to surgical bypass in aortic atherosclerotic lesions. Two rare cases of chronic mesenteric ischemia treated with a stent implantation are reported. The patients were a 72-year-old woman and a 57-year-old woman. They presented with severe abdominal pain after meals, repeatedly. Angiography revealed severe stenosis and occlusion of the super mesenteric artery (SMA). Endovascular treatment was initially and technically successful in both patients. A Palmaz stent was deployed in the ostium lesion of the SMA for both cases. Completion angiography showed successful recanalization of the SMA without any complication and with satisfactory distal flow. The patients' symptoms were alleviated. They remained asymptomatic after stent implantation. Primary stenting may be considered a viable alternative to conventional surgery in carefully selected patients with chronic mesenteric ischemia due to SMA stenosis.     

Impact of transgenic overexpression of SH2-containing inositol 5'-phosphatase 2 on glucose metabolism and insulin signaling in mice

SH2-containing inositol 5'-phosphatase 2 (SHIP2) is a 5'-lipid phosphatase hydrolyzing the phosphatidylinositol (PI) 3-kinase product PI(3,4,5)P(3) to PI(3,4)P(2) in the regulation of insulin signaling, and is shown to be increased in peripheral tissues of diabetic C57BL/KSJ-db/db mice. To clarify the impact of SHIP2 in the pathogenesis of insulin resistance with type 2 diabetes, we generated transgenic mice overexpressing SHIP2. The body weight of transgenic mice increased by 5.0% (P < 0.05) compared with control wild-type littermates on a normal chow diet, but not on a high-fat diet. Glucose tolerance and insulin sensitivity were mildly but significantly impaired in the transgenic mice only when maintained on the normal chow diet, as shown by 1.2-fold increase in glucose area under the curve over control levels at 9 months old. Insulin-induced phosphorylation of Akt was decreased in the SHIP2-overexpressing fat, skeletal muscle, and liver. In addition, the expression of hepatic mRNAs for glucose-6-phosphatase and phosphoenolpyruvate carboxykinase was increased, that for sterol regulatory element-binding protein 1 was unchanged, and that for glucokinase was decreased. Consistently, hepatic glycogen content was reduced in the 9-month-old transgenic mice. Structure and insulin content were histologically normal in the pancreatic islets of transgenic mice. These results indicate that increased abundance of SHIP2 in vivo contributes, at least in part, to the impairment of glucose metabolism and insulin sensitivity on a normal chow diet, possibly by attenuating peripheral insulin signaling and by altering hepatic gene expression for glucose homeostasis.