Central nervous system mucormycosis in a patient with hematological malignancy: A case report and review of the literature

Invasive mucormycosis is a refractory fungal infection. Central nervous system (CNS) mucormycosis is a rare complication caused by infiltration from the paranasal sinuses or hematogenous dissemination. Here, we present a case of a brain abscess, due to mucormycosis, diagnosed using burr craniotomy. A 25-year-old Japanese woman with relapsed-refractory acute lymphoblastic leukemia underwent cord blood transplantation (CBT). The patient experienced prolonged and profound neutropenia, and oral voriconazole was administered as primary antifungal prophylaxis. The patient received a conditioning regimen on day -11 and complained of aphasia and right hemiparesis on day -6. Magnetic resonance imaging (MRI) revealed a T2-weighted high-intensity area in the left frontal cortex. A brain abscess was suspected, and liposomal amphotericin B (L-AMB) administration was started. The patient underwent CBT as scheduled and underwent neutrophil engraftment on day 14. Although the patient achieved complete remission on day 28, her consciousness level gradually deteriorated. MRI revealed an enlarged brain lesion with a midline shift sign, suggesting brain herniation. Craniotomy was performed to relieve intracranial pressure and drain the abscess on day 38, and a diagnosis of cerebral mucormycosis was confirmed. The L-AMB dose was increased to 10 mg/kg on day 43. Although the patient's consciousness level improved, she died of hemorrhagic cystitis and aspiration pneumonia. Cerebral mucormycosis should be suspected if neurological symptoms are observed in stem cell transplant recipients. Prompt commencement of antifungal therapy and debridement are crucial because mucormycosis has a poor prognosis.

[Clinical features of thyroid dysfunction in adult Japanese after allogeneic hematopoietic stem cell transplantation]

We examined the incidence and clinical features of thyroid dysfunction in 661 patients who received allogeneic hematopoietic stem cell transplantation (allo-HSCT) in our hospital. At a median of 2.5 (1.0-11.3) years, 28 patients (4.2%) developed subclinical hypothyroidism, and 16 patients (2.4%) developed hypothyroidism. Eight of 16 patients (50%) with hypothyroidism were positive for anti-thyroid antibodies. Ten of 44 patients (22.7%) with thyroid dysfunction were discovered more than 5 years after allo-HSCT. Thyroid dysfunction with late onset was common in allo-HSCT recipients, and thyroid function should be monitored on a regular basis.

Retrospective comparison of hematopoietic stem cell transplantation following reduced-intensity conditioning with fludarabine/low-dose melphalan plus 4 Gy TBI versus fludarabine/ busulfan plus 4 Gy TBI

Fludarabine with intravenous busulfan (6.4 mg/kg; FB2) and fludarabine with intermediate-dose melphalan (140 mg/m²; FM140) are the most widely used reduced-intensity conditioning (RIC) regimens for allogeneic hematopoietic stem cell transplantation. FM140 generally has a lower relapse rate and higher non-relapse mortality (NRM), resulting in overall survival (OS) comparable to that seen with FB2. To evaluate the effect of reducing the melphalan dose, we retrospectively compared transplant outcomes in 156 patients who received FB2 (n = 103) or FM80 (n = 53) at our center (median age: 63 years; range 27-72 years). All patients received 4-Gy total body irradiation. Three-year OS, the cumulative incidence of relapse, and NRM were comparable between groups (FB2 vs. FM80, 58% vs. 47%, p = 0.24; 30% vs. 36%, p = 0.57; 17% vs. 21%, p = 0.44, respectively). There was no significant difference in the cumulative incidence of graft-versus-host disease (GVHD) at day 100, chronic GVHD at 3 years, or the 3-year GVHD-free/relapse-free survival rate. In the high-risk disease group, patients receiving FM80 tended to have lower 3-year OS (FB2 vs. FM80, 48% vs. 17%, p = 0.06). In summary, transplant outcomes following FB2 or FM80 were comparable except in patients with high-risk disease.

Changes in prefrontal cerebral hemodynamics during intermittent pain stimulation to gingiva: Preliminary study using functional near infrared spectroscopy

BACKGROUND/PURPOSE

Elucidating the transmission mechanism of pain signals from the orofacial area and the corresponding modification mechanism will not only aid in the understanding of pain mechanisms but also provide useful information regarding the development of pain mitigation methods. In this study, the involvement of the pain suppression system in the trigeminal area was investigated through an analysis of the activation status over time in the prefrontal cortex using functional near-infrared spectroscopy (fNIRS).

MATERIALS AND METHODS

In 28 healthy, right-handed male volunteers (average age, 30.1 ± 4.2 years) as subjects, a mild, intermittent, acute pain stimulus was administered through the implementation of pocket probing of the gingiva surrounding the right maxillary central incisor. In the prefrontal cortex, the levels of hemoglobin (Hb) were measured using the fNIRS measurement system. Average values of both oxy-Hb and deoxy-Hb were calculated at four stages: rest stage, 20 s prior to the pain stimulus application, and three stages at 20-s intervals within 1 min of stimulation. One-way analysis of variance and multiple comparisons were used to compare representative values to investigate the changes due to pain.

RESULTS

Oxy-Hb levels decreased the most during the 20 s stage directly after stimulus application. This change was seen mainly on the contralateral side, after which it returned to the resting baseline level before the stimulus application.

CONCLUSION

Our data demonstrate that in healthy males, a mechanism exists to mitigate pain involving the pain suppression system in the 20 s after feeling mild pain to the gingiva.

Successful Cord Blood Transplantation for Idiopathic CD4+ Lymphocytopenia

Idiopathic CD4+ lymphocytopenia (ICL) is the depletion of CD4+ lymphocytes to <300 cells/mm3 without human immunodeficiency virus infection or other causes of lymphocytopenia. ICL causes fatal infections; its etiology remains unclear and it lacks consensus regarding therapeutic options. We report the first patient with ICL who had a successful clinical course following a cord blood transplant (CBT). A 45-year-old woman was diagnosed with ICL and underwent partial hepatectomy for an abscess caused by the Mycobacterium avium complex. No specific gene alterations were detected through next generation sequencing-based evaluation. Following a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, busulfan, and 4 Gy total body irradiation, a single-unit CBT was performed. Neutrophils were engrafted on day +14. CD4+ lymphocyte counts increased to over 300 cells/mm3 on day +436. After 75 months, she was alive without any sequelae. CBT with an RIC regimen could be a curable treatment option for ICL.

Outcome of allogeneic hematopoietic stem cell transplantation for T-cell lymphoblastic leukemia/lymphoma: A single-center study

Although the indications for allogeneic hematopoietic stem cell transplantation (allo-HSCT) as a treatment for T-cell acute lymphoblastic leukemia/lymphoma (T-ALL/LBL) and Philadelphia chromosome (Ph)-negative B-cell acute lymphoblastic leukemia (B-ALL) are similar, few studies have compared its outcomes for T-ALL/LBL and Ph-negative B-ALL. The clinical data of 28 patients with T-ALL, 16 with T-LBL, and 99 with Ph-negative B-ALL who underwent the first allo-HSCT from 2000 to 2019 were retrospectively analyzed. Complete remission (CR) rates at allo-HSCT were 79 %, 63 %, and 75 % for T-ALL, T-LBL, and B-ALL, respectively; the 3-year overall survival (OS) rates were 55.7 %, 56.2 %, and 58.6 %, respectively (p = 0.92). Univariate analysis revealed that disease subtypes were not significantly associated with OS (B-ALL vs. T-ALL: hazard ratio [HR]=0.89, p = 0.70; T-LBL vs. T-ALL: HR=0.87, p = 0.75), and CR at allo-HSCT was the only prognostic factor for OS (HR=0.25, p < 0.001). Multivariate analysis demonstrated that CR at allo-HSCT was the only predictor of OS (HR=0.24, p < 0.001). In all three disease subtypes, patients in CR at allo-HSCT tended to have a lower cumulative incidence of relapse than did those in non-CR (T-ALL: 13.6 % vs. 50.0 %, p = 0.10; T-LBL: 20.0 % vs. 50.0 %, p = 0.21; B-ALL: 10.0 % vs. 56.0 %, p < 0.01). Thus, the outcomes of allo-HSCT for T-ALL/LBL were comparable to those of Ph-negative B-ALL. Irrespective of the disease subtypes, achieving CR before allo-HSCT was associated with a favorable OS. Further advances in chemotherapy before allo-HSCT and defining the optimal timing of allo-HSCT would improve the prognosis of patients with T-ALL/LBL.

Clinical assessment of cemento-osseous dysplasia based on three-dimensional diagnostic imaging: A case report

Cemento-osseous dysplasia (COD) is a lesion in which periapical bone is replaced by fibrous tissue, including osseous or cementum-like tissue. In the initial stage of COD, radiolucencies are noted at the root apex on periapical radiography, which can be confused with apical periodontitis. Understanding of correct pathological condition and careful assessment of COD is critical to avoid unnecessary endodontic interventions in healthy teeth. This report describes the ability and usefulness of cone-beam computed tomography (CBCT) and multi-slice computed tomography (MSCT) to detect COD. The findings in this case suggest that MSCT is more appropriate than CBCT, especially for patients with early- to middle-stage COD. However, the radiation dose is higher in MSCT than in CBCT; the application of MSCT should be limited to assessment of whether treatment or surgical management is necessary.

[Vacuolar myelopathy after allogeneic bone marrow transplantation in a patient with acute lymphoblastic leukemia]

Vacuolar myelopathy (VM) is known to be a neurological complication in patients with acquired immunodeficiency syndrome (AIDS). In autopsy-based studies, VM was reported in approximately 20-50% of patients with AIDS. It manifests in various says, mainly presenting as a painless spastic paraparesis with a sensory ataxia. We present a rare case of VM after bone marrow transplantation (BMT) in a patient without AIDS. A 50-year-old man developed weakness in the lower legs, leg muscle atrophy, and difficulty in walking 86 days after BMT. The patient died from septic shock on day 309. The autopsy revealed intralamellar vacuolation in the spinal white matter, which was compatible with VM.

Application of Deep Learning in the Identification of Cerebral Hemodynamics Data Obtained from Functional Near-Infrared Spectroscopy: A Preliminary Study of Pre- and Post-Tooth Clenching Assessment

In fields using functional near-infrared spectroscopy (fNIRS), there is a need for an easy-to-understand method that allows visual presentation and rapid analysis of data and test results. This preliminary study examined whether deep learning (DL) could be applied to the analysis of fNIRS-derived brain activity data. To create a visual presentation of the data, an imaging program was developed for the analysis of hemoglobin (Hb) data from the prefrontal cortex in healthy volunteers, obtained by fNIRS before and after tooth clenching. Three types of imaging data were prepared: oxygenated hemoglobin (oxy-Hb) data, deoxygenated hemoglobin (deoxy-Hb) data, and mixed data (using both oxy-Hb and deoxy-Hb data). To differentiate between rest and tooth clenching, a cross-validation test using the image data for DL and a convolutional neural network was performed. The network identification rate using Hb imaging data was relatively high (80‒90%). These results demonstrated that a method using DL for the assessment of fNIRS imaging data may provide a useful analysis system.

Prognostic impact of TP53 mutation, monosomal karyotype, and prior myeloid disorder in nonremission acute myeloid leukemia at allo-HSCT

Outcomes after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in nonremission acute myeloid leukemia (AML) are dismal [2-year overall survival (OS): 20-30%]. Though several risk classifications have been used, some factors are unavailable until the start of conditioning or transplantation. We analyzed prognostic gene mutations by targeted next-generation sequencing to identify predisposing factors for predicting OS at 1 month before transplantation. We enrolled 120 patients with nonremission AML who underwent first allo-HSCT between 2005 and 2018. Mutations were found in 98 patients; frequently mutated genes were FLT3-ITD, TP53, RUNX1, and WT1. TP53 mutation was detected in 21 patients and was the only predictor of poor OS. Multivariate analysis using Cox regression hazard model revealed primary AML, monosomal karyotype (MK), and TP53 mutation as independent factors for predicting poor OS. Based on these, patients were stratified into three groups. The low-risk group included patients with prior myeloid disorder without MK (n = 26). Among the rest, patients with TP53 mutation were assigned to the high-risk group (n = 19) and the rest into the intermediate-risk group (n = 75). Two-year OS in low-, intermediate-, and high-risk groups differed significantly (50.0%, 24.9%, and 0%, respectively). This suggests that the indication of allo-HSCT should be carefully judged for high-risk patients.

[Tyrosine kinase inhibitor maintenance therapy following allogenic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia]

There have been many reports regarding tyrosine kinase inhibitor (TKI) administration to prevent relapse following allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL). However, there are no commonly accepted standards for the choice of TKIs. We retrospectively analyzed the clinical features of Ph+ALL patients who received TKIs after allo-HSCT at our institution. The prophylactic administration of TKIs (pro) occurred in eight patients, and six patients received preemptive TKI administration (pre). The median follow-up period after allo-HSCT was 1,427 (range, 161-2,428) days in the pro group and 773.5 (range, 156-2,243) days in the pre group. Only one patient with non-hematological complete remission before allo-HSCT relapsed among the patients in the pro group. In the pre group, four patients treated with only TKIs achieved negativity of minimal residual disease. The 2-year overall survival rate after allo-HSCT was 85.7% in the pro group and 100% in the pre group. We used lower doses of TKIs compared with previous reports and this analysis shows that the dose is safe and effective as the treatment.

The emergence of rare nocardiosis following allogeneic hematopoietic stem cell transplantation in the era of molecular taxonomy

OBJECTIVE

The purpose of this study was to describe the clinical features of nocardiosis after allogeneic hematopoietic stem cell transplantation (allo-HSCT), focusing on new Nocardia species.

METHODS

We retrospectively reviewed data from patients with nocardiosis after allo-HSCT treated at our hospital and documented cases in the medical literature.

RESULTS

Fifty-seven cases were identified from our institution and the literature review. Although 51 patients (89.5%) responded to initial treatment, 28 (49.1%) patients were switched over to other treatment regimens due to the recurrence of nocardiosis or adverse events of antimicrobials. Nocardiosis-attributed mortality occurred in ten patients (17.5%). Antimicrobial susceptibilities varied among intra- and inter-species except linezolid (LZD). In the present study, five species were newly discovered after 2000, including N. cyriacigeorgica, N. veterana, N. abscessus, N. aobensis, and N. mexicana. All isolates of N. cyriacigeorgica, N. veterana, N. abscessus, and N. aobensis were sensitive to trimethoprim/sulfamethoxazole, amikacin (AMK), imipenem (IPM), and LZD; however, N. mexicana was resistant to AMK and IPM.

CONCLUSION

Newly identified Nocardia species have various antimicrobial susceptibility patterns. Long-term maintenance therapy could be challenging due to the adverse events of antimicrobials, especially in the allo-HSCT setting. Prudent evaluation is crucial for selecting a second-line or further treatment options.

Evaluation of an artificial intelligence system for detecting vertical root fracture on panoramic radiography

OBJECTIVES

The aim of this study was to evaluate the use of a convolutional neural network (CNN) system for detecting vertical root fracture (VRF) on panoramic radiography.

METHODS

Three hundred panoramic images containing a total of 330 VRF teeth with clearly visible fracture lines were selected from our hospital imaging database. Confirmation of VRF lines was performed by two radiologists and one endodontist. Eighty percent (240 images) of the 300 images were assigned to a training set and 20% (60 images) to a test set. A CNN-based deep learning model for the detection of VRFs was built using DetectNet with DIGITS version 5.0. To defend test data selection bias and increase reliability, fivefold cross-validation was performed. Diagnostic performance was evaluated using recall, precision, and F measure.

RESULTS

Of the 330 VRFs, 267 were detected. Twenty teeth without fractures were falsely detected. Recall was 0.75, precision 0.93, and F measure 0.83.

CONCLUSIONS

The CNN learning model has shown promise as a tool to detect VRFs on panoramic images and to function as a CAD tool.

[Transfusion-associated circulatory overload with pulmonary alveolar hemorrhage following allogeneic bone marrow transplantation]

A 51-year-old man underwent allogeneic bone marrow transplantation (BMT) for recurrent acute myeloid leukemia. Although the patient developed slight edema, pleural effusion, and cardiac effusion 6 months after BMT, his clinical condition improved with furosemide treatment. The patient was transfused with red blood cells for the management of anemia 8 months after BMT. He developed acute respiratory failure with pulmonary alveolar hemorrhage 80 min after the transfusion. He was diagnosed with transfusion-associated circulatory overload (TACO) due to the presence of acute pulmonary congestion and depressed left ventricular systolic function. Reduced circulatory load due to sufficient furosemide led to ventilator weaning 3 days later. Other causes of pulmonary alveolar hemorrhage were excluded, and the patient's condition improved by cardiac failure treatment only. This clinical course indicated that pulmonary alveolar hemorrhage would breakdown the blood vessels due to acute pulmonary congestion. Chemotherapy and prolonged anemia are high risks for cardiac failure in patients with hematological malignancies. Therefore, the possibility of cardiac failure is considered when patients with hematological malignancies have fluid retention, such as cardiac enlargement, edema, and pleural effusion. Moreover, the body fluids should be monitored before and after blood transfusion.

Successful hematopoietic stem-cell mobilization with plerixafor plus granulocyte-colony stimulating factor in multiple myeloma patients treated with pomalidomide

Autologous stem-cell transplantation is an effective procedure for the treatment of multiple myeloma, and involves the collection of hematopoietic stem cells (HSCs). However, in some patients, HSCs in the bone marrow fail to mobilize. Pomalidomide upregulates CXCR4 in hematopoietic stem cells, in a manner similar to that of lenalidomide, and is, thus, likely to have a negative impact on hematopoietic stem-cell mobilization in multiple myeloma patients. Here, we report the two cases in which hematopoietic stem cells were mobilized using plerixafor plus granulocyte-colony stimulating factor after exposure to lenalidomide and pomalidomide. Use of plerixafor with a sufficient washout period may lead to successful mobilization following pomalidomide use, although further study of this potential use is needed.

Disseminated adenovirus infection in a patient with relapsed refractory multiple myeloma undergoing autologous stem cell transplantation and pomalidomide/dexamethasone as salvage regimens

BACKGROUND

Disseminated adenovirus (ADV) infection is a fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), however, it is rare following autologous peripheral blood stem cell transplantation (auto-PBSCT) or chemotherapy alone.

CASE

A 66-year-old Japanese female with relapsed and refractory multiple myeloma (RRMM) received auto-PBSCT, achieving partial response. To obtain a greater response, pomalidomide/dexamethasone was started on day 28 after auto-PBSCT, but was stopped on day 41 due to thrombocytopenia, fever, and gross hematuria. Additionally, she complained of abdominal pain on day 46. Blood tests revealed elevation of transaminases and alkaline phosphatase. There was no evidence of bacterial or fungal infections or progression of MM. ADV titer in urine and serum were 3.41 × 10⁵ copies/mL and 6.76 × 10³ copies/mL, respectively. CT scans revealed cystitis, urethritis, and peritonitis. Since more than two organs were infected with ADV, she was diagnosed with disseminated ADV disease. After 5 weeks of supportive care, all symptoms resolved. ADV titer decreased to 5.90 × 10² copies/mL in urine and became negative in serum on day 80. However, she succumbed to the MM a little more than a month later.

CONCLUSION

Disseminated ADV infection can occur even in non-allogeneic transplant settings, such as in severely immunocompromised patients with MM who receive auto-PBSCT and repeated salvage therapies. Although it is a rare event, the mortality rate of this disease is very high, and hence, early diagnosis and interventions are needed in suspected cases.

[Disseminated fusariosis in patients with acute leukemia: a retrospective analysis of three cases]

We report three cases of fusariosis that occurred during the treatment of acute leukemia, during the past 5 years at our institution. Case 1: A 70-year-old male with relapsed and refractory acute lymphoblastic leukemia (ALL) developed fever and multiple nodular lesions in both the lungs. Blood culture that was subsequently obtained revealed Fusarium species. Treatment with liposomal-amphotericin B (L-AMB) was ineffective, and the condition of the patient deteriorated rapidly leading to death. Case 2: A 28-year-old male with T-ALL developed echthyma gangrenosum (EG) ulcers on the scrotum during conditioning for transplantation. Antifungal therapy with L-AMB was ineffective, and later, itraconazole and micafungin (MCFG) were introduced. However, the engraftment was not achieved, and the patient died on day 27. Microbiological examination of EG samples collected on day 13 revealed infection by Fusarium species post mortem. Case 3: A 50-year-old male with blast crisis of chronic myeloid leukemia developed EG primarily on the trunk during chemotherapy. The patient died without any response to L-AMB and MCFG. A culture obtained from EG on day 19 yielded Fusarium species, post mortem. The prognosis of fusariosis is extremely poor. However, skin lesions such as EG may assist in the early diagnosis of the disseminated disease.

Effect of a brief episode of experimental muscle pain on jaw movement and jaw-muscle activity during chewing

The aims of this study were to determine whether: (i) the jaw motor system develops a new pattern of jaw movement and/or jaw-muscle activity after resolution of an acute episode of jaw-muscle pain; and (ii) if jaw-muscle activity and jaw-movement features change progressively with repetition of a chewing sequence. Jaw movement and jaw muscle (masseter, anterior temporalis, and digastric) activity were recorded during free and rate-standardized chewing in eight asymptomatic participants (pain infusion group), before and at three time blocks up to 45 min after a single 0.2-ml bolus infusion of 5% hypertonic saline into the right masseter muscle. The same procedure, without infusion, was performed in another eight participants (control group). There were no significant main effects of group on jaw movement and muscle activity, suggesting that there were no persistent post-pain effects on chewing. Across groups, repetitions of free and unstandardized chewing movements were associated with progressive increases in velocity and amplitude of jaw movement and masseter and temporalis electromyographic (EMG) activity. These findings suggest that factors unrelated to pain, such as practice effects, may be playing a role in the changes in jaw movement and jaw-muscle activity observed after resolution of an acute episode of jaw-muscle pain.

Measurement of cerebral blood volume dynamics during volitional swallowing using functional near-infrared spectroscopy: an exploratory study

The aim of this study was to examine cerebral blood volume dynamics during volitional swallowing using multi-channel functional near-infrared spectroscopy (fNIRS) to understand the basic cortical activation patterns. Fifteen volunteers (age, 26.5±1.3 years, mean±SD) performed volitional swallowing of a 5-ml bolus of water as a task. A 52-channel fNIRS system was used for measuring oxy-Hb levels. We determined the oxy-Hb concentration changes in each channel by calculating the differences between rest and task oxy-Hb levels. Differences in rest and task data were assessed using a paired-t test (p<0.05). A significant increase in oxy-Hb was found in 21 channels. The cortical regions that exhibited increased oxy-Hb concentration included the bilateral precentral gyrus, postcentral gyrus, inferior frontal gyrus, superior temporal gyrus, middle temporal gyrus, and supramarginal gyrus. These data provide a description of cortical activation patterns during volitional swallowing using fNIRS, which will be useful for the evaluation of dysphasia and the effects of the rehabilitation [Corrected].

Effectiveness of dental computed tomography in diagnostic imaging of periradicular lesion of each root of a multirooted tooth: a case report

Radiography by use of the three-dimensional (3D) Accuitomo XYZ Slice View Tomograph (3DX), a device for compact computed tomography in dentistry, was performed as a new diagnostic imaging technique for a patient who needed endodontic therapy. The 3DX was used for examining and diagnosing the presence and expansion of periradicular lesions in each root of a multirooted tooth. High-resolution 3D images were observed and compared with those obtained by routine conventional radiography. It was difficult to diagnose the cause of clinical symptoms by general examinations including the usual intraoral radiography and panoramic radiography. The images obtained by the 3DX, however, clearly showed the apparent presence and expansion of a periradicular lesion in only one root of the multirooted tooth. The 3DX, a newly developed dental computed tomography, provides abundant new image information not attainable by either intraoral radiography or panoramic radiography, and its application for clinical use is very effective for examining and diagnosing regions of interest for endodontic therapy.

CT virtual endoscopy of the stomach: comparison study with gastric fiberscopy

BACKGROUND

We evaluated the value of computed tomographic (CT) gastric virtual endoscopy (VE) by comparing it with real gastric fiberscopy (GF).

METHODS

Sixty-six VE findings in 63 patients were compared with lesions found with GF. After a GF examination, the examinees were given bubble-making granules for the stomach and placed in a supine position on the CT table. Abdominal CT slices of 1 mm thickness were obtained by multidetector row CT (Siemens Sensation 16) and reconstructed to VE images with volume and surface rendering on the same day.

RESULTS

VE images were successful in showing subtle alterations in the gastric mucosal folds. Gastric cancer, polyps, ulcers, erosions, and gastritis were clearly visualized. Comparison studies between VE and GF (as the gold standard) showed a sensitivity of 92.7% and a specificity of 90.9%. Original CT images were also useful in detecting lesions in other abdominal organs such as the liver, adrenal gland, and kidney.

CONCLUSION

Because VE is a good noninvasive screening method, except for minimal radiation exposure, it is expected to become a new technique for stomach examinations.

Success rate of endodontic treatment of teeth with vital and nonvital pulps. A meta-analysis

OBJECTIVE

The purpose of this study was to use meta-analysis statistics to determine the influence of factors such as apical limit (short vs. overextension), status of the pulp (vital vs. nonvital), and periapical status (presence or absence of radiolucency) on endodontic prognosis. Study design The study-list was obtained by using a MEDLINE search and Japana Centra Revuo Medicina search. Only those papers in which the criteria for success or failure was exactly described were accepted.

RESULTS

The cumulative success rate of 82.8 +/- 1.19% (average +/-95% confidence interval) was obtained for vital pulp; and 78.9 +/- 1.05%, for nonvital ones. There was a significant difference between the 2 groups.The cumulative success rates with overextension, flush, and underextension in vital teeth were 70.8 +/- 1.44, 86.5 +/- 0.88, and 85.5 +/- 0.98% respectively. There was a significant difference between flush and overextension and between flush and underextension. The rates for nonvital pulp were similar to those for vital ones.

CONCLUSION

The root canal should be filled to within 2 mm of the radiographic apex.

A survey of the incidence of single-visit endodontics

This survey was conducted to obtain answers to some basic questions regarding the timing of root canal obturation. A questionnaire was sent via e-mail to 738 randomly chosen United States endodontists listed in the 1998 to 1999 membership roster of the American Association of Endodontists. One hundred fifty-six replies were received. In pulpectomy cases, root canal obturation at the first visit was carried out by 55.8% of the responding endodontists; in infected root canal cases, the percentage was 34.4%. Of the responding endodontists, 34.2% indicated that their patients had experienced some trouble after root canal obturation at the first visit.

Development and evaluation of oral reporting system for PACS

Experimental workstations for oral reporting and synchronized image filing have been developed and evaluated by radiologists and referring physicians. The file media is a 5.25-inch rewritable magneto-optical disk of 600-Mb capacity whose file format is in accordance with the IS&C specification. The results of evaluation tell that this system is superior to other existing methods of the same kind such as transcribing, dictating, handwriting, typewriting and key selections. The most significant advantage of the system is that images and their interpretation are never separated. The first practical application to the teaching file and the teaching conference is contemplated in the Osaka University Hospital. This system is a complete digital system in terms of images, voices and demographic data, so that on-line transmission, off-line communication or filing to any database will be easily realized in a PACS environment. We are developing an integrated system of a speech recognizer connected to this digitized oral system.

[Development of oral reporting system in PACS environment]

An experimental radiologic reporting system using oral presentations has been developed and tested. The rewritable and compact magneto-optical disk (MOD) is employed to store oral diagnostic reports together with read radiologic images. The MOD is 5.25 inches in diameter, has a 600 MB memory capacity, and is erasable, light and compact. Advantages of the system are simultaneous retrieval of oral reports by a radiologist and the images he or she interpreted, and the capability of media circulation in addition to the function of filing. Thus MOD has a multimedia function of both off-line communication and filing. When medical images are interpreted and oral presentations are registered, automatically digitized oral reports and digitized images are filed in the MOD. Referring physicians can get oral diagnostic reports and can see the images at the same time on a personal computer. Furthermore, integration with voice recognition capability is being tried in our experiment.

[Magneto-optical disk filing system for oral diagnostic reports and their synchronized images]

The rewritable and compact media of magneto-optical disk (MOD) is firstly applied to store medical images with spoken reporting. The MOD has multi-media function of communication and filing. Our system is optimized in terms of recording length of speech based upon our clinical research. The results will have influences over the future PACS. One of their examples is possibility of multimedia PACS with images, speeches and demographic data. Another example is prevention of dispersion of images which have no interpretations by radiologists. Our next step is to recognize filed speech in background processing for printing reports.

Differential effects of calcium-regulating hormones on bone metabolism in weanling rats orally administered zinc sulfate

The effect of calcium-regulating hormones on bone metabolism was investigated in weanling rats orally administered zinc sulfate. Administration of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3 (150 ng/100 g BW) or parathyroid hormone (1-34) (PTH) (10 U/100 g) produced significant increases in alkaline phosphatase activity and DNA content in the femoral diaphysis, while calcitonin (CT) (1.0 U/100 g) did not have a significant effect. Administration of zinc (1.0 mg/100 g) caused a significant elevation of alkaline phosphatase activity and DNA content in the femoral diaphysis. In combination with these hormones and zinc, both 1,25(OH)2D3 and zinc caused a synergistic increase in diaphyseal alkaline phosphatase activity and DNA content, while the combination with zinc and PTH, or zinc and CT did not cause a synergistic increase. The synergistic effects in combination with 1,25(OH)2D3 and zinc were completely inhibited by treatment of mitomycin C (10 micrograms/100 g). Meanwhile, the increase in diaphyseal zinc content following zinc administration was not altered by treatment with 1,25(OH)2D3. These results indicate that zinc synergistically enhances 1,25(OH)2D3-stimulated bone metabolism. This suggests a physiologic significance of zinc in the regulation of bone metabolism.

Effect of essential trace metals on bone metabolism in weanling rats: comparison with zinc and other metals' actions

The effect of essential trace metals on bone metabolism was investigated in the femoral diaphysis of weanling rats. Oral administration of zinc (1.53-306 mumol/100 g body weight) for 3 days produced significant increases in alkaline phosphatase activity and DNA content. These biochemical indices were also increased by oral administration of chromium (III), cobalt, copper, manganese, and nickel with the dose of 1.53 mumol/100 g. With the dose of 15.3 mumol/100 g of above all metals, except zinc, the enzyme activity was significantly decreased in comparison with control, while DNA content was not decreased significantly. Moreover, the effect of zinc on alkaline phosphatase activity and DNA content was not enhanced by simultaneous administration of other metals (1.53 mumol/100 g). The present study indicates that, of the essential trace metals, zinc can effectively stimulate the bone growth and calcification with comparatively higher dose levels. This suggests a nutritional significance of zinc on bone growth.

Early esophageal carcinoma accompanied by esophageal varices: a case report

This is a case report of early esophageal carcinoma accompanied by esophageal varices. Our conclusion from the experience is that when an esophagogram is performed on a patient with esophageal varices an air-contrast study in addition to an ordinary barium study should be performed as a routine examination.

Computed tomography in the detection of small hepatocellular carcinomas

Thirty-two patients with hepatocellular carcinoma less than 5 cm in diameter were examined by computed tomography. At the examination 26 patients (81%) were correctly diagnosed. A common type of CT image series was detectable as low density on the precontrast scan, a positive or mixed pattern on dynamic scan, and visible on postcontrast scan. In 10 patients with minute tumors (less than 2 cm), 7 were correctly diagnosed. CT was valuable for diagnosis of the small hepatocellular carcinomas larger than 1 cm by using the dynamic study after an intravenous bolus injection of the contrast medium.

Computed tomography in the detection of small renal cell carcinoma

Small renal cell carcinoma, less than 3 cm in diameter, was detected with computed tomography (CT) in three patients. The patients had no urological complaints and the carcinomas were discovered by chance during tests made for liver diseases. After making a comparison study between these three cases and a false-positive case, dynamic CT images were evaluated to be beneficial for detection of the tumors: dense staining in the early phase which became less dense than normal parenchyma in the late nephrogram phase.

The use of computed tomography in fulminant hepatic failure

We report on a case of fulminant hepatic failure induced by a hepatitis-B virus. Computed tomography (CT) was valuable in the recognition of severe liver atrophy with ascites. CT was also an efficient means for evaluating the progress of fulminant hepatic failure.

Storage and retrieval of radiological images using a laser video disk

A laser video disk was used for recording radiographs and CT images. Although some deterioration of the image quality was observed in the stored radiographs, this drawback was compensated for by several advantages such as easy video recording, large storage capacity, random access to a desired image, and rapid retrieval and display on the monitor. Connection to a microcomputer further widened its applications in the area of education. Overall, the laser video disk was evaluated to be of practical use.

Arterioportal fistula in hepatocellular carcinoma

A hepatic arterioportal fistula was visualized in a patient with hepatocellular carcinoma by sequential computed tomography (CT) after rapid bolus injection of contrast medium. Early contrast staining was demonstrated in the trunk and branches of the portal vein. The CT findings corresponded with those of celiac angiography.

Duplication of the renal pelvis and ureter: associated anomalies and pathological conditions

Thirty-one patients with anomalous and/or pathological conditions in the duplication of the renal pelvis and ureter were studied in order to analyze the urographic findings. A segmental defect evident in the visualization was caused by the abscess of one of the poles in the kidney. In patients with hypoplasia of one of the poles, the other normal pelvis extended to the neighboring segment, and consequently showed the same pattern as a simple pelvis and ureter on urography. The renal hypoplasia was apt to be combined with simple or ectopic ureterocele and ectopic ureteral opening. In patients with non-visualization of two pelves, hydronephrosis or renal hypoplasia was proved by other radiological modalities including computed tomography. Incidence of vesicoureteral reflux was more frequent in the ureter of the lower pelvis. Reflux was also found between the two ureters of the bifid ureter. It was concluded that these urographical findings correlated closely with pathological conditions.

Computed tomography of carcinoma of the ampulla of Vater

CT findings were studied in 14 cases with carcinoma of the ampulla of Vater which were all proved by surgery. At pre-operation period, only 4 cases (29%) were accurately diagnosed and other 10 cases (71%) were misinterpreted on CT. The most concomitant error was a confusion with the pancreatic head carcinoma (57%). Although a mass was retrospectively visualized in 4 cases, indirect signs were rather prominent, such as enlargement of the pancreatic head (57%), dilatation of the pancreatic duct (71%) and that of the common bile duct (79%).

CT of hepatoma: effects of portal vein obstruction

CT images were studied in five patients with hepatocellular carcinoma associated with obstruction of branches of the portal vein. Two were solitary tumors located near the porta hepatis and were seen as low density areas. In addition noncancerous areas with impaired portal drainage also had lower densities than normally perfused areas. In one instance, gross and histologic studies performed on the resected specimen showed atrophy of hepatic tissue. The other three patients had disseminated tumors with multiple low density areas on CT. Additional low density areas were seen in patients with concomitant obstruction of branches of the portal vein. A decrease in portal blood flow will change the appearance of hepatocellular carcinoma of CT.

Computed tomography and angiography of hepatocellular carcinoma

Thirty patients with primary hepatocellular carcinoma were studied by computed tomography (CT) and angiography. Tumor images on CT could be classified into four groups according to the differences between precontrast and postcontrast scans. In comparing the findings of angiography and CT, hypervascular tumor shadows on angiography were visualized as low density areas on CT. However, in several cases, the vessel character of the tumor, hypervascularity, and prolonged capillary staining may have been responsible for the CT tumor appearance after contrast medium administration. The studies of cases with therapeutic embolization of the hepatic artery showed a marked decrease in density on CT. Patients with obstruction of branches of the portal vein had homogeneous low densities in the areas drained by the obstructed branches. Although the characteristics of the hepatic artery played an important role, portal blood flow was as significant in determining equally or more noticeably the CT appearance of hepatocellular carcinoma.

Angiographic diagnosis of a pancreatic islet tumor in a patient with the WDHA syndrome

A patient with an islet cell tumor of the pancreas that produced the watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome is presented. On celiac angiography an extremely vascular mass was seen in the body of pancreas with hypertrophied arteries and persistent, dense tumor staining.