Development and validation of a transanal endoscopic rectal purse string simulator

BACKGROUND

Rectal purse string placement for transanal mesorectal excision is challenging, and practice is difficult. The objective of this study is to build an endoscopic rectal purse string simulator and provide evidence for the validity of its use.

METHODS

A low-cost transanal endoscopic rectal purse string simulator was created and used to measure the performance of participants. Participants included general surgery residents, fellows, and staff surgeons from several Canadian university-affiliated institutions across Canada. The performance of the rectal purse string placement was measured by the time to completion of the task as well scoring with a modified objective structured assessment of technical skills (OSATS) score and a modified advanced laparoscopic suturing (ALS) score.

RESULTS

Thirty-nine participants were recruited into the study. Participants were split into three groups, based on prior experience with laparoscopic suturing, for the analysis of suturing a rectal purse string on the simulator based on three performance measures. There was a significant difference found in all three measures of performance in the three groups (time to completion p = 0.014, mean blinded OSATS score p = 0.007, mean blinded ALS score p = 0.020). Participants with previous laparoscopic suturing had significantly faster times to completion and higher skills scores when compared to residents (time: 5.1 ± 1.4 min vs 9.0 ± 4.8 min, p = 0.005; OSATS: 19.7 ± 2.8 vs 13.0 ± 5.8, p = 0.00398, ALS: 27.4 ± 4.0 vs 18.9 ± 8.5, p = 0.0151).

CONCLUSIONS

A transanal endoscopic purse string simulator was constructed and preliminary testing has shown variable performance based on prior laparoscopic suturing experience.

A case of equine cryptorchidism with undetectable serum anti-Müllerian hormone

Serum anti-Müllerian hormone (AMH), a marker of equine cryptorchidism, is detectable in intact and cryptorchid stallions but not in geldings because it is secreted from Sertoli cells. A 4-year-old uncastrated Thoroughbred racehorse had no visible testes; therefore, the horse was considered a bilateral cryptorchidism. However, the serum AMH was undetectable (<0.08 ng/ml). Human chorionic gonadotrophin (hCG) stimulating test result indicated that the horse was a gelding. The results of sex chromosomal analysis and sequence analysis of SRY gene suggested that the horse was a genetically-intact stallion (X/Y). Only one small degenerative testis was present in the abdominal cavity. The reasons of undetectable serum AMH levels and negative response to hCG stimulation might be low numbers of Sertoli and Leydig cells. This study reports a case of serum AMH-undetectable cryptorchid stallion.

Changes of lying behavior in Thoroughbred foals influenced by age, pasturing time, and weather conditions

The lying behavior of Thoroughbred foals on breeding farms was continuously measured using triaxial accelerometers. Accelerometers were attached on the side of the hind limb cannon and under the halter of six foals to record triaxial angle data every 10 sec for a period of 24 hr. Lying behavior was divided into sternal lying and lateral lying based on head angle. Sampling was performed for two consecutive days each week until weaning. Sampling periods were divided into two periods on the basis of pasturing time: daytime pasturing (period A: 7-hr pasturing period, 2–60 days of age) and overnight pasturing (period B: 19-hr pasturing period, 32–152 days of age). Lying duration and frequency were longer and higher, respectively, in period A (44.6% of the time and 26.8 ± 7.4 times per day) than those in period B (27.7% of the time and 15.3 ± 4.2 times per day). In addition, foals spent more time laterally in period A (48.1% of total lying time) than in period B (38.9% of total lying time). Foals lie down longer in stalls than in pastures (Period A, 56.3 vs. 16.0%; Period B, 52.5 vs. 21.1%). Lateral lying was also longer in the stall than in the pasture. Lying duration and frequency changed with age in period A. Wet weather prevented lying behavior in the pasture. These results suggested that age, weather, and pasturing time affected the lying behavior of Thoroughbred foals under management at a breeding farm. Triaxial accelerometers may be useful for monitoring equine lying behavior.

Effect of Myostatin SNP on muscle fiber properties in male Thoroughbred horses during training period

Variants of the Myostatin gene have been shown to have an influence on muscle hypertrophy phenotypes in a wide range of mammalian species. Recently, a Thoroughbred horse with a C-Allele at the g.66493737C/T single-nucleotide polymorphism (SNP) has been reported to be suited to short-distance racing. In this study, we examined the effect of the Myostatin SNP on muscle fiber properties in young Thoroughbred horses during a training period. To investigate the effect of the Myostatin SNP on muscle fiber before training, several mRNA expressions were relatively quantified in biopsy samples from the middle gluteal muscle of 27 untrained male Thoroughbred horses (1.5 years old) using real-time RT-PCR analysis. The remaining muscle samples were used for immunohistochemical analysis to determine the population and area of each fiber type. All measurements were revaluated in biopsy samples of the same horses after a 5-month period of conventional training. Although the expressions of Myostatin mRNA decreased in all SNP genotypes, a significant decrease was found in only the C/C genotype after training. While, expression of VEGFa, PGC1α, and SDHa mRNAs, which relate to the biogenesis of mitochondria and capillaries, was significantly higher (54-82%) in the T/T than the C/C genotypes after training. It is suggested that hypertrophy of muscle fiber is directly associated with a decrease in Myostatin mRNA expression in the C/C genotype, and that increased expressions of VEGFa, PGC1α, and SDHa in the T/T genotype might be indirectly caused by the Myostatin SNP.

Aborted fetal sizes of Thoroughbred horses in Hidaka, Japan, between 2005 and 2015

The degree of fetal growth restriction has been unclear in equine reproduction. In this study, 2,195 fetuses from 2,137 abortions during 11 seasons were examined to determine the causes of abortion, and fetal size dimensions (crown rump length and body weight) were measured. In total, 900 cases (42.1%) of abortion were identified as caused by viral infection (215, 10.1%), bacterial infection (156, 7.3%), fungal infection (25, 1.2%), circulation failure (406, 19.0%), multiple causes (66, 3.1%), deformity (13, 0.6%), placental abnormality (12, 0.6%), and other causes (7, 0.3%). All viral infections originated from equine herpes virus. Of all abortions, 94.3% occurred between 181–360 days of pregnancy, and the gestational ages at abortion were different based on the causes. Fetal sizes in viral abortions were considerably larger than those due to other reasons. Compared with viral infection, the crown rump length size dimension of fetuses aborted from multiple and fungal infection was affected. In addition, bacterial infection, circulation failure, and unknown causes of abortions also contributed to growth restriction in terms of body weight. In conclusion, the present study showed details of equine abortion and the relationships between causes of abortion and fetal size. Most of the aborted fetuses showed restrictions in their growth. The manifestations of growth restriction were more related to weight than skeletal length.

Quantitative evaluation of cervical cord compression by computed tomographic myelography in Thoroughbred foals

Five Thoroughbred foals (age, 8–33 weeks; median age, 31 weeks; weight, 122–270 kg; median weight, 249 kg) exhibiting ataxia with suspected cervical myelopathy (n=4) and limb malformation (n=1) were subjected to computed tomographic (CT) myelography. The areas of the subarachnoid space and cervical cord were measured on transverse CT images. The area of the cervical cord was divided by the area of subarachnoid space, and stenosis ratios were quantitatively evaluated and compared on the basis of histopathological examination. The sites with a ratio above 52.8% could have been primary lesion sites in the histopathological examination, although one site with a ratio of 54.1% was not a primary lesion site. Therefore, in this study, a ratio between 52.8–54.1% was suggested to be borderline for physical compression that damages the cervical cord. All the cervical vertebrae could not be scanned in three of the five cases. Therefore, CT myelography is not a suitable method for locating the site of compression, but it should be used for quantitative evaluation of cervical stenosis diagnosed by conventional myelography. In conclusion, the stenosis ratios determined using CT myelography could be applicable for detecting primary lesion sites in the cervical cord.

A clinical case of equine fungal placentitis with reference to hormone profiles and ultrasonography

Fungal placentitis is an infectious disease inducing abortion in pregnant mares. In the present report, we describe a field case of abortion caused by fungal placentitis with consecutive examinations. The progesterone level and combined thickness of the uterus and placenta (CTUP) were abnormal before the onset of clinical signs. Additionally, the estradiol level started to change before the appearance of clinical signs. Abnormal serum amyloid A values and an abnormal fetal heart rate were observed after the onset of clinical signs. The present report demonstrates that the progesterone level and CTUP may be adequate as early diagnostic markers of fungal placentitis and bacterial infection. Endocrinological evaluation based on cutoff values or serial measurements were also useful for early diagnosis.

Physiological responses of young thoroughbred horses to intermittent high-intensity treadmill training

BACKGROUND

Training of young Thoroughbred horses must balance development of cardiopulmonary function and aerobic capacity with loading of the musculoskeletal system that can potentially cause structural damage and/or lameness. High-speed equine treadmills are sometimes used to supplement exercise on a track in the training of young Thoroughbreds because the horse can run at high speeds but without the added weight of a rider. We tested the hypothesis that intermittent high-intensity exercise on a treadmill of young Thoroughbred horses entering training can enhance development of aerobic capacity (VO2max) and running performance more than conventional training under saddle, and do so without causing lameness.

RESULTS

Twelve yearling Thoroughbreds trained for 8 months with conventional riding (C) only, conventional riding plus a short (2 month, S) interval of once-per-week high-intensity treadmill exercise, or a long (8 month, L) interval of once-per-week high-intensity treadmill exercise. Three treadmill exercise tests evaluated VO2max, oxygen transport and running performance variables in June of the yearling year (only for L), October of the yearling year and April of the 2-year-old year. No horses experienced lameness during the study. Aerobic capacity increased in all groups after training. In both October and April, VO2max in L was higher than in C, but did not differ between L and S or S and C. Running speeds eliciting VO2max also increased in all groups after training, with S (809±3 m/s) and L (804±9 m/s) higher than C (764±27 m/s). Maximum heart rate decreased for all groups after training. Hematocrit and hemoglobin concentration increased for L throughout training.

CONCLUSIONS

Young Thoroughbred horses can increase aerobic capacity and running performance more than by strictly using track training under saddle with the addition of intermittent high-intensity treadmill exercise, and they can do so without experiencing lameness. This finding suggests that young racehorses might be able to achieve higher aerobic fitness during training without subjecting their musculoskeletal systems to increased loading and risk of developing lameness. The findings of this preliminary study do not indicate a specific protocol to best achieve this goal.

Vaginal cuff dehiscence after total laparoscopic hysterectomy: examination on 677 cases

INTRODUCTION

Total laparoscopic hysterectomy has been reported as having a higher incidence of vaginal cuff dehiscence compared with the abdominal and/or vaginal hysterectomy. The cause of vaginal cuff dehiscence after total laparoscopic hysterectomy is not specified, but possible causes may be the use of thermal energy for vaginal incision, reduced suturing width due to magnification, low quality of laparoscopic suturing skills and early resumption of regular activities after surgery.

METHODS

We performed 677 cases of total laparoscopic hysterectomy for benign diseases, such as fibroids or adenomyosis, from January 2007 to December 2008 in our institute. We experienced four cases (0.6%) of vaginal cuff dehiscence. We checked the operative parameters for these cases, such as whether the retroperitoneum was sutured or not and intrapelvic adhesion, as well as examined operative duration, blood loss, weight of removed organs, and body mass index.

RESULTS

Sexual intercourse was the triggering event for three cases (96 days, 103 days and 47 days after total laparoscopic hysterectomy) and the other case occurred during defecation (18 days and no sexual intercourse after total laparoscopic hysterectomy). There were no significant differences in vaginal cuff dehiscence with or without retroperitoneum suture and intrapelvic adhesion.

CONCLUSION

After these four cases of vaginal cuff dehiscence, we recognized the need to review these cases carefully in order to discover the cause and how to prevent this from occurring in other patients. We do not have the answers to prevent this complication at present, but reducing the power-source and attempting different suturing techniques may be important steps.

Utilisation of the time constant calculated from heart rate recovery after exercise for evaluation of autonomic activity in horses

REASONS FOR PERFORMING STUDY

Heart rate (HR) recovery immediately after exercise is controlled by autonomic functions and the time constant (T) calculated from HR recovery is thought to be an index of parasympathetic activity in man.

OBJECTIVES

To investigate whether it is possible to evaluate autonomic function using the time constant in horses.

METHODS

Five Thoroughbred horses were subjected to a standard exercise test. Following pre-medication with saline, atropine and/or propranolol, the horses ran for 2.5 min at a speed of 8 m/sec at a 10% incline and T was calculated from HR after the exercise. Secondly, 7 Thoroughbred horses were then trained for 11 weeks and T and maximal oxygen uptake (VO2max) measured at intervals of 1 or 2 weeks. In 6 horses, T with atropine pre-medication was also measured before and after the whole training period. Furthermore, the HR variability at rest was evaluated by power spectral analysis at intervals of 3 or 4 weeks.

RESULTS

Time constant was increased by atropine and/or propranolol pre-medication, decreased with the progress of training and inversely correlated with VO2max during training (r = 0.43, P<0.005). Parasympathetic blockade significantly decreased T only after and not before, the training; however, T was lower in post training than in pretraining, irrespective of parasympathetic blockade. On the other hand, parasympathetic activity at rest was attenuated and sympathetic activity became predominant following the training.

CONCLUSION

Heart rate recovery is affected by sympathetic withdrawal and parasympathetic reactivation in horses and suggests that physical training hastened HR recovery by improving the parasympathetic function after exercise with aerobic capacity. However, the effects of other factors need to be considered because the training effect appeared on T even under parasympathetic blockade. The parasympathetic activity at rest is in contrast to that after exercise, suggesting that T does not reflect parasympathetic activity at rest.

POTENTIAL RELEVANCE

If demonstrated how HR recovery is controlled after exercise, its analysis will be important in the evaluation of physical fitness in horses.

Effects of warm-up intensity on oxygen transport during supramaximal exercise in horses

OBJECTIVE

To determine whether warm-up exercise at different intensities alters kinetics and total contribution of aerobic power to total metabolic power in subsequent supramaximal exercise in horses.

ANIMALS

11 horses.

PROCEDURES

Horses ran at a sprint until fatigued at 115% of maximal oxygen consumption rate (VO(2max)), beginning at 10 minutes following each of 3 warm-up protocols: no warmup (NoWU), 1 minute at 70% VO(2max) (moderate-intensity warm-up [MoWU]), or 1 minute at 115% VO(2max) (high-intensity warm-up [HiWU]). Cardiopulmonary and blood gas variables were measured during exercise.

RESULTS

The VO(2) was significantly higher in HiWU and MoWU than in NoWU throughout the sprint exercise period. Blood lactate accumulation rate in the first 60 seconds was significantly lower in MoWU and HiWU than in NoWU. Specific cardiac output after 60 seconds of sprint exercise was not significantly different among the 3 protocols; however, the arterial mixed-venous oxygen concentration difference was significantly higher in HiWU than in NoWU primarily because of decreased mixed-venous saturation and tension. Run time to fatigue following MoWU was significantly greater than that with NoWU, and there was no difference in time to fatigue between MoWU and HiWU.

CONCLUSIONS AND CLINICAL RELEVANCE

HiWU and MoWU increased peak values for VO(2) and decreased blood lactate accumulation rate during the first minute of intense exercise, suggesting a greater use of aerobic than net anaerobic power during this period.

Experimental evidence of phase coherence of magnetohydrodynamic turbulence in the solar wind: GEOTAIL satellite data

Magnetohydrodynamic (MHD) turbulence is commonly observed in the solar wind. Nonlinear interactions among MHD waves are likely to produce finite correlation of the wave phases. For discussions of various transport processes of energetic particles, it is fundamentally important to determine whether the wave phases are randomly distributed (as assumed in the quasi-linear theory) or have a finite coherence. Using a method based on the surrogate data technique, we analysed the GEOTAIL magnetic field data to evaluate the phase coherence in MHD turbulence in the Earth's foreshock region. The results demonstrate the existence of finite phase correlation, indicating that nonlinear wave-wave interactions are in progress.

Immunomodulatory effects of selective leucocytapheresis as a new adjunct to interferon-alpha2b plus ribavirin combination therapy: a prospective study in patients with high plasma HCV viraemia

Efficacy of interferon-alpha2b (IFN) + ribavirin (IFN/RBV) combination in patients with high plasma hepatitis C virus (HCV) is very poor. Dysregulated CD4+ /CD8+ T cells is involved in both impaired cell-mediated immunity and resistance to IFN. Adsorptive granulocytes and monocytes apheresis (GMA) can remove infected leucocytes which are extrahepatic HCV reservoirs and also has been associated with intriguing immunomodulation and increases in CD4+ T cells. Our aim was to see if GMA enhances the efficacy of IFN/RBV. Twenty-four patients, 13 IFN resistant and 11 IFN naive were enrolled. Seventeen were genotype 1b and 7 were 2a or 2b. Mean plasma HCV-RNA was 612.9 (100-850) kIU/mL and alanine aminotransferase, 108 (41-373) U/L. GMA was performed with Adacolumn at one session/day for five consecutive days and IFN/RBV was started within 24 h after the last GMA session. Daily 6 million units of IFN, six times/week for 2 weeks and then three times/week for 22 weeks were given with RBV (600-800 mg/day/patient). Patients were followed for 6 months. GMA was associated with a significant increase in lymphocyte counts, complement activation fragment C3a and falls in tissue necrosis factor-alpha, and IL-8 produced by peripheral blood leucocytes. At week 24, 20 of 24 patients (83%) were HCV negative and by end of follow-up (week 49), the remission was sustained in 14 of 24 patients (58%) including 100% of patients with 2a or 2b. In conclusion, enhanced efficacy of IFN/RBV following GMA might be attributed to a more efficient immune function and a renewed IFN signaling towards HCV.

Effect of purine-free low-malt liquor (happo-shu) on the plasma concentrations and urinary excretion of purine bases and uridine--comparison between purine-free and regular happo-shu

To determine whether purine-free and regular low-malt liquor beverages (happo-shu) increase the plasma concentration and urinary excretion of purine bases (hypoxanthine, xanthine, uric acid) and uridine, 6 healthy males were given regular (10 ml/kg of body weight) and purine-free happo-shu (10 ml/kg of body weight). Plasma concentration-time curves were plotted, and the areas under the curves for uric acid and total purine bases (the sum of hypoxanthine, xanthine, and uric acid) were greater in the regular than in the purine-free happo-shu ingestion experiment (both p < 0.05). In addition, the total urinary excretion of xanthine, total purine bases, and uridine was greater in the regular than in the purine-free happo-shu ingestion experiment (p < 0.05 in all cases), although the total urinary excretion of hypoxanthine and uric acid was no different between the regular and the purine-free happo-shu ingestion experiments. These results suggest that uridine contained in regular happo-shu might contribute to an increase in the urinary excretion of uridine along with ethanol, and that the purines contained in regular happo-shu may contribute to the increase in plasma concentration of uric acid due to purine degradation.

Effects of novelty stress on neuroendocrine activities and running performance in thoroughbred horses

This study investigated the effects of novelty stress on neuroendocrine activities and running performance in Thoroughbred horses. First, to examine the neuroendocrine responses to novelty stress, we exposed horses to two types of novel environmental stimuli (audiovisual or novel field stimuli). After the stimuli, plasma concentrations of vasopressin, catecholamines and adrenocorticotropin (ACTH), as well as heart rates, were significantly increased in each experiment. Second, we investigated neuroendocrine activities during incremental exercise. Plasma concentrations of vasopressin, catecholamines, ACTH and blood lactate increased as the exercise load increased. Finally, we investigated the effects of novelty stimuli on neuroendocrine activities and running performance during supra-maximal exercise (110% VHRmax). When the novelty stimuli were presented to horses, the increases in plasma vasopressin and catecholamines due to exercise load were significantly smaller than those in the control experiments. Blood lactate during supra-maximal exercise was also significantly lower and total run time until exhaustion was prolonged in the novel environmental stimuli compared to the control. These results suggest that novelty stimuli facilitate vasopressin release from the posterior pituitary in addition to activating the sympatho-adrenomedullary and the hypothalamic-pituitary-adrenocortical axes in thoroughbred horses, and increase exercise capacity, resulting in improvement of running performance during supra-maximal exercise.

Parametric instabilities of circularly polarized Alfvén waves in a relativistic electron-positron plasma

Dispersion relation and nonlinear evolution of the parametric instabilities of circularly polarized Alfvén waves in a relativistic electron-positron plasma are investigated by theoretical and numerical approaches. In the nonrelativistic limit, when 2omega(2)(p)>omega20, the characteristics of the instabilities are similar to those in an electron-ion plasma, except that the modulational instability takes place only if v(2)(s)<omega(2)(0)/k(2)(0), where omega(p) and v(s) denote the plasma frequency and the acoustic speed, and omega(0), k(0) indicate the frequency and the wave number of the parent wave. On the other hand, when 2omega(2)(p)<omega20, two new types of instabilities emerge between the parallel or antiparallel propagating Alfvén-like waves and the parallel propagating Langmuir-like wave. The weakly relativistic effect is discussed for all the instabilities. The one-dimensional full particle simulation and bicoherence analysis of the simulation result suggest that successive decay via the interaction between the parallel propagating Langmuir-like wave and antiparallel propagating Alfvén-like wave can efficiently generate a continuum of low frequency electromagnetic waves, which can interact with energetic particles.

Biomechanical implications of uphill training on the aetiology of tendinitis

It has been reported that a small decrease in the strain in the superficial digital flexor tendon (SDFT) occurs if the toe is raised during walking. Although walking on a slope appears similar to raising the toe, it is unclear whether uphill exercise decreases the strain in the SDFT. Because the force or strain on tendons is one of the important factors leading to tendon stress injury, we hypothesised that reducing the force in the SDFT during exercise may prevent tendinitis. The purpose of this study was to determine the effects of treadmill inclination on the force in the SDFT in the walking horse. 'Arthroscopically implantable force probes' (AIFP) were implanted into the SDFT of the forelimb of 4 horses. The AIFP output was recorded during walking on a treadmill inclined at 0%, 3%, 8% and then 0% again. When the inclination increased from 0 to 8%, the first peak of force in the SDFT decreased significantly, the second increased significantly, but the maximal force and the area under the force-time curve did not change. In conclusion, uphill walking on an inclined treadmill did not decrease the maximal force in the SDFT or the area under the force-time curve, however, the patterns of force were altered. Future research should focus on the force distributions of tendons and ligaments at faster gaits, because the effects of a change in hoof angle and slope may be greater at faster gaits.

An atypical case of primary renal tubular hypokalaemic metabolic alkalosis with chronic tophaceous gout

A 55-year-old woman was referred to our ward for further evaluation of marked hyperuricaemia and suspected tophi. On physical examination, huge subcutaneous nodules were observed on the knee joints as well as a small nodule on the lateral side of the left sole. Blood chemistry showed marked hyperuricaemia (0.85 mmol/l), hypokalaemia (2.7 mmol/l) and a mild degree of renal insufficiency. Arterial blood gas analysis showed signs of metabolic alkalosis. Daily urinary uric acid excretion on a purine non-restricted diet was 8.9 mmol/day. Uric acid clearance and fractional uric acid clearance were 0.8 ml/min and 2.6%, respectively. Plasma renin activity was 21.8 ng/ml/h, and plasma angiotensin II and aldosterone concentrations were 61 and 121 pg/ml, respectively. However, pressor response to an intravenous administration of angiotensin II was normal. The urinary calcium to creatinine molar ratio was 0.069, and serum magnesium concentration was normal to supranormal. A biopsy of the subcutaneous nodule showed a typical appearance of tophus. Based on these findings, the patient was diagnosed with an atypical case of renal tubular hypokalaemic metabolic alkalosis, with marked hyperuricaemia and tophi as the initial manifestations. So far, only four cases of Bartter's syndrome with gout and/or hyperuricaemia have been described in Japan. This rare case is presented and its mechanism of hyperuricaemia discussed.

Functioning adrenal black adenoma with pulmonary and cutaneous cryptococcosis: a case report and review of English literature

A 53-year-old woman experienced progressive general weakness and lumbago in the 2 years prior to a physical examination which disclosed cushingoid manifestations and a skin ulcer on the back of her right knee joint. Her plasma cortisol concentration ranged from 24.7 to 31.1 microg/dl, with an ACTH level <5 pg/ml. Urinary excretions of 17-hydroxycorticosteroid (17-OHCS) and 17-ketosteroid (17-KS) were 20.5 mg/day and 5.1 mg/day, respectively, and urinary cortisol was also increased (421 microg/day). Cortisol was not suppressed after the administration of 8 mg dexamethasone. Abdominal ultrasound sonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI) studies demonstrated a left adrenal tumor and further, a chest X-ray examination showed a cavitary lesion containing a fungus ball-like mass in the left lower lung field. The serum cryptococcal antigen titer was positive at 1:128 and a bronchoalveolar lavage fluid culture yielded a growth of Cryptococcus neoformans. A biopsy specimen of the skin ulcer also suggested cryptococcosis. As a result, a left adrenectomy was performed, and the excised specimen was shown to be an adenoma consisting of compact cells with abundant pigmentation (black adenoma). A diagnosis of functioning black adenoma of the adrenal gland, complicated with pulmonary and cutaneous cryptococcosis was made.

Effect of norepinephrine on the urinary excretion of purine bases and oxypurinol

To examine whether norepinephrine affects the plasma concentrations and urinary excretion of purine bases and oxypurinol, we orally administered allopurinol (300 mg) to 5 healthy subjects and 9 hours later intravenously administered norepinephrine (12 to 20 microg/kg body weight), which causes a more than 10 mm Hg increase in diastolic pressure for 2 hours. Norepinephrine decreased the urinary excretion of uric acid by 33% (P <.01), oxypurinol by 32% (P <.01), and xanthine by 51% (P <.01), as well as the fractional clearance of uric acid by 32% (P <.01), oxypurinol by 24% (P <.05), and xanthine by 21% (P <.05) when measured 1 to 2 hours after administration. These results indicate that norepinephrine decreases the urinary excretion of uric acid, oxypurinol, and xanthine, probably via hemodynamic change. It is also suggested that the hypouricemic effect of allopurinol may be more potent than that expected in gout patients with enhanced sympathetic tone, such as in salt-sensitive hypertension.

Effect of fenofibrate on plasma concentration and urinary excretion of purine bases and oxypurinol

OBJECTIVE

To investigate whether fenofibrate increases the clearance of purine bases (hypoxanthine, xanthine, uric acid) and oxypurinol.

METHODS

We administered fenofibrate (150 mg) 3 times a day for 3 days, and then allopurinol (300 mg) 4 h after the last administration of fenofibrate, to 5 healthy subjects. Ten hours later, a clearance study was done.

RESULTS

Following 3 day administration of fenofibrate, fractional clearance of xanthine, uric acid, and oxypurinol increased by 41% (p < 0.05), 101% (p < 0.01), and 51% (p < 0.01), respectively, compared to baseline values, while the respective plasma concentrations decreased by 46% (p < 0.05), 46% (p < 0.05), and 19% (p < 0.05).

CONCLUSION

Our results suggest that fenofibrate, fenofibric acid, or fenofibrate derivatives can increase fractional clearance of xanthine, uric acid, and oxypurinol by acting on their common renal pathways. It is suggested that the hypouricemic effect of combination therapy using allopurinol and fenofibrate may be less than additive.

Spontaneous regression of hepatic adenoma in a patient with glycogen storage disease type I after hemodialysis: ultrasonographic and CT findings

A 23-year-old woman was admitted to our hospital with recurrent gouty arthritis. Laboratory findings showed hypoglycemia, lactic acidosis, hyperlipidemia, and hyperuricemia, with normal values of serum alfa-fetoprotein (AFP) and protein induced by vitamin K absence (PIVKA-II). A diagnosis of glycogen storage disease type I (GSD-type I) was made on the basis of the laboratory data, liver biopsy findings, and partially deficient thrombocyte glucose-6-phosphatase (G-6-Pase) activity. Ultrasonography and computed tomography revealed multiple focal hepatic masses. Biopsied specimens of the lesion demonstrated a hepatic adenoma, which changed in appearance in the relatively short period between echography and computed tomography. This interesting phenomenon may highlight the importance for careful follow-up of hepatic adenomas, because of the potential of rupture, hemorrhage, or malignant transformation. During follow-up, the present patient received hemodialysis due to renal failure, and the adenoma regressed spontaneously after 8 years. Included are diagnostic images, demonstrating the association of hepatic adenoma and GSD-type I.