[A study of the minimum number of slices required for quantification of pulmonary emphysema by computed tomography]

We attempted to determine the minimum number of slices required for quantification of overall emphysema by computed tomography (CT). Forty-nine patients underwent CT scanning with a 15-mm slice interval, and 13 to 18 slices per patient were obtained. The percentage of low attenuation area (LAA%) per slice was measured with a method that we reported on previously, utilizing a CT program and NIH image. The average LAA% values for 1, 2, 3, and 6 slices evenly spaced through the lungs [LAA% (1), LAA% (2), LAA% (3), and LAA% (6)] were compared with those for all slices [LAA% (All)]. The correlation coefficients for LAA% (1), LAA% (2), LAA% (3), and LAA% (6) with LAA% (All) were 0.961, 0.981, 0.993, and 0.997, respectively. Mean differences +/- SD were -3.20 +/- 4.21%, -2.32 +/- 3.00, -0.20 +/- 1.84, and -0.16 +/- 1.26, respectively. From these results, we concluded that overall emphysema can be quantified by using at least three slices: one each of the upper, middle, and lower lung.

Zonisamide - induced urinary lithiasis in patients with intractable epilepsy

We report here three patients with intractable epilepsy who developed urinary lithiasis during zonisamide (ZNS) treatment. Abdominal pain due to left-sided hydronephrosis was the initial symptom in the first patient, and it was resolved after the excretion of a stone. The second patient, who had no specific symptoms, was found to have a thick sludge of calcium phosphate in the bladder when he suffered from aspiration pneumonia and dehydration. The third patient, who had a history of recurrent urinary obstruction, was also found to have a thick sludge of calcium oxalate in the bladder. The urinalysis of the three patients revealed alkaline urine and hypercalciuria. Although their urinary lithiasis was resolved by discontinuation of ZNS and supportive therapy, routine examination of urine parameters such as pH and sediments, and daily urine-output checks are thought to be necessary during treatment with ZNS, especially for patients who are bedridden for a long time and receive multiple antiepileptic drugs.

Chronic intestinal pseudo-obstruction due to dialysis-related amyloid deposition in the propria muscularis in a hemodialysis patient

Dialysis-related amyloidosis (DRA) is one of the most serious complications interfering with rehabilitation in dialysis patients. Here, we report a case of beta2-microglobulin (beta2M)-related amyloidosis, in which the patient developed a severe intestinal pseudo-obstruction. The patient was a 42-year-old male who had been undergoing hemodialysis for 13 years, and who had no history of osteoarticular involvement of DRA. The first symptoms of the disease were severe abdominal fullness and nausea after meals. The whole intestinal wall biopsy revealed massive amyloid deposition in the propria muscularis. The patient became malnourished and died of acute subendocardial infarction 3 years after the onset. An autopsical examination revealed a massive deposition of amyloid, which was positively stained with anti-beta2M antibody but not AA amyloid, predominantly in the gastrointestinal muscular layer, including the tongue, esophagus, stomach, small intestines, colon, and rectum. These results suggest that the gastrointestinal involvement of beta2M-related amyloidosis might occur during the course of hemodialysis treatment, and that this possibility should be considered if patients suffer from intestinal pseudo-obstruction without osteoarticular symptoms.

Open surgical treatment for dialysis-related arthropathy in the shoulder

The clinical results of open surgical treatment for hemodialysis-related arthropathy in the shoulder were evaluated, and the pathology was investigated. Fifteen shoulders of 11 patients (6 female and 5 male) were treated during the past 6 years. The average age was 56.7 years. The duration of hemodialysis averaged 17.5 years. Simple curettage was performed in 7 shoulders, and curettage and bone graft were performed in 5 shoulders. Repair of the rotator cuff was performed in 3 shoulders. Pathologic foci always existed in the intertubercular sulcus and the greater tuberosity of the humerus. Marked proliferations of the bursa and multiple cystic bone lesions were found, and amyloid depositions were observed on histologic evaluation in all cases. Open surgical treatment was quite effective, and relief from the clinical symptoms was maintained for a satisfactory period of time. Enthesopathy induced by the amyloid deposition is considered the main pathology.

Transforming growth factor-beta is involved in the pathogenesis of dialysis-related amyloidosis

BACKGROUND

Advanced glycation end product-modified beta2-microglobulin (AGE-beta2m) is an important component of dialysis-related amyloidosis (DRA). Its presence induces monocyte chemotaxis and the release of the proinflammatory cytokines through macrophage activation. Transforming growth factor-beta (TGF-beta) is a multifunctional cytokine that also has chemotactic activity for monocytes at very low (0.1 to 10 pg/mL) concentrations and inhibits proinflammatory cytokine production of macrophages. In this study, we investigated the role of TGF-beta in the pathogenesis of DRA.

METHODS

We performed an immunohistochemical study of DRA tissues (8 cases) to confirm the existence of TGF-betas and their receptors; we also performed a chemotaxis assay of human monocytes as well as enzyme-linked immunosorbent assay (ELISA) of TGF-beta1, tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and interleukin-1 receptor antagonist (IL-1Ra) in the supernatant of human monocyte-derived macrophage cell culture under varying conditions of incubation with TGF-beta1, AGE-beta2m, and TGF-beta1 antibody additions.

RESULTS

There was positive staining for TGF-betas (types 1, 2, and 3) and their receptors (types I, II, and III) in infiltrated macrophages (CD68+), synovial lining cell, as well as vascular walls around amyloid deposition. AGE-beta2m also induced TGF-beta1 production by macrophages in a dose-dependent manner (410 +/- 80 pg/mL at 12.5 microg/mL, 621 +/- 62 pg/mL at 25 microg/mL, and 776 +/- 62 pg/mL at 50 microg/mL of AGE-beta2m). AGE-beta2m induced significant TNF-alpha and IL-1Ra production by macrophage. The addition of exogenous TGF-beta1 (0.1 to 10 ng/mL) decreased AGE-beta2m-induced TNF-alpha production and increased IL-1Ra production in a dose-dependent fashion. IL-1beta production was not effected by any experimental conditions. In chemotaxis assay, anti-TGF-beta1 antibody (0.1 to 10 microg/mL) attenuated AGE-beta2m-induced monocyte chemotaxis.

CONCLUSIONS

These results provide the first evidence to our knowledge for the presence of TGF-beta in DRA tissue, as well as the stimulatory action of AGE-beta2m on tissue macrophages. In turn, TGF-beta suppresses the proinflammatory activation of macrophages, suggesting a dual role for TGF-beta in the inflammatory process of DRA. These observations may provide a pathophysiologic link between TGF-beta and DRA.

Can recovered protein from the CAPD patient's own dialysis effluent substitute for dextrose?

Albumin has been evaluated as an osmotic agent for peritoneal dialysis as being physiologically safe and having modest colloidal osmotic pressure. However its extremely high cost inhibits clinical applications, and hypoalbuminemia is often seen in continuous ambulatory peritoneal dialysis (CAPD) patients, especially those with high peritoneal equilibration test (PET) values and who lose a large quantity of albumin everyday. This study aims at recovering protein from CAPD effluent and reusing it safely at reasonable cost as a substitute for dextrose. The dialysis effluent was collected and concentrated with a semipermeable membrane. Uremic toxins and low-molecular-weight solutes were removed by repeated filtration and water dilution. The concentrate was acidified with hydrochloric acid down to pH 2, thence de-acidified with water dialysis up to pH 5. At this point, the isoelectric point of albumin, at which precipitate was deposited, the precipitate was separated from the supernatant and re-dissolved into electrolyte solution. The acidified concentrate exhaled an unpleasant odor, like that of decayed food. The precipitate solution, however, did not smell at all. The initial ultrafiltration rate of the recovered protein solution was measured and compared with that of dextrose and dextran by using a high-sensitivity differential manometer, one end of which was connected with the test solution cell, and the other with the serum cell. The ends were separated by a semipermeable membrane. The recovered protein solution at 20 g/dL concentration was almost equivalent in initial ultrafiltration rate to the 2.0 g/dL dextrose solution and to 20 g/dL dextran (MW: 75,000 dalton) solution.

cDNA-derived amino acid sequence of acetoacetyl-CoA synthetase from rat liver

In order to examine the primary structure of acetoacetyl-CoA synthetase (acetoacetate-CoA ligase, EC 6.2.1.16; AA-CoA synthetase), the cDNA clone encoding this enzyme has been isolated from the cDNA library which was prepared from the liver of rat fed a diet supplemented with 4% cholestyramine and 0.4% pravastatin for 4 days. Nucleotide sequence analysis of cloned cDNA revealed that AA-CoA synthetase of rat liver contains an open reading frame of 2019 nucleotides, and the deduced amino acid sequence (672 amino acid residues) bears 25.0 and 38.9% homologies with acetyl-CoA synthetases of Saccharomyces cerevisiae and Archaeoglobus fulgidus, respectively.

Eph receptors and ephrins

The Eph receptors are the largest known family of receptor tyrosine kinases. The Eph receptors and their membrane-attached ligands, ephrins, show diverse expression patterns during development. Recent studies have demonstrated that Eph receptors and ephrins play important roles in many developmental processes, including neuronal network formation, the patterning of the neural tube and the paraxial mesoderm, the guidance of cell migration, and vascular formation. In the nervous system, Eph receptors and ephrins have been shown to act as positional labels to establish topographic projections. They also play a key role in pathway finding by axons and neural crest cells. The crucial roles of Eph receptors and ephrins during development suggest involvement of these genes in congenital disorders affecting the nervous system and other tissues. It has also been suggested that Eph receptors and ephrins may be involved in carcinogenesis. It is therefore of clinical importance to further analyse the function of these molecules, as manipulation of their function may have therapeutic applications.

Effects of a parathyroidectomy on the immune system and nutritional condition in chronic dialysis patients with secondary hyperparathyroidism

BACKGROUND

Parathyroid hormone (PTH) has an adverse effect on the immune system and may cause immunologic disorders in patients with chronic renal failure. The in vivo effects of a parathyroidectomy on the immunologic parameters was examined.

METHODS

Thirty-four patients under dialysis therapy received a parathyroidectomy (PTx) for secondary hyperparathyroidism (HPT). They were prospectively studied regarding serum immunoglobulins, complements, CD markers, and serum soluble IL-2 receptor (sIL-2R) until 12 months after PTx.

RESULTS

The serum levels of IgG, IgA and IgM showed significant increase until 12 months after PTx (P<0.001, respectively). C3, C4, and CH50 also indicated significant increase at 12 months after PTx. In cellular immunity, only serum sIL-2R showed significant increase 2 weeks after PTx (P = 0.028). The hematocrit and serum albumin also improved significantly at 12 months.

CONCLUSIONS

PTx showed beneficial effects on humoral immunological markers. The effects are probably due to the remarkable PTH reduction and partly improved nutritional state after PTx.

Effects of development on acetoacetyl-CoA synthetase biosynthesis in rat liver

In order to investigate the physiological role of acetoacetyl-CoA synthetase (acetoacetate-CoA ligase, EC 6.2.1.16), a cytosolic acetoacetate-activating enzyme, the effects of animal development on the activity and content of the enzyme were examined in rat liver. In male rats, the enzyme specific activity increased 21-fold at 4 weeks of age from that at 2 weeks of age, and then gradually decreased, while in female rats, it increased similarly to that of male rats, but further increased, reaching a maximum about 3-fold higher than that of male rats, at 6 weeks of age. The developmental patterns of the enzyme content correlated with that of the enzyme specific activity. These results indicate that changes in this enzyme activity and content during the developmental process might influence the rate of ketone body utilization for the formation of physiologically important lipidic substances in rat liver.

Intraoperative navigation for breast cancer surgery using 3D ultrasound images

The aim of this work was to develop an intraoperative image-guidance system for breast cancer surgery using three-dimensional (3D) ultrasound imaging. Using a 10-MHz annular array mechanical sector probe, ultrasound images were obtained from nine volunteer patients with breast cancer immediately before removal of the tumor in the operating room. A 3D tumor image was reconstructed using a workstation, then superimposed on the video image of the breast based on geometrical data. These data were obtained simultaneously by an optical 3D position sensor. The 3D images of the tumors were validated by the pathological data obtained after the surgery. In eight cases, the superimposed images were successfully obtained in approximately 15-20 min following scanning of the tumor. Scattered lesions around the main tumor were also visualized in the reconstructed tumor images, but artifacts of the ductal lesion caused by noise could not be eliminated in some cases. This system should be very effective in helping the surgeon to recognize the extent of a tumor within the breast itself and to determine the margin of surgical resection for breast conservation surgery.

[Relationship between cancer chemotherapeutic drug-induced delayed emesis and plasma levels of substance P in two patients with small cell lung cancer]

We investigated the relationship between delayed emesis caused by cisplatin (CDDP) based chemotherapy and plasma levels of serotonin, 5-hydroxy-indoleacetic acid (5-HIAA), and substance P in two patients with small cell lung cancer. In each of the cases, we used the 5-HT3 receptor antagonist ramosetron every morning on day 1-4 of the chemotherapy. In case 1, plasma levels of serotonin were low, whereas substance P levels increased since 24 hours after the injection of CDDP. The increase in substance P levels paralleled the onset of vomiting. In this case, however, substance P levels decreased and yet vomiting occurred. Similarly, in case 2, plasma levels of serotonin were low, whereas substance P levels increased since 24 hours. The increase in plasma levels of substance P and the onset of vomiting were observed at the same time 2-3 days after cisplatin administration. In this case, however, vomiting was not observed during the 5 days when the substance P was highest. Therefore, we suggested that substance P was closely associated with CDDP-induced delayed emesis, though some chemical mediators other than substance P might also be related to the emesis.

[Successful removal of a left ventricular fibroma in a 10-year-old patient]

A 10-year-old girl with negative T wave in leads I, II, III, aVF, and V2-6 in the ECG was examined. The two-dimensional echocardiogram and the MRI revealed that she had a tumor in the free wall near the apex of the left ventricle. We removed the intramural fibroma (50 x 35 x 30 mm) of the left ventricle under cardiopulmonary bypass very carefully not to perforate the left ventricular cavity. After the removal, the defect was repaired by the sutures of the myocardial layers so that the volume inside the left ventricle could be kept and its shape could be maintained. She has been doing well without any trouble for 5 months after the operation.

Acute renal failure due to hypokalemic rhabdomyolysis in Gitelman's syndrome

A 46-year-old-male developed acute renal failure (ARF) secondary to hypokalemic rhabdomyolysis. Potassium supplementation restored renal function following improvement of the rhabdomyolysis. After recovery from ARF, further evaluation disclosed he had hypokalemic metabolic alkalosis, normotensive hyperreninemia, hyperaldosteronism, renal hypomagnesemia, hypocalciuria and hyperplasia of the juxtaglomerular apparatus which are a diagnostic set of disorders in Gitelman's syndrome, a variant of Bartter's syndrome. This is the first reported case of ARF due to hypokalemic rhabdomyolysis associated with Gitelman's syndrome.

Image guidance of breast cancer surgery using 3-D ultrasound images and augmented reality visualization

This paper describes augmented reality visualization for the guidance of breast-conservative cancer surgery using ultrasonic images acquired in the operating room just before surgical resection. By combining an optical three-dimensional (3-D) position sensor, the position and orientation of each ultrasonic cross section are precisely measured to reconstruct geometrically accurate 3-D tumor models from the acquired ultrasonic images. Similarly, the 3-D position and orientation of a video camera are obtained to integrate video and ultrasonic images in a geometrically accurate manner. Superimposing the 3-D tumor models onto live video images of the patient's breast enables the surgeon to perceive the exact 3-D position of the tumor, including irregular cancer invasions which cannot be perceived by touch, as if it were visible through the breast skin. Using the resultant visualization, the surgeon can determine the region for surgical resection in a more objective and accurate manner, thereby minimizing the risk of a relapse and maximizing breast conservation. The system was shown to be effective in experiments using phantom and clinical data.

Disadvantage of long-term CAPD for preserving cardiac performance: an echocardiographic study

The indices of cardiac performances were compared between 31 continuous ambulatory peritoneal dialysis (CAPD) and 20 long-term hemodialysis (HD) patients. They were subdivided into three groups according to dialysis duration: L-CAPD (n = 16, mean age and CAPD duration were, respectively, 53 +/- 8 [SD] years and 77 +/- 13 months); S-CAPD (n = 15; 52 +/- 12 years, 28 +/- 12 months); HD (n = 20; 51 +/- 10 years, 162 +/- 52 months). The diabetic HD patients (DM-HD; n = 13; 60 +/- 13 years of age, 22 +/- 11 months) were chosen separately. Thirteen normotensive subjects with normal kidney function (mean age, 57 +/- 9 years) were selected as an age-matched control group. There were no significant differences between groups in age, gender, incidence of original kidney disease, or serum biochemical data. The blood pressure and the cardiothoracic ratio in L-CAPD were highest among groups. The indices of left ventricular (LV) hypertrophy as well as LV performance by means of echocardiography or pulsed Doppler were compared. Among nondiabetic dialysis patients, the calculated LV mass index (LVMI) of 166.4 +/- 84.3 g/m2 and the ratio of the peak atrial filling velocity to the peak diastolic flow velocity of 1.25 +/- 0.4 in L-CAPD were greatest, and the left ventricular fractional shortening (%FS) of 34.2 +/- 10.8% in L-CAPD was smallest. LVMI or %FS of L-CAPD was the same as DM-HD of 161.0 +/- 40.7 g/m2 or 31.6 +/- 8.2%. Possibly, poor control of hypervolemia, which is caused by peritoneal problems induced by either peritonitis or chronic exposure to high-glucose dialysate, causes a substantial cardiac preload leading to incipient cardiac failure in L-CAPD. According to the similar results of L-CAPD and DM-HD, it may be that hypertension, hyperlipidemia, or long-term constant glucose loading of CAPD fluids in addition to impaired glucose tolerance by chronic renal failure is more or less related to the progression of LV hypertrophy and latent cardiac dysfunction in long-term CAPD patients. In this context, CAPD of more than 5 years' duration is disadvantageous for preserving cardiac function as compared with HD.

Surgical treatments for orthopaedic complications in long-term haemodialysis patients--a review of 546 cases over the last 8 years

We reviewed 546 operative cases in haemodialysis patients during the past 8 years between June 1990 and May 1998. The average age of the 257 male and the 289 female patients was 57.1 years. The average period of haemodialysis was 14 years and 4 months. We discussed the etiology, pathological focus, frequency, symptoms, problems and operative indications. Carpal tunnel syndrome occurred most frequently, occupying 289 cases. Short-term postoperative results were positive in the initial case within 6 months after the occurrence of the first symptoms. Because no effective method preventing recurrence existed, synovectomy was used as much as possible in the initial operation. Surgical treatment was used for amyloid arthropathy in 15 shoulders. It was effective in cases resistant to any conservative treatment. For the knee joint, the arthroscopic synovectomy was performed in 8 cases, and total knee replacement in 6 cases. The results of the total knee replacement cases were good. However, recurrences were observed in 40% of the synovectomy cases. In the hip joint, the curettage and bone grafting were performed in 7 hips of 6 patients. All bone grafts were consolidated and there was no case of postoperative pathological fracture. In some cases with destructive spondyloarthropathy, the vertebrae involved spontaneously fused without severe kyphotic deformity. A case with mild pain and without neurological deficit can be treated conservatively. A case with severe pain, instability, and myelopathy indicates operative measures must be taken. Attention must be paid for a possible collapse of the grafted bone after the cervical level two anterior fusion. Haemodialysis patients are vulnerable to infection. This diagnosis is difficult to distinguish due to the weakened state of the immune system. Rigorous attention is required to prevent and detect infection in cases using artificial joints or instrumentation. The treatment of bone and joint disturbances from dialysis-related amyloidosis has become surgical due to the advancement of dialysis control. However, it remains one of the more conservative treatments. Determining the cause and establishing a method of treatment are desired as early as possible.

Early development of Epstein-Barr virus-associated T-cell lymphoma after a living-related renal transplantation

We herein report a case of Epstein-Barr virus (EBV)-associated T-cell lymphoma that developed within a month after a kidney transplantation. The recipient was a 37-year-old man who had evidence of a previous EBV infection. Cyclosporine, methylprednisolone, and azathioprine were used for immunosuppression, and acute rejection was treated with high-dose methylprednisolone. The lactate dehydrogenase level started to increase on day 24 and thereafter peaked on day 37 while also demonstrating progressive jaundice and a bleeding tendency. A transplant nephrectomy was done on day 37; however, the patient could not recover and eventually died of respiratory failure as a result of diffuse pulmonary edema. A pathological examination of the resected kidney revealed a diffuse proliferation of large atypical lymphoid cells in the parenchyma. Immunohistochemically, the tumor cells were positive for CD45 and T-cell marker, CD45RO, but negative for B-cell markers. EBV-encoded RNA was demonstrated within the neoplastic cells by in situ hybridization.