Inguinal hernia repair in patients with artificial urinary sphincter after radical prostatectomy

PURPOSE

Stress urinary incontinence (UI) often develops after radical prostatectomy for prostate cancer, and in those patients with moderate-to-severe stress UI an artificial urinary sphincter (AUS) is implanted. Inguinal hernias (IHs) often occur after radical prostatectomy. As the prevalence of AUS implantation increases, it is possible to encounter patients with IHs undergoing AUS implantation (IHA). This study investigated our treatment and discussed an appropriate approach for IHAs.

METHODS

We retrospectively investigated patients who underwent IH repair with AUS implantation at our hospital from January 2018 to March 2023. We classified IHAs into Types A-D based on the positions of the IHs and AUS devices (the positions of the control pump, pressure-regulating balloon, and connecting tube). The hernia and control pump were ipsilateral in Types A and B, whereas the hernia and pressure-regulating balloon were ipsilateral in Types A and C.

RESULTS

This study included 12 IHs of 11 patients. The median patient age was 77 years. We conducted open repair in nine patients with all types and laparoscopic repair in two patients with Type B. The median operation times for unilateral and bilateral repairs were 96 and 182 min, respectively. There were no complications with AUS or hernia surgeries.

CONCLUSION

IHA has its own characteristics, and multidisciplinary knowledge thereof will help surgeons safely perform IH surgery.

P1958Baseline glycated hemoglobin level was differently associated with long-term prognosis in peripheral artery disease patients with and without hemodialysis

Introduction

Diabetes (DM) is the leading cause of induction of hemodialysis (HD), and both are major prognostic factors in patients with peripheral artery disease (PAD). However, the prognostic importance of baseline glycated hemoglobin (HbA1c) levels in PAD patients with and without HD is yet to be elucidated.

Purpose

We hypothesized that baseline HbA1c levels had different prognostic impacts after endovascular therapy (EVT) in between PAD patients with and those without regular HD.

Methods

This observational study included 643 consecutive patients who received EVT between 2013 and 2017. Each of 313 HD patients and 330 Non-HD patients was respectively divided into 2 groups by the comorbidity of diabetes, and DM patients were further divided into 3 subgroups depending on HbA1c level at the time of EVT; DM-Low (HbA1c: <6.0%), DM-Mid (6.1–7.0%), and DM-High (>7.1%) groups. The primary endpoint of this study was major amputation-free survival (AFS).

Results

HD group included significantly more patients presenting critical limb ischemia than Non-HD group (46.6% vs. 30.0%, p<0.001). During the observation period after EVT, there were 81 events (25.9%), including 55 death and 26 major amputations in HD group, and 45 events (13.6%), including 30 death and 15 major amputations in Non-HD group. Kaplan-Meier analysis revealed that DM patients had a significantly higher AFS rate in HD group (Log-rank: p=0.003, Figure A). In contrast, in Non-HD group, there was no statistical difference in AFS between DM and Non-DM patients (p=0.36). In Cox regression analysis in HD group, the higher HbA1c-DM group showed the higher hazard ratio (HR) for AFS (p=0.039, Figure B), and DM patients with HbA1c >6.0% had significantly higher HR than Non-DM patients. Whereas, in Non-HD group, HbA1c-DM class adversely associated with HR for AFS (p=0.003), even any classes did not reach statistical differences from Non-DM patients.

Figure 1

Conclusions

Comorbidity of diabetes at the time of EVT worsened long-term prognosis in PAD patients receiving regular HD, but not in those without HD. Additionally, baseline HbA1c levels oppositely affected prognosis in PAD patients with and without HD.

Reliability of endoscopic esophageal mucosectomy using TxHood, a multipurpose treatment hood

Endoscopic mucosectomy, comprising both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), is a minimally invasive treatment for patients with early esophageal carcinoma. The use of ESD is appropriate for mucosal lesions of any size. However, ESD techniques are relatively difficult and can lead to serious complications such as perforation and massive bleeding, which have been reported more frequently after ESD than after EMR. This study describes a novel technique for ESD using a newly designed multipurpose treatment hood (TxHood) as well as basic experiments to ensure its safety. The TxHood includes various therapeutic tools such as an electric needleknife, a snare wire, and an injection needle, and the lines can be selected freely before insertion of an enodoscope covered by a TxHood. The main techniques for ESD are endoscopic submucosal saline injections on demand through a working channel of the endoscope or TxHood and a cut or swing cut with a needleknife attached to the TxHood. Moreover, the target area can be grasped with a grasping forceps through a working channel of the endoscope to obtain effective countertraction. In these experiments, an electric needleknife set parallel to the shaft of the endoscope offered safety and ease of handling for the dissecting procedures. Altogether, 16 resections of mucosa with an average size of 3.5 x 2.5 cm (range, 2 x 2 to 7 x 4 cm) were performed. The average time required for each targeted endoscopic resection area was about 15 min. No perforations or instances of uncontrollable bleeding occurred. In conclusion, this basic study demonstrates that the new ESD technique with the TxHood provides a useful treatment for early esophageal carcinoma and may be applicable for all mucosal or submucosal tumors in the gastrointestinal tract.

Older boys benefit from higher initial prednisolone therapy for nephrotic syndrome. The West Japan Cooperative Study of Kidney Disease in Children

BACKGROUND

A long course of the initial prednisolone therapy has been shown to be more effective than standard-course therapy in reducing relapse rates in children with idiopathic nephrotic syndrome, but it is commonly accompanied by corticosteroid toxicities. There has been no study on prednisolone dosage for the effective treatment of nephrotic syndrome.

METHODS

Sixty-eight children (42 boys and 26 girls) with an initial attack of nephrotic syndrome were randomly allocated into two different long-course treatment groups. Patients in Group 1 received a daily prednisolone dose of 60 mg/m2 for six weeks, followed by an alternate-day dose of 40 mg/m2 for six weeks. Patients in Group 2 had a daily dose of 40 mg/m2 instead of 60 mg/m2.

RESULTS

Four children in each group did not respond within six weeks. Group 1 was associated with a significantly earlier response but more frequent corticosteroid toxicities than Group 2. Boys in Group 1 had a higher rate of sustained remission than boys in Group 2 (P = 0.0073), especially boys four years old or more (P = 0.0027), but girls did not show a significant difference (P = 0.863). Boys four years old or more in Group 1 had a course of frequent relapsing less often than those in Group 2 (2 of 13 vs. 6 of 8, P = 0.0075).

CONCLUSION

These findings indicate that efficient prednisolone doses may vary between sexes and ages, and that a higher initial prednisolone therapy may be of greater benefit to older boys.

Clinical application of diadenosine tetraphosphate (Ap4A:F-1500) for controlled hypotension

BACKGROUND

In our animal study, it was revealed that diadenosine tetraphosphate (Ap4A:F-1500) has a dose-dependent hypotension effect of up to 60% decrease in mean arterial pressure compared to control value. Furthermore, in healthy male volunteers, the safety of Ap4A up to 4 mg.min-1 was confirmed. In patients who require surgical procedures under general anesthesia together with controlled hypotension, hypotension was induced by Ap4A in order to examine its hypotensive effect and modulating action on the blood pressure.

METHODS

Ten patients who required controlled hypotension and who were scheduled for elective surgery under general anesthesia were studied. Anesthesia was maintained with isoflurane (n = 7) or sevoflurane (n = 3) in oxygen-nitrous oxide. Controlled hypotension was induced by Ap4A administered at a rate of 10-20 micrograms.kg-1.min-1. The dose was adjusted at a maximum rate of 80 micrograms.kg-1.min-1 until the target blood pressure was achieved. Arterial blood pressure and heart rate were monitored. Arterial samples were drawn at 4 separate time points to measure the concentration of Ap4A in the plasma.

RESULTS

The time required for attaining the target blood pressure after initiation of Ap4A infusion was about 16 min, and the time lapse between withdrawal of infusion to recovery of blood pressure was about 18 min. No reflex tachycardia was observed during infusion of Ap4A and no rebound hypertension was evident after withdrawal. The plasma Ap4A concentration increased in response to the acceleration rate of Ap4A administration with a tendency of augmented hypotensive effect.

CONCLUSION

As it produces an excellent hypotensive effect together with a modulating action on blood pressure, Ap4A was assessed as useful in producing controlled hypotension.

[Two cases of infantile autism with intermittent water intoxication due to compulsive water drinking and episodic release of antidiuretic hormone (SIADH)]

The syndrome of water intoxication, resulting from dilutional hyponatremia and characterized by lethalgy, confusion, seizures, and coma was seen in two autistic boys living in the institution for mentally retarded children. Patient 1, a 19 year-old autistic boy showed loss of attention, inactiveness, sleepiness and delirium and then followed by overbreathing, severe vomiting and finally convulsive seizures several times, or coma, since October 1985. In August 1988, he was admitted with generalized tonic clonic convulsion associated with frequent vomiting EEG showed diffuse spike and wave complex with slow background activity. Laboratory data showed inappropriately high serum ADH level (8.5 pg/ml), low sodium concentration (121 mOsm/m/l), serum osmolality (237 mOsm/l) which was lower than urine osmolality (334 mOsm/l), and remarkable body weight gain (8.5 kg). He was diagnosed as water intoxication due to compulsive water drinking and SIADH. Diminished GH secretion to insulin-induced hypoglycemia and exaggerated prolactin response to LHRH stimulation suggested a hypothalamic lesion. Patient 2, a 17-year-old autistic boy, showed essentially the same symptoms and laboratory data as Patient 1, except that he had no epileptic discharge in EEG, and curious GH response to insulin-induced hypoglycemia. A remarkable daily body weight change suggested excessive water drinking and a possible episodic release of ADH. With mild water restriction, this became smaller. Since Patient 1 had epileptic attacks several times without hyponatremia and his EEG showed epileptic discharges, he was diagnosed as having epilepsy. Patient 2 has been seizure-free until now. Abnormality of hypothalamic or pituitary defects and polydipsia and possibility of water intoxication should always be considered when an autistic patients shows recurrent epileptic attacks or episodic strange behaviors with hyponatremia.

Persistent hypercholesterolaemia in frequently relapsing steroid-responsive nephrotic syndrome

OBJECTIVE

To investigate long-term changes of serum cholesterol levels in children with frequently relapsing steroid-responsive nephrotic syndrome (NS).

METHODOLOGY

Serum cholesterol values just before and during or immediately after 'relapse' were reviewed and the incidence of hypercholesterolaemia (> or = 200 mg/dL) was determined in eight patients (M:F, 6:2).

RESULTS

The patients with frequently relapsing NS usually showed hypercholesterolaemia (mean incidence, 81%) just before 'relapse' during clinical remission, as well as in relapse (mean incidence, 96%). A high incidence of steroid therapy was also found in each case (mean, 89%) just before relapse.

CONCLUSIONS

Our results demonstrate that children with frequently relapsing NS have prolonged periods of hypercholesterolaemia, even during clinical remission. It is suggested that serum lipid profiles be monitored carefully in such patients.

High-performance liquid chromatographic determination of diadenosine 5',5'"-p1,p4-tetraphosphate with precolumn fluorescence derivatization and its application to metabolism study in whole blood

Diadenosine 5',5'"-p1,p4-tetraphosphate (Ap4A) was converted with chloroacetaldehyde to the fluorescent di-1,N6-ethenoadenosine derivative within 60 min at 80 degrees C. It was separated by reversed-phase HPLC and detected fluorimetrically (excitation and emission wavelengths of 275 and 410 nm, respectively). The detection limit of Ap4A was ca. 0.2 microgram/ml in plasma when 10 microliters of the sample was applied to the column. The rate of degradation of Ap4A added to whole blood (5 micrograms/ml) was examined using this method. Half-lives (means +/- S.E., n = 3) were 0.88 +/- 0.30 min (in rat blood), 13.7 +/- 3.6 min (in dog blood) and 17.2 +/- 1.4 min (in human blood). A marked species difference in the degradation rate of Ap4A in blood was observed.

Urinary N-acetyl-beta-D-glucosaminidase excretion in term and preterm neonates

Urinary N-acetyl-beta-D-glucosaminidase (NAG) excretion was measured in term and preterm neonates on days 1, 4, 7, 14 and 28 of life. Urinary NAG showed a peak level on day 4 or 7 in these infants. In addition, it tended to be higher with the degree of prematurity. In sick preterms who were depressed at birth and had respiratory failure, the NAG activity was further elevated during the first 2 weeks, suggesting the presence of renal tubular injury in this period. These observations thus suggest that urinary NAG may be a sensitive measure of renal maturation or damage in neonates.

Renal handling of albumin and beta-2-microglobulin in neonates

Urinary albumin and beta 2-microglobulin (B2M) were measured during the neonatal period. Urinary albumin decreased postnatally in term neonates, while it remained almost constant in preterm neonates. Urinary B2M showed a peak level on day 7 both in term and preterm neonates. There was some trend towards higher levels of albumin and B2M with decreasing gestation, showing that glomerular permeability increases and proximal tubular protein reabsorption decreases with increasing degrees of prematurity. In sick preterms who were depressed at birth and had respiratory failure, both parameters were elevated during the first 2 weeks, indicating the presence of glomerular and tubular damage in this period. The changes in B2M with gestation or clinical condition were more pronounced than those in albumin.

An autopsy case of Binswanger's disease without hypertension and associated with cerebral infarction in the terminal stage

We report here an autopsy case of Binswanger's disease (BD) without hypertension and associated with cerebral infarction in the terminal stage. The female patient, who was 74 years old at the time of death, had initially demonstrated manic-depressive disorder-like mental disorder, followed by dementia and neurological deficits. A brain CT scan showed white matter low attenuation bilaterally and symmetrically. BD was clinically diagnosed despite the lack of hypertension. In the terminal stage, she suffered an infarction in the left anterior cerebral artery region, and died of pneumonia. Neuropathologically, we found the infarction of the left anterior cerebral artery region, demyelination, fibrillary gliosis, lacunae and arteriosclerosis of the small arteries and arterioles in the white matter.

Determination of 14C in microplates by radioluminography

A method alternative to liquid scintillation counting for detecting 14C was developed. The new method involves putting an aqueous radioactive sample onto the flat-bottomed wells of a polystyrene microplate, preparing a pellicle by lyophilization, and determining the radioactivity using radioluminography. It provides a simple, inexpensive, sensitive and reliable technique for determining the radioactivity of a few hundred samples simultaneously.

Evaluation of proximal tubular function in preterm infants by urinary alpha 1-microglobulin

alpha 1-Microglobulin is a low molecular weight protein that is relatively stable in urine of low pH. There have been few reports on urinary alpha 1-microglobulin (U-A1M) excretion in preterm infants. This study was designed to establish the ranges for U-A1M in clinically stable preterm infants and to investigate changes observed in sick preterm infants. We measured U-A1M and urinary beta 2-microglobulin (U-B2M) levels at 1, 4, 7, 14, 28 and 90 days after birth in stable preterm infants (Group 1) and sick preterm infants who were depressed at birth and required immediate resuscitation (Group 2). In Group 1 infants, both parameters were high during the first 28 days and appeared to decline thereafter. U-A1M in Group 2 infants was only significantly increased compared with Group 1 on day 1, as was U-B2M. On each day of the study, U-A1M had significant positive correlations with U-B2M for all the infants studied. The changes of the two parameters observed in Group 1 probably reflect postnatal evolution of proximal tubular function in stable preterm infants. A comparison of groups 1 and 2 shows a high prevalence of acute tubular injury at birth in sick infants and also suggests that U-A1M as well as U-B2M may be a sensitive index for detecting acute tubular damage and for following its course in preterm infants.

Dual-energy X-ray absorptiometry in the lumbar spine, proximal femur and distal radius in children

Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD) in the lumbar spine, proximal femur and distal radius in 48 Japanese children aged 3-18 years. In the normal children (n = 32), BMD increased with age in all locations, with a nearly twofold increase from preschool age to adolescence. Most of the children with chronic diseases known to affect bone metabolism (e.g., steroid osteoporosis) (n = 16) had low BMD in every region, indicating that these disease states probably affect multiple sites of the skeleton in children.

Evaluation of lumbar bone mineral density by dual energy x-ray absorptiometry

Using dual-energy x-ray absorptiometry (DEXA), the lumbar spinal bone mineral density (BMD) in 49 Japanese children with or without metabolic bone disease (MBD) was determined. The following results were obtained: (a) The normal data for healthy Caucasians (J Clin Endocrinol Metab 1990; 70: 1330-1333) appear to be applicable to Japanese children; (b) BMD was normal in patients with congenital hydronephrosis with normal renal function; (c) One patient with congenital renal failure and one with Lowe syndrome had low BMD, but the MBD in the former improved markedly with peritoneal dialysis; (d) A reduced BMD was found in patients treated with long-term steroids, probably because of decreased turnover of bone; (e) A reduction in BMD was pronounced in preterm infants during the first few months of life. In conclusion, DEXA is a useful method of bone densitometry in MBD in children.

Leukotriene B4 production in children with steroid-responsive nephrotic syndrome

Leukotriene B4 (LTB4) production in polymorphonuclear leucocytes (PMN) was examined in ten children with steroid-responsive nephrotic syndrome (SRNS) before, during, and after steroid administration. Comparison of LTB4 production was made in 14 children with non-inflammatory disease who were not receiving steroid therapy. No significant change was noted in PMN LTB4 biosynthesis in children with SRNS throughout any phase of the disease. Furthermore, there was no significant difference in LTB4 biosynthesis in PMN between SRNS patients before steroid therapy and patients with non-inflammatory disease. These findings suggest that inhibition of LTB4 production is not involved in the mechanism underlying steroid action in SRNS.

[MR imaging in infantile spasms]

CT and MRI in 13 patients with infantile spasms were analyzed. Cortical atrophy was found in 8 cases and ventricular dilatation in 9 cases. The patients with severe cortical atrophy or ventricular dilatation had poorer prognosis than the patients with normal CT findings. In addition to cortical atrophy and ventricular dilatation which were shown in CT, MRI revealed poor differentiation of gray and white matters in all cases and periventricular hyperintensity area in 9 patients. Six patients with the periventricular hyperintensity area of grade III and IV had severe developmental delay. With regard to the prognosis, MRI plays a more useful role in detecting intracranial pathology in infantile spasms.

Pre-operative anxiety of recipients and donors in renal transplantation from living relatives

The pre-operative anxiety of recipients and donors was investigated through psychiatric interviews in the case of 27 renal transplants from living relatives. The pairs of recipients and donors were divided into 3 classes, as follows: Group A (n = 8), both stable; Group B (n = 6), recipient anxiety-donor stability; and Group C (n = 13), donor anxiety-recipient stability. The recipients in Group B showed many psychiatric problems in relation to therapists and nursing staff, so that psychiatric consultations were required. For donors in Group C, such consultation was also required.

Septo-optic dysplasia with infantile spasms

A 21-month-old boy with septo-optic dysplasia and infantile spasms is reported. Eighteen hours after birth he had generalized convulsions, dyspnea, and hypoglycemia which were followed by recurrent clonic seizures despite administration of phenobarbital and valproic acid. At 16 months of age he had hypoglycemia and apnea attacks during varicella infection. At 19 months of age left hemiconvulsions and left hemiparesis occurred; his mental and motor development, which had been delayed but progressive, deteriorated. Tonic spasms appeared at 21 months of age and electroencephalography revealed multifocal spikes. At 27 months of age electroencephalography disclosed hypsarrhythmia. Cranial computed tomography depicted brain atrophy, right microphthalmia, and intact septum pellucidum. Magnetic resonance imaging demonstrated hypoplasia of the corpus callosum and a small pituitary gland. Coloboma of the right optic disc was detected. Physical examination revealed short stature, left hemiparesis, micropenis, and cryptorchidism. Endocrinologic loading tests revealed hypofunction of the hypophysial anterior lobe.

Anorexia nervosa precipitated by a prepubertal pyometra

A severe pyometra was found in a typical case of anorexia nervosa, with the latter illness apparently precipitated by the former. Compulsory alimentation before and after operation brought some weight gain as well as reversal of dilated cerebral sulci and hypothyroidism, though hypothalamo-pituitary dysfunction persisted.

Organic acids and branched-chain amino acids in body fluids before and after multiple exchange transfusions in maple syrup urine disease

We successfully treated a critically ill infant with the classical type of maple syrup urine disease by multiple exchange transfusions via a peripheral artery and vein and with positive calorie supplementation in the early stage of therapy. Clinical improvement was definite after the plasma leucine level fell below 1 mmol/l. There was a close linear correlation between plasma concentrations of branched-chain amino acids and their corresponding branched-chain alpha-keto acids and branched-chain alpha-hydroxy acids. alpha-Hydroxy acids were more easily excreted in the urine than alpha-keto acids and amino acids. Our studies on urinary organic acids supported the existence of minor metabolic pathways of branched-chain alpha-keto acids, although they were not thought to be important in eliminating accumulated alpha-keto acids. Urinary excretion of succinic acid and alpha-ketoglutaric acid, which are components of the citric acid cycle, increased transiently during the patient's convalescence. The cerebrospinal fluid/plasma ratios for branched-chain amino acids, alpha-keto acids, and alpha-hydroxy acids were very high before the transfusions and decreased after improvement. The cerebrospinal fluid/plasma ratios for 5-carbon acids, alpha-ketoisovaleric acid and alpha-hydroxyisovaleric acid were much higher than for other branched-chain acids not only in the patient but also in normal controls. Cerebrospinal fluid levels of alpha-ketoisocaproic acid and alpha-hydroxyisovaleric acid were as high as 1 mmol/l in our patient.