The improvement of the enforcement rate of the standard regimen (A) of tuberculosis chemotherapy by the introduction of common database system for tuberculosis

OBJECTIVE: The purpose of this study was to improve the enforcement rate of the standard regimen (A) of tuberculosis chemotherapy. SUBJECTIVE AND METHODS: We introduced the common database system for tuberculosis in three national hospitals in Hokkaido. From January 2002 to December 2003, we collected the anonymous informations of the patients with tuberculosis at the start of treatment, at the discharge and at the end of treatment. Then, we reported the enforcement rate of the standard regimen (A) as a clinical indicator periodically to three hospitals. RESULTS: Four hundred and twenty-nine patients were registered. In patients below 80 years old, the enforcement rate of the standard regimen (A) was 48.5% in 2002. The enforcement rate rose significantly to 62.7% (p = 0.0126) in 2003. In elder smear-positive patients (> or =75) and in elder smear-negative patients (> or =70), the enforcement rate was low (29.1% and 25.0%, respectively). Furthermore in young smear-negative patients (< or =29), the enforcement rate was low (28.0%). As the extent of their disease was minimal, they were treated with other regimens. In patients treated with the standard regimen (A), there were no significant differences in the frequency of adverse effects between elder patients ( 70) and other patients (< or =69). There were also no significant differences in the frequency of changing the regimen between them. Median admission period of 2002 was 114 days. In 2003, it was shortened significantly to 110 days (p = 0.0487). CONCLUSION: By the introduction of the common database system for tuberculosis, the enforcement rate of the standard regimen (A) was improved. Low enforcement rate in young smear-negative patients in an important problem to be improved in the future. The clinical indicator based on the common database system between hospitals, is useful to clarify the problems, and then to improve the quality of medical performance.     

Lymphadenectomy along the middle colic artery in laparoscopic resection of transverse colon

BACKGROUND/AIMS: Although laparoscopic-assisted colectomy has been replacing open colectomy, dissection of lymph nodes along the main artery is sometimes difficult and dangerous in laparoscopic-assisted colectomy, especially, lymph nodes at the origin of the middle colic artery in laparoscopic resection of the transverse colon. METHODOLOGY: After the isolation of colon, meso-colon in both ends was excised. Then, the colon was rotated clockwise 90 degrees by centering at the base of the meso-colon. This procedure made it easier to isolate the anterior and posterior leaf of the meso-colon at its base. The middle colic artery was divided at the root with the dissection of lymph nodes around the base of the meso-colon. RESULTS: Successful lymphadenectomy of the lymph node along the origin of the middle colic artery was performed. Twelve patients with early transverse colon cancer underwent laparoscopic transverse colon resection using this method. CONCLUSIONS: This method may contribute to the easy and safe laparoscopic transverse colectomy by improving the limited view of the laparoscope and raises the possibility for laparoscopic resection of advanced colon cancer.     

A case of invasive hemolymphangioma of the pancreas

Hemolymphangioma of the pancreas is a very rare benign tumor. There were only five reports of this disease until March 2008. Herein, we report a case of hemolymphangioma of the pancreas with gastrointestinal bleeding due to duodenal invasion. A 53-year-old man had been admitted a referral hospital because of severe anemia due to gastrointestinal bleeding in December 2005. He was then transferred to our institute with a diagnosis of a tumor of the head of the pancreas with duodenal invasion in January 2006. No abnormalities were revealed except for anemia in laboratory data including CEA and CA19-9. Gastrointestinal endoscopy revealed bleeding at the duodenum. Computed tomography also demonstrated a heterogenous mass at the pancreatic head and suspected invasion to the duodenal wall. Ultrasonography showed a huge mass at the pancreatic head with a mixture of high and low echoic areas. Pylorous-preserving pancreatoduodenectomy was performed. The pancreatic tumor was soft and had invaded to the duodenum. The pathological diagnosis was a hemolymphangioma of the pancreas invaded to the duodenum. His postoperative course was uneventful and he was discharged on the 26th d after surgery. Hemolymphangioma of the pancreas is a very rare benign tumor. In a literature review until March 2008, we found five case reports. Major symptoms are abdominal pain and distension due to the enlarged tumor. However, we experienced a case of hemolymphangioma of the pancreas with gastrointestinal bleeding due to invasion to the duodenum. This disease is a very rare entity, but should be considered when patients have gastrointestinal bleeding.     

Fluvastatin improves arterial stiffness in patients with coronary artery disease and hyperlipidemia: a 5-year follow-up study.

BACKGROUND: The present study was designed to test the hypothesis that fluvastatin might improve arterial stiffness, as assessed with pulse wave velocity (PWV), in patients with coronary artery disease (CAD) and hyperlipidemia over the long term. METHODS AND RESULTS: Ninety-three patients were randomly assigned to either fluvastatin (group A, n=50) or bezafibrate (group B, n=43) and followed for 5 years. There was no difference in the clinical findings between the 2 groups. In group A, there was a progressive reduction in the brachial-ankle PWV along with a decrease in serum low-density lipoprotein-cholesterol (LDL-C) and C-reactive protein (CRP) by 12 months after fluvastatin, and the improvement was maintained until 5 years after treatment. In group B, despite identical lowering of the serum lipid, PWV was progressively increased. In group A, the percentage change in PWV correlated significantly with that of the serum CRP (r=0.49, p<0.001), but not with that of the serum LDL-C after treatment. CONCLUSIONS: The beneficial vascular effects of fluvastatin persisted for a long period in patients with CAD and hyperlipidemia. Its anti-inflammatory action might contribute to the favorable effects on arterial stiffness.     

Cardiac troponin T mutation R141W found in dilated cardiomyopathy stabilizes the troponin T-tropomyosin interaction and causes a Ca2+ desensitization

A missense mutation R141W in the strong tropomyosin-binding region of cardiac troponin T (cTnT) has recently been reported to cause dilated cardiomyopathy (DCM), following the first report of a DCM-causing deletion mutation DeltaK210. To clarify the molecular mechanism for the pathogenesis of DCM caused by this novel mutation in cTnT gene, functional analyses were made on the recombinant human cTnT mutant proteins. Exchanging human wild-type and mutant cTnTs into rabbit skinned cardiac muscle fibers revealed that R141W mutation resulted in a decrease in the Ca(2+) sensitivity of force generation, as in the case of DeltaK210 mutation lying outside the strong tropomyosin-binding region. In contrast, a missense mutation R94L in the vicinity of the strong tropomyosin-binding region associated with hypertrophic cardiomyopathy (HCM) resulted in an increase in the Ca(2+) sensitivity of force generation, as in the case of the other HCM-causing mutations in cTnT reported previously. An assay using a quartz-crystal microbalance (a very sensitive mass-measuring device) revealed that R141W mutation increased the affinity of cTnT for alpha-tropomyosin by approximately three times, whereas an HCM-causing mutation DeltaE160 in the strong tropomyosin-binding region, as well as DeltaK210 and R94L mutations, had no effects on the interaction between cTnT and alpha-tropomyosin. Since cTnT has an important role in structurally integrating cardiac troponin I (cTnI) into the thin filaments via its two-way interactions with cTnI and tropomyosin, the present results suggest that R141W mutation in the strong tropomyosin-binding region in cTnT strengthens the integrity of cTnI in the thin filament by stabilizing the interaction between cTnT and tropomyosin, which might allow cTnI to inhibit the thin filament more effectively, leading to a Ca(2+) desensitization.     

Idiopathic extensive peliosis hepatis treated with liver transplantation

A 50-year-old Danish man, who neither had wasting disease nor was taking steroid-containing drugs, complained of abdominal distension, due to a markedly enlarged liver. Percutaneous needle biopsies were taken from the liver, and the findings gave suspicion of a neoplastic tumor. Because of reduced liver function and treatment-resistant ascites, he underwent liver transplantation without a definite preoperative diagnosis. The resected liver weighed 2900?g, and almost all of the parenchyma was destroyed and replaced by multicystic blood-filled spaces, diagnosed as extensive peliosis hepatis complicating liver cirrhosis. Extensive peliosis with liver cirrhosis is a rare condition. Only two cases, caused by contraceptives and treated by liver transplantation, are reported in the English-language literature. We could find no cause other than alcohol abuse lasting several years in this patient, and classified the present case as idiopathic extensive peliosis hepatis. Although scarce subjective findings and misleading liver biopsies made an exact diagnosis difficult, an orthotopic liver transplantation was the only treatment for such complicated peliosis hepatis.     

Distal Hemorrhoidectomy With ALTA Injection: A New Method for Hemorrhoid Surgery

Aluminum potassium sulfate and tannic acid injection (ALTA) is a useful and less-invasive treatment for internal hemorrhoids. However, it is not a treatment option for external hemorrhoidal diseases, including mixed hemorrhoids. Distal hemorrhoidectomy with ALTA injection involves surgical resection of external piles, followed by injection therapy on internal piles. We report technical details and the short-term results of this procedure in patients with mixed hemorrhoids. Seventy-two patients with mixed hemorrhoids treated between 2010 and 2011 were included. The main outcome measures were the short-term response and complication rates. At 28 days after surgery, the disappearance rate of prolapse was 100%. Three patients (4%) had postoperative complications, all minor in nature. No prolapse recurrence was observed within a median follow-up period of 6 months. Distal hemorrhoidectomy with ALTA injection appears to be a promising treatment option for patients with mixed hemorrhoids.Key words: Hemorrhoidectomy, Sclerotherapy, Aluminum potassium sulfate and tannic acidHemorrhoids are a very common anorectal condition, defined as the symptomatic enlargement and distal displacement of normal anal cushions. The most common symptom of hemorrhoids is anal bleeding and prolapse.¹Hemorrhoidectomy is the most effective treatment for prolapsed hemorrhoids and is associated with the lowest recurrence rate. However, hemorrhoidectomy is not without complications, which include postoperative pain, urinary retention, secondary hemorrhage, formation of skin tags, anal stenosis, and fecal incontinence.²Aluminum potassium sulfate and tannic acid (ALTA) is an injectable sclerosant for treating hemorrhoids. In a comparative study of ALTA injection and hemorrhoidectomy for prolapsed hemorrhoid cases, ALTA injection produced almost the same effects as hemorrhoidectomy, without the specific complications.^3,4 However, ALTA injection is effective only for internal hemorrhoids. In the case of mixed hemorrhoids with predominant external hemorrhoids or thrombosed hemorrhoids, application of ALTA is not appropriate.^3,5Distal hemorrhoidectomy with ALTA injection (DHA) is another option for the management of mixed hemorrhoids. The procedure involves surgical resection of the external piles, followed by ALTA injection on the remaining internal piles. This study aimed to describe the technical details and evaluate the short-term response and complication rates in patients with mixed hemorrhoids treated with this combined approach.     

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.Key words: Nonobstructive afferent loop syndrome, Biliary stasis, Hepaticojejunostomy, Hepatobiliary scintigraphy, Double-balloon enteroscopyIt has been reported that cholangitis occurs in between 6.7% and 14.3% of postoperative pancreatoduodenectomy (PD).¹ Most cases of cholangitis originate due to biliary stasis, which is broadly caused by either anastomotic or nonanastomotic stenosis. In many cases, anastomotic stenosis is accompanied by intrahepatic biliary duct dilatation and obstructive jaundice, making early diagnosis and treatment possible.^2–3 On the other hand, nonanastomotic stenosis, including those of afferent loop syndrome, is performed as a conservative treatment for unexplained fever and cholangitis. However, in many cases, the cause remains unidentified, thereby causing this condition to repeat itself. Since cholangitis can at times be fatal, it is therefore important to identify the cause.It has been reported that afferent loop syndrome occurs in around 13% of postoperative PD patients.⁴ Afferent loop syndrome is generally caused by mechanical occlusion due to the recurrence or metastasis of cancer,^4–6 adhesion,^7–8 torsion,⁹ internal hernia,¹⁰ enterolithiasis,^11–12 etc., and thereafter, leads to a syndrome associated with acute abdominal symptom or acute cholangitis. On the other hand, nonobstructive afferent loop syndrome may also be caused by biliary stasis due to jejunal motility failure or the length of the blind end or jejunum, and thereafter, leads to acute cholangitis, liver abscess, and the formation of enterolithiasis and intrahepatic stones. Nonobstructive afferent loop syndrome occurs in around 37% of all of the afferent loop syndrome,^12–13 but few cases have actually been reported.We herein report a rare case in which the patient experienced recurrent cholangitis and liver abscess by biliary stasis due to nonobstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy (PPPD) for cholangiocarcinoma.     

Drug concentration estimation using contrast-enhanced MRI in intra-arterial chemotherapy for head and neck cancers

ObjectiveIn cases of head and neck cancer treated with intra-arterial chemotherapy, no objective indices are available for determining the distribution of anticancer drugs administered to multiple arteries. To establish such indices, noninvasive measurements of drug concentrations are required in the arterial perfusion area of each artery. In MRI, changes in 1/T₁ (Δ1/T₁) are correlated with the contrast agent concentration. We focused on these properties and investigated whether it is possible to estimate anticancer drug concentrations within tissue based on Δ1/T₁.MethodsWe employed the fast spin echo (FSE) sequence to determine optimum imaging parameters using a phantom. Subsequently, contrast agent was administered via the lingual and external carotid arteries for seven cases of tongue cancer. Δ1/T₁ were then measured in tumor and nontumor tissues. The results of this study were compared with those of a previous study in which intratumor concentrations of anticancer agent were measured in excised specimens.ResultsThe optimum imaging parameters for the FSE was two repetition times (TR, 500 and 1000 ms). When compared with the external carotid artery administration, the lingual artery administration of contrast agent resulted in significantly higher Δ1/T1 in both tumor and nontumor tissues (2.13 and 2.62 times, respectively). The multiplying factor for the nontumor tissue and high homogeneity of the contrast agent concentration were reasonably consistent with the results of the previous study.ConclusionThis method can be applied to estimating intratissue concentrations of intra-arterially administered anticancer drugs, thus possibly providing useful information in determining the distribution of anticancer drugs.