Laparoscopic intervention for late-onset perforating peritonitis due to a ventriculoperitoneal shunt: a case report and literature review

BACKGROUND

Ventriculoperitoneal (VP) shunt placement is commonly performed to treat hydrocephalus and complications are not uncommon. We report here a case of generalized peritonitis caused by migration of the abdominal end of a VP shunt catheter into the bowel after multiple VP shunt revisions over 30 years. Laparoscopic surgery was successfully performed for the peritonitis and the VP shunt system subsequently reconstructed without complications.

CASE PRESENTATION

The patient was a 49-year-old woman who had a VP shunt placed for obstructive hydrocephalus at the age of 13 years. The shunt system required seven revisions because of various malfunctions, including two occasions where a nonfunctioning shunt catheter was left inside the abdomen for safety reasons. Approximately 1 year after the seventh revision, she developed abdominal pain and fever. Abdominal computed tomography suggested that the shunt catheter had migrated into the small intestine and caused an intra-abdominal abscess. We performed emergency exploratory laparoscopy, which revealed perforation of the small intestine by the tip of a nonfunctioning shunt catheter. A growing abscess was found around the perforated intestinal wall, causing bacterial ascites. After the functioning shunt catheter was pulled out from the abdomen, the nonfunctioning catheter that had perforated the intestinal wall was removed. The functioning shunt catheter was then connected to the cerebrospinal fluid drainage system to manage her severe hydrocephalus. Finally, the contaminated abdominal cavity was copiously irrigated with saline solution and a peritoneal drain placed. Twenty-five days later, she underwent another VP shunt surgery in which a VP shunt catheter was placed. She was discharged 45 days after the surgery for peritonitis without complications.

CONCLUSION

In cases of peritonitis with a history of VP shunt placement, perforation by a VP shunt catheter is possible, though rare. A delay in treatment could lead to a potentially fatal complication, such as septic shock. Laparoscopic surgery enabled a faster, more hygienic, and minimally invasive operation for managing this rare but serious complication of VP shunt placement.

Laparoscopic-assisted treatment for diospyrobezoar-induced intestinal obstruction after distal gastrectomy and cholecystectomy

Diospyrobezoar is a relatively uncommon cause of small bowel obstruction. Here we report successful treatment in a patient with small bowel obstruction due to diospyrobezoar by laparoscopic-assisted surgery. A 93-year-old woman who had undergone distal gastrectomy and laparoscopic cholecystectomy presented with nausea and anorexia. An intestinal obstruction and an intestinal intraluminal mass were discovered on abdominal enhanced computed tomography. Following a transnasal ileus tube placement, the patient underwent laparoscopic surgery to remove the diospyrobezoar from the small intestine. The postoperative course of the patient was uneventful. Laparoscopic-assisted surgery following the transnasal ileus tube was beneficial for the patient's small bowel obstruction caused by diospyrobezoar.

[Safety of Pancreaticoduodenectomy in Patients of Advanced Age and Our Efforts to Prevent Postoperative Pneumonia]

With the aging of society, surgical patients are becoming older. The same trend can be seen in patients undergoing highly invasive operations, such as pancreaticoduodenectomy(PD). The risk of postoperative complications is reportedly higher in patients of advanced age, and postoperative pneumonia occurs at particularly high frequency. We investigated the safety of PD in patients of advanced age with a focus on the prevention of postoperative pneumonia. In total, 223 patients underwent PD at our department from January 2015 to December 2020. We compared various parameters between older patients(≥80 years of age, n=32)and younger patients(<80 years of age, n=191). Although older patients had lower nutrition scores, there was no significant difference in the incidence of postoperative complications between the two groups. Three older patients who were undergoing swallowing rehabilitation by a speech-language therapist did not develop postoperative pneumonia. However, one patient who did not receive swallowing rehabilitation developed postoperative pneumonia. Based on these findings, we plan to incorporate swallowing evaluation before postoperative oral intake into the clinical pathway and introduce speech-language therapy intervention in patients of advanced age.

Conversion hepatectomy for advanced hepatocellular carcinoma after right portal vein transection and lenvatinib therapy

Background

Lenvatinib is a novel tyrosine kinase inhibitor that exhibits an antitumor effect on hepatocellular carcinoma (HCC). An established strategy that involves surgery and usage of lenvatinib for advanced HCC remains elusive.

Case presentation

A 58-year-old male patient with advanced HCC and untreated hepatitis B was referred to our hospital. The tumor at the right lobe was 10 cm in diameter with right portal vein thrombus. Because of the possible lung metastasis and concern about the remaining hepatic function after extended right hepatectomy, lenvatinib was initiated before surgery. After the confirmation of a sharp decrease of tumor markers during the 3-week lenvatinib therapy, only a right portal vein transection was done leaving the enlargement of the left lobe for improved post-hepatectomy liver function while lenvatinib therapy was continued. The laparotomy revealed that the tumor was invading the right diaphragm. After 7 weeks of lenvatinib administration after right portal vein transection, an extended right hepatectomy with resection of the tumor-invaded diaphragm was successfully done. The lung nodules that were suspected as metastases had disappeared. The patient has been doing well without any sign of recurrence for 1 year.

Conclusion

The strategy involving the induction of lenvatinib to conversion hepatectomy including the portal vein transection was effective for advanced HCC.

[Esophagogastric Junctional Cancer Complicated by Follicular Lymphoma-A Case Report]

A 59-year-old female was referred to our hospital due to abnormal upper gastrointestinal(GI)findings in July 2019. Endoscopy showed an advanced type Ⅱ tumor at the esophagogastric junction. The bioptical diagnosis was adenocarcinoma. Computed tomography(CT)and positron emission tomography(PET)revealed a swollen lymph node and abnormal accumulation. Total gastrectomy and Roux-en-Y reconstruction were performed. The final diagnosis was esophagogastric junctional cancer and follicular lymphoma. The chance of encountering double cancer is likely to increase. It is vital to prioritize treatment and determine an appropriate treatment plan according to the clinical stage and prognosis in patients with double cancer.

A case of Trousseau's syndrome due to intrahepatic cholangiocarcinoma with an extremely high level of CA19-9

BACKGROUND

Trousseau's syndrome is a cancer-associated thrombosis. Trousseau's syndrome with cholangiocarcinoma is a rare condition with poor prognosis.

CASE PRESENTATION

A 59-year-old female was admitted to our hospital with abdominal pain, headache, and nausea. Abdominal enhanced computed tomography revealed liver tumor, splenic infarction, and bilateral renal infarction. Multiple acute cerebral infarctions were also detected by magnetic resonance imaging. Her preoperative serum levels of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were > 120,000 U/mL and 589.6 ng/mL, respectively, which were extremely high. Histopathology after right hepatectomy revealed moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma. Her serum levels of CA19-9 were trending down to 9029.2 and 2659.8 U/mL at 1 and 3 weeks after surgery, respectively. However, at 7 weeks after surgery, her CA19-9 levels increased in the presence of positive imaging findings in the remnant liver, hilar lymph nodes, and peritoneal cavity. The initiation of combination chemotherapy including gemcitabine and cisplatin had a significant effect. The patient was doing well at 6 months after the surgery.

CONCLUSION

This rare case of Trousseau's syndrome due to cholangiocarcinoma suggests that extremely high CA19-9 levels might be a pathogenic factor of this syndrome.

Laparoscopic surgery for two patients with strangulated transomental hernias

Background

Transomental hernias are a rare type of internal hernia. We report two cases of successful cases of laparoscopic repair. One required laparotomy due to concern for intestinal viability.

Case presentation

The first patient was a 67-year-old man who presented with abdominal pain and vomiting. He had no history of laparotomy or abdominal injury. Computed tomography suggested small bowel obstruction and possible intestinal strangulation. Emergent laparoscopy found approximately 200 cm of small bowel was strangulated around the greater omentum. The strangulation was released laparoscopically, but because of the color of the strangulated bowel, laparotomy was performed to evaluate viability. The involved portion of intestine was not resected. The patient experienced transient postoperative paralytic ileus and was discharged on postoperative day 14. The second patient was a 56-year-old man who presented with abdominal pain. Abdominal computed tomography revealed dilatation of the small intestine and a closed loop suggesting ileus due to intestinal strangulation. An emergency laparoscopy found a transomental hernia, and the strangulation was released laparoscopically. Recovery was uneventful, and the patient was discharged on postoperative day 6.

Conclusion

Transomental hernia can be successfully treated laparoscopically. In cases where bowel viability is a concern, laparotomy should not be hesitated.

Single incision laparoscopic surgery (SILS) for Meckel's diverticulum

A 65-year-old male patient presented with a chief complaint of abdominal pain. Abdominal computed tomography (CT) showed slight intestinal dilation and obstruction of the upper right quadrant of the small intestine, while ectopic gastric mucosal scintigraphy revealed abnormal accumulation in agreement with the CT-identified structure. The cause of bowel obstruction was diagnosed as Meckel’s diverticulum; the patient was referred for surgery. A small laparotomy was performed with a 35-mm skin incision to the center of the navel. Once a lap disk was attached, a laparoscope was inserted to visualize the abdominal cavity. The small intestine that includes the structure was pulled out from the umbilicus to the outside of the peritoneal cavity and partially resected. On the pathological tissue findings, the patient was diagnosed with Meckel’s diverticulum. We report our experience with single-lap laparoscopic surgery for a case of intestinal obstruction caused by Meckel’s diverticulum and review pertinent literature.

Hypogenesis of right hepatic lobe in a laparoscopic cholecystectomy for acute gallstone cholecystitis: A case report

Hypogenesis or agenesis of right hepatic lobe is a rare abnormality and is generally associated with gallbladder and biliary tract abnormalities. Cases of biliary injury following cholecystectomy have been reported in patients with agenesis of right hepatic lobe because the anatomical anomalies complicate the surgical approach. We report a case of laparoscopic cholecystectomy in a patient with hypogenesis of right hepatic lobe. A 92-year-old male patient was admitted to our hospital with fever and right lower abdominal pain with suspected acute appendicitis. Abdominal computed tomography revealed gallstones with acute cholecystitis and hypogenesis of right hepatic lobe. He underwent laparoscopic cholecystectomy with the left semilateral decubitus position. The patient's postoperative course was uneventful. In conclusions, some patients with liver lobe hypoplasia do not present with the typical symptoms of acute cholecystitis due to dislocation of the gallbladder. The left semilateral decubitus position with modified placement of port sites is useful for laparoscopic cholecystectomy in patients with hypogenesis of right hepatic lobe.

Complete remission of advanced hepatocellular carcinoma following transient chemoembolization and portal vein ligation

Background

Macroscopic diffuse-type hepatocellular carcinoma with concomitant major portal vein tumor thrombus (PVTT) and peritoneal dissemination indicates poor prognosis. Additionally, triple-positive tumor marker status is a predictor of poor outcome even after hepatectomy. Sorafenib is recommended in such patients, but it has limited therapeutic effectiveness.

Case presentation

A 54-year-old man was diagnosed with a liver abscess that was treated by puncture and drainage at a regional hospital. However, the diagnosis was subsequently changed to hepatocellular carcinoma with macroscopic portal vein tumor thrombus, based on the results obtained for the triple-positive tumor markers (alpha-fetoprotein, 45,928 ng/ml; protein induced by vitamin K absence or antagonist-II, 125,350 mAU/ml; and alpha-fetoprotein-L3, 38.3%). As the patient’s liver functional reserve was not adequate for curative resection, chemoembolization was performed with a hepatic arterial infusion of cisplatin (50 mg) and 5-FU (1000 mg), followed by mild embolization with cisplatin (50 mg) suspended in lipiodol (5 ml) and starch microspheres (300 mg) containing mitomycin C (4 mg). As the thrombus had progressed to the bifurcation of the right and left portal veins, the right vein was surgically ligated. Three peritoneal nodules could be identified and were removed. Three additional rounds of hepatic arterial chemotherapy/chemoembolization were performed after the initial surgery. At the 2-year evaluation, all tumor markers were observed to have normalized and diagnostic imaging showed complete remission.

Conclusions

Complete remission of hepatocellular carcinoma with macroscopic portal vein tumor thrombus and peritoneal dissemination was obtained with a treatment regimen that involved four rounds of hepatic arterial infusion chemotherapy and transient chemoembolization, portal vein ligation, and the removal of peritoneal dissemination. This regimen can be recommended for patients with advanced hemiliver lesions who cannot undergo curative resection.

Liver Function in Areas of Hepatic Venous Congestion After Hepatectomy for Liver Cancer: 99mTc-GSA SPECT/CT Fused Imaging Study

Background/Aim: The sacrifice of a major hepatic vein can cause hepatic venous congestion (HVC). We evaluated the effects of HVC on regional liver function using the liver uptake value (LUV), that was calculated from^99mTc-labeled-galactosyl-human-serum-albumin (^99mTc-GSA) single-photon emission computed tomography (SPECT) /contrast-enhanced computed tomography (CE-CT) fused images. Patients and Methods: Sixty-two patients underwent^99mTc-GSA SPECT/CE-CT prior to hepatectomy for liver cancer and at 7 days after surgery were divided into groups with (n=8) and without HVC (n=54). In the HVC group, CT volume (CTv) and LUV were separately calculated in both congested and non-congested areas. Results: The remnant LUV/CTv of the HVC group was significantly smaller than that of the non-HVC group (p<0.01). The mean functional ratio was 0.47±0.05, and all ratios were ≥0.39. Conclusion: After hepatectomy with sacrifice of major hepatic vein, liver function per unit volume in the congested areas was approximately 40% of that in the non-congested areas.

A Case of 15-Year Recurrence-free Survival After Microwave Coagulation Therapy for Liver Metastasis from Gastric Cancer

A 70-year-old man with a growing liver tumor had undergone subtotal gastrectomy with pancreaticoduodenectomy for gastric cancer (T4b P0 H0 N1, Stage IIIB) 30 months before admission to our hospital. Enhanced computed tomography revealed two hypervascular nodules in segments 4 and 8. After histological diagnosis of small liver metastases from gastric cancer in segment 8, the patient underwent open microwave coagulation therapy (MCT) for the tumor (diameter: 30 mm) in segment 4. MCT was performed by using 1.5-cm and 3-cm monopolar needle electrodes with 22 times of puncture under the condition of 100 W × 60 sec. Liver abscess developed at the MCT site; however, it was decreased with percutaneous drainage. The patient is alive, without tumor recurrence even after 15 years since the MCT. This successful case proves that appropriate MCT is a promising treatment for patients with gastric liver metastases.

Hepatic Resection Followed by Hepatic Arterial Infusion Chemotherapy for Hepatocellular Carcinoma with Intrahepatic Dissemination

BACKGROUND/AIM

To investigate the utility of adjuvant hepatic arterial infusion chemotherapy (HAIC) following hepatectomy for patients with hepatocellular carcinoma (HCC) with intrahepatic dissemination (IHD) after local ablation therapy.

PATIENTS AND METHODS

Twelve patients with HCC with IHD were divided into two groups: HAIC group (n=6) underwent hepatectomy followed by HAIC; and the non-HAIC group (n=6) underwent hepatectomy alone. HAIC with cisplatin and 5-fluorouracil was started within a month and was continued for a month: Results: At the first local ablation, tumors close to the major portal vein and insufficient ablation were recognized in eight (67.7%) and six (58.3%) of the patients, respectively. In the HAIC group, the 1-, 3-, and 5-year disease-free and overall survival rates were 50.0%, 16.7%, and 16.7%, and 83.3%, 83.3% and 62.5%, respectively. Three patients in the HAIC group remain alive after 10 years of follow-up.

CONCLUSION

Hepatic resection with short-term postoperative HAIC may provide excellent outcomes in patients with HCC and IHD.

Hepatic sclerosed hemangioma with special attention to diffusion-weighted magnetic resonance imaging

BACKGROUND

A hepatic sclerosed hemangioma (HSH) is a very rare benign liver tumor. The correct preoperative diagnosis of HSH is very difficult because its features of imaging are similar to those of intrahepatic cholangiocarcinoma or colorectal liver metastasis.

CASE PRESENTATION

We experienced five patients who were diagnosed histologically with HSH. The preoperative diagnoses were HSH in two patients, cavernous hemangioma in one, intrahepatic cholangiocarcinoma in one, and colorectal liver metastasis in one. All patients were treated with hepatectomy (one laparoscopic and four laparotomies), and the diagnosis was completed by histological investigation of the resected specimen. In particular, we investigated the apparent diffusion coefficient (ADC) mean value using diffusion-weighted sequences of magnetic resonance imaging (DW-MRI). The average of the ADC mean (ADC_mean) value of HSH was 1.94 × 10^-3 mm²/s (range 1.73-2.10 × 10^-3 mm²/s), which was higher than the value of common malignant liver tumors. Interestingly, the ADC_mean values were almost the same between the degenerate (1.90 ± 0.17 × 10^-3 mm²/s) and the non-degenerate areas (1.95 ± 0.26 × 10^-3 mm²/s) in HSH.

CONCLUSIONS

The ADC_mean value seemed to be quite useful to preoperatively distinguish HSH from other malignant liver tumors.

The Number of Positive Tumor Marker Status Is Beneficial for the Selection of Therapeutic Modalities in Patients with Hepatocellular Carcinoma

Hepatic resection (HR) and radiofrequency ablation (RFA) are popular local therapies for early-stage hepatocellular carcinoma (HCC). Alpha-fetoprotein, Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein, and des-c-carboxy prothrombin are well-known and useful tumor markers for HCC. The positive number status of these tumor markers has recently been demonstrated as beneficial for predicting outcome for HCC patients treated with local therapy. Although the normal ranges reported have differed by institution, the positivity of tumor markers is consistent and can easily be assessed. Kumamoto and Wakayama's group clearly demonstrated the following: 1) Regardless of the degree of tumor stage, a triple-positive tumor marker profile can predict poor outcome in HCC patients undergoing HR; 2) For RFA alone, HCC patients with double- and triple-positive status, having less than three lesions and lesions ≤3 cm in diameter show comparably insufficient outcomes; 3) For HCC patients with lesions ≤5 cm in Child-Pugh grade A, HR is preferred over RFA; 4) Microvascular invasion rates increased even in the double-positive patients, while poorly differentiated HCC was frequently observed only in the triple-positive patients; and 5) RFA with chemoembolization, anatomical liver resection, and postoperative adjuvant chemoembolization or hepatic arterial chemotherapy might improve the outcome for patients with highly malignant HCC with multiple positive tumor markers. However, the impacts of these therapies still need to be evaluated in prospective comparative studies.

C1s and O1s photoelectron satellite spectra of CO with symmetry-dependent vibrational excitations

The photoelectron shake-up satellite spectra that accompany the C1s and O1s main lines of carbon monoxide have been studied by a combination of high-resolution x-ray photoelectron spectroscopy and accurate ab initio calculations. The symmetry-adapted cluster-expansion configuration-interaction general-R method satisfactorily reproduces the satellite spectra over a wide energy region, and the quantitative assignments are proposed for the 16 and 12 satellite bands for C1s and O1s spectra, respectively. Satellite peaks above the pi(-1)pi(*) transitions are mainly assigned to the Rydberg excitations accompanying the inner-shell ionization. Many shake-up states, which interact strongly with three-electron processes such as pi(-2)pi(*2) and n(-2)pi(*2), are calculated in the low-energy region, while the continuous Rydberg excitations are obtained with small intensities in the higher-energy region. The vibrational structures of low-lying shake-up states have been examined for both C1s and O1s ionizations. The vibrational structures appear in the low-lying C1s satellite states, and the symmetry-dependent angular distributions for the satellite emission have enabled the Sigma and Pi symmetries to be resolved. On the other hand, the potential curves of the low-lying O1s shake-up states are predicted to be weakly bound or repulsive.

Synthesis of bioactive PMMA bone cement via modification with methacryloxypropyltri-methoxysilane and calcium acetate

Bone cement consisting of polymethylmethacrylate (PMMA) powder and methylmethacrylate (MMA) liquid is clinically used for fixation of implants such as artificial hip joints. However, it does not show bone-bonding ability, i.e., bioactivity. The lack of bioactivity would be one of factors which cause loosening between the cement and the implant. The present authors recently showed the potential of bioactive PMMA-based bone cement through modification with gamma-methacryloxypropyltrimethoxysilane (MPS) and calcium acetate. In this study, the effects of the kinds of PMMA powder on setting time, apatite formation and compressive strength were investigated in a simulated body fluid (Kokubo solution). The cement modified with calcium acetate calcined at 220 degrees C could set within 15 min when the PMMA powder had an average molecular weight of 100,000 or less. The addition of calcium acetate calcined at 120 degrees C in the PMMA powder required a much longer period for setting. The modified cements formed an apatite layer after soaking in the Kokubo solution within 1 day for cement starting from PMMA powder with a molecular weight of 100,000 or less. Compressive strengths of the modified cements were more than 70 MPa for cements starting from 100,000 and 56,000 in molecular weight. After soaking in Kokubo solution for 7 days, the modified cement consisting of PMMA powder of 100,000 in molecular weight showed a smaller decrease in compressive strength than that consisting of 56,000 in molecular weight. These results indicate that bioactive PMMA cement can be produced with appropriate setting time and mechanical strength when PMMA powders with a suitable molecular weight are used. Such a type of design of bioactive PMMA bone cement leads to a novel development of bioactive material for bone substitutes.

Chromosomal instability and radiosensitivity in myelodysplastic syndrome cells

Myelodysplastic syndrome (MDS) is a clonal disorder of hematopoietic stem cells. To investigate whether chromosomal instability and/or DNA repair defects are involved in the development of MDS, we measured the micronucleus (MN) frequency in peripheral blood lymphocytes exposed to various doses of X-rays, using a cytokinesis-block micronucleus assay. The spontaneous MN frequencies in RAEB and RAEB-T patients were significantly higher than those in normal individuals (P = 0.0224, P = 0.008, respectively). Also, the X-ray-induced MN frequencies in RA/RARS, RAEB, and RAEB-T patients were significantly higher than those in normal individuals (P = 0.007, P = 0.003, P = 0.003, respectively, at 2 Gy). In order to elucidate the cause of unusual radiosensitivity, we measured the expression levels of nucleotide excision repair (NER) genes in peripheral blood mononuclear cells using a RT-PCR method. Reduction of NER gene expression was found in only one of 10 patients with low risk MDS, but in four of 11 patients with high risk MDS. Our data suggest that chromosomal instability and DNA repair defects may be involved in the pathophysiology of disease progression of MDS.

Elevated levels of inhibin-A and immunoreactive inhibin in aged male Wistar rats with testicular Leydig cell tumor

This study was undertaken to investigate the endocrine changes that occur in male Tig:Wistar rats with Leydig cell tumors, with special reference to immunoreactive inhibin (ir-inhibin) and its dimeric forms. Adult male rats from 2 to 28 months of age were used. Blood samples were taken to measure plasma concentrations of ir-inhibin, inhibin-A, inhibin-B, 17beta-estradiol (E2), testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Inhibin bioactivity in both peripheral plasma and testicular extracts was also measured. Rats aged 18 months and older had testicular Leydig cell tumor. Testicular tissue sections from 27-month-old rats examined immunohistochemically showed strong positive staining for all 3 inhibin subunits, in particular inhibin alpha and betaA subunits, in the tumor cells. Plasma concentrations of ir-inhibin began to rise significantly (P < .05) at 18 months of age. High bioactivity of inhibin was detected not only in testicular extracts but also in peripheral plasma of aged rats. Thus, plasma concentrations of bioactive inhibin-A, but not inhibin-B, were significantly elevated with increasing age. The concentrations were significantly higher than those in normal male (P < .01) or normal female (P < .05) rats. Plasma concentrations of E2 were significantly (P < .05) elevated only at 23-24 months of age. A marked reduction (P < .05 to .001) in plasma LH and FSH concentrations was observed at 18 months of age and older. Plasma concentrations of testosterone were highest at 2 months of age and then decreased gradually and significantly (P < .05 to .001) afterward. Significant (P < .05 to .001) positive (testosterone vs LH) and negative (ir-inhibin vs FSH, ir-inhibin vs LH, and E2 vs FSH) correlations were observed. It is suggested that plasma inhibin-A levels are elevated in male Tig:Wistar rats with Leydig cell tumor, and thus inhibin-A may be used as a specific marker of testicular Leydig cell tumors. The present results also suggest that the age-related decline in plasma gonadotropins and thus testosterone levels in Tig:Wistar rats may be due to the development of tumors of the Leydig cells rather than to aging per se.

Tolerability and safety of a calcium channel blocker in comparison with a diuretic in the treatment of elderly patients with hypertension: secondary analysis of the NICS-EH

A randomized prospective controlled study, the National Interventional Cooperative Study in Elderly Hypertensives (NICS-EH), previously demonstrated that the preventive effect of the long-acting calcium channel blocker nicardipine on the cardiovascular endpoint was similar to that of the diuretic, trichlormethiazide. The present report is a sub-analysis in which we compare the tolerability and safety of the calcium channel blocker with that of a diuretic in the long-term treatment of elderly hypertensives. A total of 429 elderly patients with hypertension were assigned to the nicardipine group or the diuretic group by the double-dummy method and were followed up for 5 years. Two hundred four patients in the nicardipine group and 210 patients in the diuretic group were analyzed. The incidences of fatal and nonfatal cardiovascular (CV) events in the two groups were comparable, and there was no significant difference in the cumulative event-free rate. However, the total incidence of adverse reactions, including non-CV events and unfavorable BP changes, was 31 cases (15.2%) in the nicardipine group, which was significantly lower than the 47 cases (22.4%) in the diuretic group (log-rank: p=0.026, G. Wilcoxon: p=0.01). The total number of medical endpoints, including CV events, the withdrawal of the patient from the study, was 52 (25.5%) in the nicardipine group, which was significantly lower than the 65 (31.0%) in the diuretic group (log-rank: p=0.078, G. Wilcoxon: p=0.044). It was concluded that sustained-release nicardipine is better tolerated, as it exhibits a lower incidence of medical-related withdrawals such as adverse drug reactions, non-cardiovascular events and unfavorable BP responses during the treatment.

[MALT lymphoma producing IgG-kappa type M-protein]

A 72-year-old woman, who has been administered prednisolone and azathioprine with diagnoses of idiopathic thrombocytopenic purpura (ITP) and autoimmune hepatitis (AIH), underwent a complete medical examination because of monoclonal gammopathy (IgG-kappa). Tumors were found in the ileum and descending colon. Pathological examination of biopsy specimens suggested a diagnosis of marginal zone B-cell lymphoma of the MALT type with a high-grade component. Flow cytometric analysis by two-color staining revealed that the neoplastic B cells expressed CD38, CD19, IgG and kappa, but not CD5 or CD10. There were no abnormal plasma cells in bone marrow smears. The patient achieved complete remission after receiving three cycles of THP-COP chemotherapy, which resulted in a decrease of the IgG level to within the normal range. These findings indicated that monoclonal IgG-kappa might be produced by lymphoma cells. However, the relationship of the immunosuppressive agents to the pathogenesis of the MALT lymphoma remains to be clarified.

Establishment and characteristics of four sub-strains of F344 rats reared on various low protein and low energy diets

Four sub-strains, reared by sib-mating and having for their origin the F344/DuCrj strain of rats, were established by feeding with different levels of low protein and low energy diets, and their characteristics investigated. The amounts of crude protein (CP) and digestible energy (DE) in the four diets were 17.6%-3.0 kcal, 10.5%-2.5 kcal, 8.4%-2.0 kcal, and 10.5%-2.5 kcal, respectively, and the four sub-strains established here were provisionally designated as F344/Tig1, F344/Tig2, F344/Tig3 and F344/Tig4, respectively. Intakes of nitrogen-corrected metabolizable energy (MEn) did not differ, and a large intake of digestible crude protein (DCP) was observed in F344/Tig1 rats. The body weight of rats provided with lower-nutrient diets showed a tendency to decrease until the F2 generation, but no change among the generations was seen subsequently, and the same compiled differences in protein content were maintained. Similar transitions were observed in the lifetime rearing test. Though F344/Tig3 rats, which were reared on minimum nutrients, showed a tendency to delayed puberty, we were easily able to breed four pairs in every generation using procedures similar to those used for other strains of rats. There were no differences among the F344/Tig1 to -3 strains of rats in body length, digestive tract length, or organ weight per body weight, and all the rats had a normal range of biochemical values. But the F344/Tig4 showed a high glutamic-oxaloacetic transaminase (GOT), and a tendency to decreased liver function and a shorter lifespan. These sub-strains of F344 rats clarified differences in fatty acid compositions, such as docosahexaenoic acid (DHA) in serum, liver and the brain. The rats were intended to be useful animal models for the study of nutritional environments and their influence on the memory and learning.

Transcatheter embolization of mycotic aneurysm of the subclavian artery with metallic coils

Mycotic aneurysms of the subclavian artery are rare. This report describes an experience of 2 rare cases in which transcatheter embolization with metallic coils was performed for the management of these lesions alternative to surgery. Two patients who had been treated with chemotherapy for malignant neoplasms were diagnosed as having mycotic aneurysms of the left subclavian artery. The causes of these lesions were presumed to be the invasion of the arterial wall by the pulmonary abscess in case 1, and wound infection after placement of the reservoir for intraarterial chemotherapy in case 2. In both cases, proximal and distal sites of the aneurysm were embolized with metallic coils. In case 1, the vertebral artery was also embolized with Guglielmi detachable coils to avoid retrograde blood flow. Both aneurysms were completely occluded by a single embolization. In case 1, although weakness and paresthesia of the left hand remained, lethal hemoptysis due to aneurysmal fistulization to the lung parenchyma ceased. In case 2, no neurological deficit except for mild paresthesia in the left thumb had been observed. Both patients died of primary disease 10 and 5 months after the procedure. Transcatheter embolization is technically feasible and effective enough to treat the mycotic aneurysm of the subclavian artery even in the situation in which the surgical option seems to be difficult or risky.

ZK7, a novel zinc finger gene, is induced by vascular endothelial growth factor and inhibits apoptotic death in hematopoietic cells

Vascular endothelial growth factor (VEGF) inhibits radiation-induced apoptosis in the leukemia cell line, CMK86 (O. Katoh et al., Cancer Res., 55: 5687-5692, 1995). To elucidate the molecular mechanisms underlying this inhibitory effect of VEGF, we attempted to identify a transcription factor involved in the cellular response to VEGF stimulation. We cloned the cDNA of a novel Kruppel-type zinc finger (ZNF) gene, ZK7, from a cDNA library constructed from the human leukemia cell line CMK86 after incubation with VEGF. This cDNA encoded a protein of 289 amino acids, which contained a Kruppel-associated box A-box domain at the NH2 terminus and seven ZNF motifs at the COOH terminus. These ZNF motifs were identical to those of HZF16 (M. Saleh et al., Am. J. Hum. Genet., 52: 192-203, 1993). ZK7 and HZF16 genes appear to be the splice variants transcribed from the same gene. Northern blotting and quantitative reverse transcription-PCR analysis revealed that expression of ZK7 mRNA in CMK86 cells and human hematopoietic progenitor cells was increased after VEGF stimulation, whereas that of HZF16 mRNA remained unchanged. To examine the function of ZK7 protein, we generated clones of a human monocytoid leukemia cell line, U937, which were stably transfected with ZK7 or HZF16 cDNA. Importantly, ZK7-overexpressing cells had lower sensitivity to ionizing radiation and the chemotherapeutic agent etoposide than U937 parent cells or HZF16-overexpressing cells. Therefore, ZK7 protein may be involved in the inhibitory effect of VEGF on apoptotic cell death in human hematopoietic cells.

Effect of long-term treatment with antihypertensive drugs on quality of life of elderly patients with hypertension: a double-blind comparative study between a calcium antagonist and a diuretic. NICS-EH Study Group. National Intervention Cooperative Study in Elderly Hypertensives

We investigated the effect of long-term treatment with a calcium antagonist (nicardipine hydrochloride retard tablet) and a diuretic (trichlormethiazide) on quality of life (QOL) in elderly hypertensives in a multicenter, randomized, double-blind, comparative study (National Intervention Cooperative Study in Elderly Hypertensives Study Group). The percentage of patients who experienced side effects was 17.2% in the nicardipine group and 18.1% in the trichlormethiazide group and 2.9% and 4.3% of participants, respectively, withdrew due to those side effects. These results suggested that nicardipine was tolerated slightly better than trichlormethiazide. There were no significant differences between the two groups in terms of total QOL score or in degree of change (delta score) before and after calcium antagonist or diuretic administration. Lower score was seen in 3 categories (general symptoms, sleep scale, and sexual function) in the trichlormethiazide group (p< 0.05) and in one category (cognitive function) in the nicardipine group, but there was no significant difference in delta score in any of the individual items. In conclusion, the two anti-hypertensive agents had nearly equivalent effects on QOL in the long-term treatment of hypertension in the elderly and that neither resulted in a deterioration in QOL.

Gastric tumor induction by 1,2-dimethylhydrazine in Wistar rats with intestinal metaplasia caused by X-irradiation

Five-week-old male Wistar rats were X-irradiated with a total of 20 Gy in 2 equal fractions at a 3-day interval. 1,2-Dimethylhydrazine (DMH) solution was injected i.m. into the back musculature at a dose of 20 mg/kg body weight weekly for 10 weeks, beginning 20 weeks after the final irradiation. Twelve months after the initial carcinogen treatment, tumors in the fundus of the glandular stomach were observed in 5 of 23 animals receiving both X-irradiation and DMH treatment. No tumors of the glandular stomach were observed in the DMH and X-ray alone or nontreatment groups. It is concluded that the presence of intestinal metaplasia may increase sensitivity to the induction of gastric tumors by carcinogens like DMH.

Influence of concomitant miso or NaCl treatment on induction of gastric tumors by N-methyl-N'-nitro-N-nitrosoguanidine in rats

Six-week old male Sprague-Dawley (CD) rats were treated with 100 ppm N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) for 16 weeks in their drinking water with control, miso or sodium chloride (NaCl) supplemented diets. All animals were autopsied 12 months after the beginning of the MNNG treatment. Despite higher intake of MNNG in the high dose miso and NaCl groups, the total tumor incidences were decreased compared to middle and lowest values. The glandular stomach adenocarcinoma incidences in the 10% and 5% miso groups were significantly decreased as compared to those in the 2.2% or 1.1% NaCl groups, with the same concentration of NaCl.

Vascular endothelial growth factor inhibits apoptotic death in hematopoietic cells after exposure to chemotherapeutic drugs by inducing MCL1 acting as an antiapoptotic factor

We reported previously that vascular endothelial growth factor (VEGF) inhibits the apoptotic death of hematopoietic cells that is induced by exposure to ionizing radiation (O. Katoh et al., Cancer Res., 55: 5687-5692, 1995). In this study, we show that VEGF also inhibits apoptotic cell death that is induced by exposure to the chemotherapeutic drugs etoposide and doxorubicin. To elucidate the molecular mechanisms underlying this inhibitory effect of VEGF, we examined expression levels of BCL2 family proteins in CMK86, a human leukemia cell line, after treatment with VEGF. Northern blotting and immunoblotting analyses revealed that the expression level of MCL1, a member of the BCL2 family, was increased by VEGF. Moreover, to examine the effects of MCL1 on apoptotic cell death induced by exposure to etoposide, we generated a clonal U937 myeloid leukemia cell line transfected with vectors that promoted the constitutive expression of MCL1. MCL1 decreased the caspase 3 activity induced by exposure to etoposide and increased the viability of the transfected cells after etoposide exposure. Therefore, MCL1 may be involved in the inhibitory effect of VEGF on apoptotic cell death.

The Krüppel-type zinc finger family gene, HKR1, is induced in lung cancer by exposure to platinum drugs

To investigate the molecular mechanism associated with the signaling pathway of platinum drug administration, we focused on the C2H2-type zinc finger (ZNF) transcription factor gene family. Here we show cloning of a Krüppel-type ZNF gene, HKR1, which contains Krüppel-associated box (KRAB) domain and ZNF motifs. We found that mRNA expression of the HKR1 gene was induced in lung-cancer cell lines by exposure to cisplatin using Northern blot analysis. Moreover, we also found that HKR1 mRNA expression levels in lung cancers were higher than those in normal lung tissues, and that high expression levels in lung cancers were associated with antemortem platinum drug administration. These results suggest that HKR1 may be associated with the regulation of a signaling pathway involved in the progression of lung cancer or the acquisition of resistance to platinum drugs.

Induction of ovarian tumors by heavy ion irradiation in B6C3F1 mice

Six-week-old B6C3F1 mice were exposed to 0.439 Gy heavy ion irradiation as a 290 MeV/u carbon-ion beam (LET 10 keV/micron) at 2 cm from the upper proximal point of a spread Bragg beam and autopsied 13.5 months after the irradiation. In males total tumor incidences, mainly liver tumors, were 37.0% in irradiated group and 25.0% in control (P>0.05). In females the total tumor incidences were 32.3%, mainly ovarian tumors, in the irradiated group and 0% in the controls. These results indicate that heavy ion irradiation induces ovarian tumors in females but does not target any organ in males.

No susceptibility of colon tissue implanted into the glandular stomach of rats to N-nitroso-N-methylurea carcinogenesis

The present study was undertaken to determine the response of colonic mucosa implanted into the stomach fundus in 6-week-old male F344 rats to oral administration of N-nitroso-N-methylurea (MNU). In graft + MNU, 15% animals had tumors in the implanted colon tissue whereas a 26% incidence of gastric tumors was observed for the pyloric mucosa. In MNU alone, 30% of rats demonstrated gastric tumors. In graft alone 10% of tumors were observed in the grafted site but none in the pylorus. Thus while graft tissue may intrinsically have an elevated risk of tumor development, no susceptibility to MNU was observed in the present study.

Effects of azoxymethane on X-ray induced intestinal metaplasia in Donryu rats

The present study was undertaken to determine the effect of azoxymethane (AOM) administration on intestinal metaplasia induced by X-irradiation in male Donryu rats. Five-week-old animals were X-irradiated with two doses of 10 Gy each at a 3-day interval or three X-ray doses of 10 Gy at a 2-day interval and then received AOM injections i.m. at a dose of 15 mg/kg body weight once weekly for 3 weeks, 6 months after irradiation. Alkaline phosphatase positive foci were decreased after AOM treatments, but aberrant crypt like-foci appeared within areas of intestinal metaplasia. In contrast no induction was observed in normal-appearing gastric mucosa.

Hepatitis C virus infection in acquired aplastic anemia

Hepatitis-associated aplastic anemia (HAAA) is an uncommon disorder that usually is not due to hepatitis A or B virus infection. Hepatitis C virus (HCV) seropositivity is infrequently observed in aplastic anemia (AA) patients who have not been extensively transfused. However, HCV seropositivity may not be detected until several weeks or months after viral infection and AA patients may exhibit defective humoral immunity. Therefore, we evaluated sera from AA patients for the presence of HCV viremia using a reverse transcriptase polymerase chain reaction (RT-PCR) based assay and several serologic assays for HCV antibodies. Serum samples from 90 AA patients who presented to the UCLA Medical Center between March 1984 and February 1990 were analyzed. Overall, 17 patients were found to have HCV viremia by RT-PCR assay, of whom 14 had a positive second-generation HCV enzyme immunoassay (EIA-2) and only 6 were EIA-1 reactive. The frequency of HCV viremia increased with the duration of time between diagnosis and sample procurement, and the number of blood products transfused prior to sampling (P = 0.026). No patient who received fewer than 20 U of blood products or who was sampled less than 20 days after diagnosis had a positive HCV RT-PCR result. Of four patients with hepatitis-associated AA (HAAA), one who was sampled 23 days after diagnosis had hepatitis C viremia and a reactive EIA-2 assay. Therefore, the high frequency of HCV viremia in this patient population is most likely due to transfusion with contaminated blood products prior to the introduction of routine blood donor screening for HCV.

The effects of dilution on the outcome of pooled plasma testing with HIV type 1 (HIV-1) RNA genome amplification as compared to the outcome of individual-unit testing with other HIV-1 markers

BACKGROUND

Proposed testing of large plasma pools with genome amplification technology (GAT) for detection of transfusion-transmissible viruses may have unanticipated complications not associated with individual unit testing. One such potential complication, the effect of dilution resulting from pool formation, was the subject of the present study.

STUDY DESIGN AND METHODS

Specimens from three plasma donor HIV type 1 (HIV-1) seroconversion panels were tested with a quantitative HIV-1 RNA GAT assay (lower detection limit, 400 copies). GAT results were compared to HIV-1 p24 antigen and anti-HIV-1/2 enzyme immunoassay results. Effects of dilution on the detection of GAT-positive panel specimens were assessed by terminal dilution with pooled volunteer-donor EDTA plasma samples.

RESULTS

Low HIV-1 RNA copy numbers (755 and 890 copies/0.1-mL input) that were detectable in two individual plasma specimens before HIV-1 p24 antigen were subsequently undetectable by GAT upon dilution with an equal volume of nonreactive plasma from a single donor. HIV-1 RNA at higher copy numbers (15,500 copies/0.1-mL input) in an HIV-1 p24 antigen-reactive and anti-HIV-1/2-nonreactive specimen was undetectable when diluted to 1-in-50 (1-in-50). Terminal dilution of seven HIV-1 RNA-containing plasma panel specimens indicated a proportional loss of HIV-1 RNA detectability with increasing dilution.

CONCLUSION

GAT for detection of HIV-1 RNA in individual specimens was more sensitive than other HIV markers. For pooled plasma testing, GAT-independent constraints, such as effects of dilution, may preclude the use of GAT detection as a replacement for individual unit testing with HIV serologic assays.

Cell kinetics of hemopoietic colony-forming units in spleen (CFU-S) in young and old mice

The growth potential of the hemopoietic progenitor cells from young and old mice is similar. Previous studies of their cell-kinetics showed no significant differences between them when measured by the incorporation of tritiated thymidine ([3H]TdR). A different approach for exploring stem-cell kinetics in aged animals is provided by another method; the incorporation of bromodeoxyuridine (BrdUrd) during DNA synthesis followed by exposure to near-ultraviolet light (near-UV) kills BrdUrd labelled cells in DNA-synthesis (S-phase). This BrdUrd-near UV cytocide (BUUV) reveals the size of cycling fractions at the level of hemopoietic progenitor cells; it also demonstrates the velocity of the cells entering S-phase when cells are labeled by a continuous infusion of BrdUrd by an osmotic pump, followed by an appropriate colony-assay for each progenitor cell. We compared the cell kinetics of young and old hemopoietic progenitor cells (CFU-S) by this approach. Osmotic pumps were implanted subcutaneously in the backs of young (2 months) and old (22 months) male C57BL/6CrSlc mice for 2, 4, 8, 12, and 16 days to continuously infuse BrdUrd at a flow-rate of 1 mg/h per kg. Cells were harvested from femoral marrow of the infused mice, plated in non-coated bacterial plates, and exposed to a single dose of near-UV at 4000 J/m2. After BUUV cytocide, bone-marrow cells were assayed for 8- and 13-day CFU-S colonies. In the 8-day colonies, the cytocide fraction of CFU-S from young mice increased rapidly, whereas the fraction from old mice showed flatter curves. Both curves reached a plateau at 52.6% for young, and 43.9% for old mice, and then converged 4 days after labeling. In the 13-day colonies, the curve for the aged was much flatter than that for the young; however, the plateaus in both young and old are similar, but at much lower values than earlier, i.e. 24.5% and 16.0%, respectively. The size of the cycling fraction of progenitor cells was close in the two groups during the steady-state cell-cycle. However, the velocity of the cell cycle at a progenitor level was very different, old mice being much slower. Further, within the progenitors, the cell cycle was much slower in the primitive ones and became faster when the stem cells differentiated into mature progenitor cells.

[Acquired pure red cell aplasia associated with relapsed non-Hodgkin's lymphoma: a case report-improvement of PRCA after acute hepatitis]

A 47-year-old male patient was admitted because of anemia. He had been diagnosed as non-Hodgkin's lymphoma (Follicular mixed, B cell type, stage ISA) by splenectomy two years before. Bone marrow examination on admission revealed lymphoma cell infiltration and marked decrease in erythroid cells. These findings confirmed relapsed lymphoma with acquired pure red cell aplasia. After several courses of combination chemotherapy, lymphoma cells disappeared from bone marrow, but PRCA was not improved. In this case there were two times remission of PRCA. At first time, acute B type hepatitis occurred during the chemotherapy, anemia improved transiently. At the second time, mild acute hepatitis associated with herpes zoster occurred. Twenty days after hepatic injury, PRCA was improved, and continued in remission state till present day. To disclose the mechanism of PRCA in this case, erythroid colony assay of marrow cells was performed. This showed the presence of inhibitory factor in patient's serum at PRCA state, that was considered to be related to the occurrence of PRCA. These findings suggest that the improvement of PRCA was associated with the changes on immunological condition after acute hepatitis in this case.

An approach for acute disruption of large arteries in patients with advanced cervical cancer: endoluminal balloon occlusion technique

OBJECTIVE

To test the feasibility of an intraluminal balloon occlusion technique for the control of sudden arterial disruption from cervical branches in patients with advanced malignancy.

BACKGROUND

A sudden disruption of large cervical arteries is a devastating complication of advanced cervical malignancy and local infection.

METHODS

Three patients with this complication underwent endoluminal balloon occlusion before surgical management. A double-lumen balloon catheter was introduced from the femoral artery to the bleeding point. Angiographic examination of the intracranial cross-filling could be performed by the injection of contrast medium from the opposite carotid artery, and consciousness levels could be directly confirmed under unilateral carotid occlusion.

RESULTS

Resection of the carotid or innominate artery was safely performed in all the patients. No neurologic complications occurred. Bleeding did not recur during follow-up (range 5-32 months).

CONCLUSIONS

This experience, although limited, suggests that surgical intervention to control cervical arterial bleeding with intraluminal balloon occlusion prevents excessive bleeding, decreases the risk of damage to the central nervous system, and improves the outcome in these critically ill patients.