Peribronchiolar metaplasia: a common histologic lesion in diffuse lung disease and a rare cause of interstitial lung disease: clinicopathologic features of 15 cases

Peribronchiolar metaplasia (PBM) is a histologic lesion consisting of peribronchiolar metaplasia (PBM) of bronchiolar-type epithelium. Although widely recognized, PBM has received little attention in the pathologic literature and is not known to have clinical significance. We identified 15 cases in which PBM was the only major histologic finding in surgical lung biopsies from patients with interstitial lung disease (PBM-ILD), and we reviewed the clinical, imaging, and pathologic findings. The mean age was 57 years (range, 44-74 years) with 13 females and 2 males. One patient had been a welder with fume and asbestos exposure; another had pigeon exposure. Smoking history was available for 13 patients: three current smokers, one cocaine user, two former smokers, and seven never smokers. Three patients had collagen vascular disease. One had elevated serum antinuclear antibody titers. Pulmonary function data were available for 10 patients: one obstructive, five restrictive, two mixed obstructive and restrictive, and two normal. Computerized tomography in 7 patients showed mosaic attenuation in 3 patients and air trapping in 1 patient; no bronchiectasis, septal lines, or honeycombing were seen in any cases. All 11 patients with available follow-up are alive; 4 of them have experienced symptomatic improvement (follow-up, 0.6-6.9 years; mean, 2.4 years). PBM was found focally in other interstitial lung diseases, which were assessed for this lesion: 59% of usual interstitial pneumonia (17 of 29), 50% of nonspecific interstitial pneumonia (10 of 20), desquamative interstitial pneumonia (3 of 6), hypersensitivity pneumonitis (9 of 18), and 11% of respiratory bronchiolitis (2 of 18). In summary, PBM is a common histologic finding in various interstitial lung disorders. It is rarely the sole major lung biopsy finding in patients presenting with interstitial lung disease (PBM-ILD). Patients are mostly older women, with mild symptoms and CT findings. Survival appears to be favorable.     

Suicide patterns and characteristics in Akita, Japan

Akita Prefecture currently has the highest rate of suicide in Japan. Given this alarming statistic, investigation of the underlying causes of suicide and identification of strategies for suicide prevention are imperative. Members of the Akita Prefectural Medical Association (APMA) see most of the individuals who commit suicides in Akita Prefecture, so data from the APMA would prove advantageous in any investigation of suicides. In this study, members of the APMA who had attended to individuals who had committed suicide were asked to complete a questionnaire about the case to determine the factors underlying suicide in Akita Prefecture. From 1 July 2001 to 30 June 2002, a total of 138 cases (102 males, 36 females) of suicide were reported. Most suicide cases were of 50-69 year olds. Many cases involved relatively lethal methods (such as hanging). Most suicides were performed at home and at a time when the rest of the family was asleep or absent. The most common complaint appeared to be economic-related problems. Depressive disorder was the most common psychiatric disorder, and many cases displayed high depressive trait scores. The present results do not exclude the possibility that economic-related problems are playing a major role in recent increases in suicide numbers. However, strategies for dealing with depression as well as economic-related problems are considered important.     

The effect of magnesium sulfate on the behavioral activities of fetal goats

OBJECTIVES: To investigate fetal heart rate accelerations, fetal breathing movements, and fetal electrocortical activities during administration of magnesium sulfate to fetal goats. METHODS: The fetal heart rate accelerations, fetal breathing movements, and fetal electrocortical activities during 6 hours of continuous magnesium sulfate infusion into the fetal jugular vein were examined in 8 chronically instrumented fetal goats at 124-131 days of gestation. Fetal breathing movements were defined as repetitive negative fluctuations of the fetal tracheal pressure. Fetal electrocortical activities were assessed by visual analysis of periods of high-voltage and low-voltage electrocortical activities. RESULTS: Continuous infusion of magnesium sulfate for 6 hours significantly increased the fetal plasma magnesium concentration from 2.8 +/- 1.2 to 8.3 +/- 2.6 mg/dL without significant changes in fetal arterial blood gases. The incidence of fetal heart rate accelerations during magnesium infusion was significantly decreased from that found during the control periods. After 2 hours of infusion, the incidence of fetal breathing movements significantly decreased from 33.9% +/- 20.5% to 1.2% +/- 1.4% and remained at this level during the remaining 4 hours of magnesium infusion. The percentage of time that the fetuses were found to have low-voltage electrocortical activities decreased from 51.6% +/- 9.0% to 40.4% +/- 8.2% after 2 hours of infusion but recovered to 49.9% +/- 12.0% by 6 hours of magnesium infusion. CONCLUSION: We concluded that fetal magnesium sulfate administration affected fetal heart rate accelerations and fetal breathing movements continuously but electrocortical activities only temporarily during 6 hours of observations.     

The outcome and a new ISN/RPS 2003 classification of lupus nephritis in Japanese

BACKGROUND: A considerable diversity in prognosis is seen with lupus glomerulonephritis (LGN). Hence, the clinical usefulness of a recent International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification to judge the long-term outcome of human LGN has been investigated. METHODS: We studied retrospectively 60 subjects with LGN (7 males, 53 females, mean age of 33 years old) who underwent renal biopsies and were followed from 1 to 366 months, with a mean of 187 months. We diagnosed renal pathology as classes, active and sclerosing lesions, according to the new and WHO1995 classification of LGN, and analyzed the clinicopathologic factors affecting to the prognosis of LGN. RESULTS: New classification got much higher consensus in the judgment of classes (98% vs. 83%, P = 0.0084). The group of Class IV-S (N = 6) or IV-G (N = 17) at initial biopsies showed higher rate of end-stage renal failure (ESRF) compared with that of Class I, II, III or V (40.9% vs. 2.6%, P < 0.001). The mean 50% renal survival time of Class IV was 189 +/- 29 months, and patients with Class IV-S tended to have a poorer prognosis (95 +/- 22 months for IV-S vs. 214 +/- 35 months for IV-G, P = 0.1495). Class IV was also selected as the most significant risk factor for ESRF by stepwise model (P = 0.002). In subanalysis for ESRF in Class IV (-S or -G), treatment including methylprednisolone pulse therapy was only selected as a significant improving factor for primary outcome (P = 0.034). In addition, activity index was the significant risk factor of death and/or ESRF after initial renal biopsies (P = 0.043). As for actuarial patient death during all follow-up periods, complications with anti-phospholipid syndrome or nephrotic syndrome were significant risk factors (P = 0.013, P = 0.041, respectively). CONCLUSION: New ISN/RPS 2003 classification provided beneficial pathologic information relevant to the long-term renal outcome and the optimal therapy preventing ESRF and/or death in patients with LGN.     

Renal Arteriovenous Fistula with Rapid Blood Flow Successfully Treated by Transcatheter Arterial Embolization: Application of Interlocking Detachable Coil as Coil Anchor

A 70-year-old woman presented to our outpatient clinic with a large idiopathic renal arteriovenous fistula (AVF). Transcatheter arterial embolization (TAE) using interlocking detachable coils (IDC) as an anchor was planned. However, because of markedly rapid blood flow and excessive coil flexibility, detaching an IDC carried a high risk of migration. Therefore, we first coiled multiple loops of a microcatheter and then loaded it with an IDC. In this way, the coil was well fitted to the arterial wall and could be detached by withdrawing the microcatheter during balloon occlusion (pre-framing technique). Complete occlusion of the afferent artery was achieved by additional coiling and absolute ethanol. This technique contributed to a safe embolization of a high-flow AVF, avoiding migration of the IDC.     

Endotracheal tube electrodes to map and monitor activities of the vagus nerve intraoperatively. Technical note

Difficulty swallowing due to damage of the vagus nerve is one of the most devastating complications of surgery in and around the medulla oblongata; therefore, intraoperative anatomical and functional evaluation of this nerve is crucial. The authors applied endotracheal tube surface electrodes to record electromyography (EMG) activity from vocal cords innervated by the vagus nerve. The vagal nucleus or rootlet was electrically stimulated during surgery and vocalis muscle EMG activities were displayed by auditory and visual signals. This technique was used successfully to identify the vagus motor nerve and evaluate its integrity during surgery. The advantages of this method compared with the use of needle electrodes include safe simple electrode placement and stable recording during surgery. In cases involving a pontine cavernoma pressing the nucleus or a jugular foramen tumor encircling the rootlet, this method would be particularly valuable. Additional studies with a larger number of patients are needed to estimate the significance of this method as a means of functional monitoring to predict clinical function.     

Tissue plasminogen activator levels after single intracisternal injection in patients with subarachnoid hemorrhage

Tissue plasminogen activator (tPA) levels were investigated in the cisternal fluid of patients with subarachnoid hemorrhage treated with single intracisternal injection of recombinant tPA during radical surgery for ruptured aneurysms. Seven patients received different doses of tPA: two of 400 microg/ml, three of 500 microg/ml, one of 700 microg/ml, and one of 800 microg/ml in a total amount of 20 ml distilled water at pH 7. Cerebrospinal fluid samples were taken directly from the cisternal fluid at 15-minute incubation after injection, immediately after irrigation during surgery, and by lumbar tap 2 days after surgery. Cisternal tPA levels decreased to about 60% of the mean injected doses after 15-minute incubation. Simple linear regression analysis showed these tPA levels after incubation correlated with the initial doses. After copious irrigation with Ringer solution at pH 8, tPA levels decreased rapidly without correlation with the initial doses. After spinal drainage for 2 days, tPA levels further decreased by an order of 10(-4) to 10(-6) from the initial dose. These values were still greater than normal controls. The final values of tPA levels were not related to the initial dose. None of the patients suffered from systemic or wound complications. Cisternal tPA injection with increased doses and irrigation may be beneficial for the selective rapid removal of blood clots with controllable safety.