Subacute bulbar palsy as the initial sign of follicular thyroid cancer

We report a 64-year-old woman with follicular thyroid cancer found by subacute bulbar palsy. Progressive bulbar palsy (PBP) was considered the most likely diagnosis, because no abnormal finding was detected on brain CT and blood test except for the decrease of free T4. An echogram of the thyroid revealed a small nodule which was shown to be class IIb by fine needle biopsy. However, 201Tl scintillation examination showed skull base metastasis. Follicular thyroid cancer sometimes seems to manifest as a distant metastasis with no clinically evident thyroid lesion. This case suggested the importance of a detailed survey for malignancy, when subacute bulbar palsy is seen.     

Anomalous Junction of Pancreaticobiliary Duct without Congenital Choledochal Cyst: A Possible Risk Factor for Gallbladder Cancer

Among 1586 patients subjected to endoscopic retrograde cholangiopancreatography, an anomalous junction of the pancreaticobiliary duct (AJPB) was found in 24 patients (1.5%). Eighteen of the 24 had an associated congenital choledochal cyst, and six did not. Four of these six patients (66.7%) had gallbladder cancer. A clinicopathological study was performed on these four and 43 such cases reported in the literature. The diagnosis of AJPB was made by direct cholangiography. Median age of these 47 (53.5 yr) was younger than those without AJPB. The length of the common channel ranged from 15 to 53 mm. The pancreatic-biliary type junction was present in 36 of 39 cases (92.3%). Gallstones were present in 7 of 40 (17.5%). Levels of amylase in bile were high in 10 of 11. Presence of AJPB without congenital choledochal cyst may be a high risk factor in gallbladder cancer; hence prophylactic cholecystectomy should be considered for patients with AJPB, without congenital choledochal cyst.     

Pharmacobezoar complicating treatment with sodium alginate

We encountered a gastric bezoar that had developed in a 9-year-old girl treated with sodium alginate (Alloid G) for acute gastritis associated with systemic lupus erythematosus. A hard mass palpated in the left upper abdomen proved, upon gastric endoscopy, to be an intragastric foreign body. Sodium alginate was detected in an analysis of a sample from this bezoar. In an in vitro simulation, sodium alginate solidified when mixed with the patients other medicines. The bezoar caused no complications, and disappeared spontaneously after discontinuation of the medications. This case indicates that this sodium alginate preparation, Alloid G, can be a cause of pharmacobezoar.     

Subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage associated with ruptured retinal arterial macroaneurysm

Purpose

To evaluate the surgical outcomes of small-gauge vitrectomy with subretinal injection of recombinant tissue plasminogen activator (rt-PA) for a submacular hemorrhage caused by a ruptured retinal arterial macroaneurysm (RAM).

Methods

Non-comparative, consecutive case-series performed at two ophthalmological institutions. We examined 22 eyes of 22 patients with a submacular hemorrhage associated with a RAM but without a preretinal or sub-internal limiting membrane hemorrhage at the fovea. During 25-gauge vitrectomy, approximately 4000–8000 IU of rt-PA was injected subretinally, followed by the injection of air or 10 % sulfur hexafluoride as a tamponade. The patients maintained an upright position for 1 hour, then turned to a facedown position for 1 to 3 days. The best-corrected visual acuity (BCVA) and postoperative complications were evaluated.

Results

The average interval from the onset of symptoms to surgery was 8.4?±?7.6 days, and the average size of the subretinal hemorrhage was 3.4?±?1.0 disc diameters. The submacular hemorrhage was displaced from the foveal area in all eyes after 1 week. The mean baseline BCVA was 1.41?±?0.41 logMAR units, and it improved to 0.91?±?0.43 at 1 month and to 0.64?±?0.45 at the final visit (P?=?0.0001, P?<?0.0001 respectively). A macular hole was detected intraoperatively in two eyes and postoperatively in two eyes, and both were closed by internal limiting membrane peeling or a second vitrectomy.

Conclusions

Small-gauge vitrectomy with subretinal rt-PA injection and gas tamponade were effective in displacing a submacular hemorrhage associated with a RAM.

     

Laparoscopic cholecystectomy for cholecystolithiasis in a case with situs inversus totalis

We report a case of cholecystolithiasis associated with situs inversus totalis (SIT) that had been successfully treated with a laparoscopic cholecystectomy. Although cholecystolithiasis associated with SIT is rare, trained surgeons who perform unusual surgical procedures, even if they have not experienced such a case, would perform laparoscopic cholecystectomy for cholecystolithiasis associated with SIT easily and safely.     

Genetic analysis of two female patients with incomplete Denys-Drash syndrome

Denys-Drash syndrome (DDS) is characterized by genital anomaly, early onset nephropathy and high risk for developing Wilms' tumor (WT). Recently, mutations in exon 8 or 9 of the Wilms' tumor suppressor gene (WT1) have been found in the majority of DDS patients studied. We analyzed these two exons of the WT1 gene in genomic DNA from two female patients with DDS by using polymerase-chain reaction (PCR) and direct sequencing. The patients were accompanied with normal external genitalia, early onset renal failure between 6 and 12 months of age, and unilateral Wilms' tumor. Genomic DNA was isolated from peripheral blood leucocytes of the patients. Amplification of exons 8 and 9 of the WT1 gene by PCR was performed, and direct sequencing of the PCR product was performed using an automatic DNA sequencer. Two heterozygous missense mutations were found in these patients, including a missense mutation in exon 9 at codon 388 replacing the wild-type Cys with Phe, and a previously described mutation in exon 9 at codon 398 replacing the wild-type Leu with Pro. Cys388Phe is a novel mutation in the WT1 gene in the DDS. These cases are considered to be "incomplete DDS" with nephropathy and Wilms' tumor and without genital anomaly, the validity of which has been confirmed by mutation analysis.     

Effects of isoproterenol on myocardial lipid metabolism in rat hearts perfused with and without exogenous substrates

Effects of isoproterenol on myocardial lipid metabolism were studied in perfused rat hearts by the Langendorff apparatus without recirculation. Fatty acids in phospholipid, free fatty acid and partial glyceride fractions did not alter during the initial 30-min perfusion. However, fatty acids in triglyceride fraction decreased along with the perfusion. Isoproterenol enhanced the decrease in triglyceride fatty acid in the presence of glucose, but not in the absence of glucose. When hearts were perfused for 30 min with exogenous myristirate in the presence of glucose, triglyceride fatty acid did not decrease in the control perfusion, and incorporation of myristiric acid into triglyceride fraction increased in the presence of isoproterenol. When hearts were perfused with myristirate in the absence of glucose, fatty acid in triglyceride fraction slightly decreased during the control 30-min perfusion, and marked bradycardia or ventricular arrest occurred within 10 min after the start of perfusion with solution containing isoproterenol. Triglyceride content 10 min after perfusion was not different from the control value. Mechanical performance of hearts with myristirate and isoproterenol improved when the amount of glucose in the perfusing solution was increased. The findings indicate that glucose may play an important role in the mechanical performance of the heart perfused with a solution containing isoproterenol.