Double rule-out technique for evaluation of acute chest pain using 128-row multidetector CT.

AIM: To evaluate the feasibility and image quality of the double rule-out (DRO) technique using 128-row multidetector computed tomography (CT) for simultaneous evaluation of the aorta and coronary arteries in patients with acute non-specific chest pain. MATERIALS AND METHODS: Sixty-eight patients underwent electrocardiography (ECG)-gated coronary CT followed by non-ECG-gated abdominal CT. The contrast-to-noise ratio and signal-to-noise ratio between the vessels and adjacent perivascular fat tissue were calculated for both the aorta and coronary arteries. Dose-length products were recorded. Two blinded readers graded the image quality of the aorta and coronary arteries on a two-point and a four-point scale, respectively. In addition, the severity of coronary stenosis was independently analysed for each coronary vessel. RESULTS: The average attenuation was more than 350 HU for the aorta and >330 HU for the coronary arteries. The average (±standard deviation) volume of contrast media was 69.5 ± 12.5 ml. Interobserver agreement on the image quality of aortic and coronary data sets was perfect and substantial, respectively. There was almost perfect interobserver agreement for the all observations of the severity of coronary stenosis. CONCLUSION: The DRO technique with a standard volume (approximately 70 ml) of contrast media is useful for acute chest pain evaluation in patients suspected of having acute aortic syndrome or acute coronary syndrome. It is also accurate and safe while maintaining the average CT attenuation of the aorta and coronary arteries >330 HU.

Identification of Vortex Cores in Cerebral Aneurysms on 4D Flow MRI.

BACKGROUND AND PURPOSE: The complexity and instability of the vortex flow in aneurysms are factors related to the rupture risk of unruptured cerebral aneurysms. We identified aneurysm vortex cores on 4D flow MR imaging and examined the relationship of these factors with the characteristics of cerebral aneurysms. MATERIALS AND METHODS: We subjected 40 aneurysms (37 unruptured, 3 ruptured) to 4D flow MR imaging. We visualized streamlines with velocities below the threshold-that is, a percentage value of the aneurysm maximum inflow velocity-and progressively decreased the threshold to identify vortex cores as thin, streamline bundles with minimum velocities. Complexity and stability were compared in aneurysms with a smooth surface and those with blebs or daughter sacs. RESULTS: The threshold for visualizing vortex cores ranged from 3% to 13% of the maximum inflow velocity. Vortex cores could be visualized in 38 aneurysms; in 2, they were not visualized through the cardiac cycle. A simple flow pattern (single vortex core) was identified in 27 aneurysms; the other 13 exhibited a complex flow pattern. The cores were stable in 32 and unstable in 8 aneurysms. Significantly more aneurysms with-than-without blebs or daughter sacs had a complex flow pattern (P = .006). Of the 3 ruptured aneurysms, 1 aneurysm had an unstable vortex core; in the other 2, the vortex core was not visualized. CONCLUSIONS: The identification of vortex cores on 4D flow MR imaging may help to stratify the rupture risk of unruptured cerebral aneurysms.

Clinical outcome of endoscopic mucosal resection for esophageal squamous cell cancer invading muscularis mucosa and submucosal layer.

When a tumor invades the muscularis mucosa and submucosal layer (T1a-MM and T1b in Japan), esophageal squamous cell cancer poses 10-50% risk of lymph node metastasis. By this stage of esophageal cancer, surgery, although very invasive, is the standard radical therapy for the patients. Endoscopic mucosal resection (EMR) is the absolutely curable treatment for cancer in the superficial mucosal layer. Because of its minimal invasiveness, the indications of EMR may be expanded to include the treatment of T1a-MM and T1b esophageal carcinoma. To date, the clinical outcomes of EMR for T1a-MM and T1b patients have not been fully elucidated. Here, the retrospective analysis of the clinical outcomes is reported. Between January 1994 and December 2007, 247 patients underwent EMR at Kanagawa Cancer Center. Of these individuals, 44 patients with 44 lesions fulfilled the following criteria: (i) extended EMR treatment for clinical T1a-MM and T1b tumor; (ii) diagnosis of clinical N0M0; and (iii) follow up for at least 1 year, and negative vertical margin. These patients were reviewed for their clinical features and outcomes. Statistical analyses were performed by the Kaplan-Meier methods, the Chi-square test, and the Cox proportional hazard model. P-value of <0.05 was considered statistically significant. The data were analyzed in February 2009. Based on the informed consent and their general health conditions, 44 patients decided the following treatments immediately after the EMR: 2 underwent surgery, 1 underwent adjuvant chemotherapy, and 41 selected follow up without any additional therapy. Of the 41 patients, 20 selected this course by choice, 12 because of severe concurrent diseases, 2 because of poor performance status, and 7 because of other multiple primary cancers. Twelve patients died; two were cause specific (4.5%), eight from multiple primary cancers, one from severe concurrent diseases, and one from unknown causes. No critical complications were noted. Median follow-up time was 51 months (12-126). Five patients ultimately developed lymph node metastasis. One patient with adjuvant chemotherapy required surgery, and another was treated with chemotherapy whose subsequent death was cause specific. The other three patients received chemoradiotherapy and have not shown cause-specific death. Overall and cause-specific survival rates at 5 years were 67.3% and 91.8%, respectively. Among 41 patients treated by EMR alone, only one died from primary esophageal cancer (2.4%), and overall and cause-specific survival rates at 5 years were 75.6% and 97.6%, respectively. Multivariate analysis revealed that severe concurrent diseases including multiple primary cancers and the administration of 5-fluorouracil-based chemotherapy for multiple primary cancers significantly influenced survival (P= 0.025, hazard ratio [HR] 13.1 [95% confidence interval 1.5-114]) and (P= 0.037, HR 0.213 [95% confidence interval 0.05-0.914]), respectively. Eight and six patients developed metachronous esophageal squamous cell cancer and local recurrence, respectively. With the exception of one patient, they could be retreated endoscopically. EMR is a reasonable option for the patients with T1a-MM and T1b esophageal carcinoma without clinical metastasis, especially for the individuals with severe concurrent diseases. The prognostic factors for the benefit of EMR in such cases should be further examined.

Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia.

This study investigates long-term clinical results (> 10 years) of periarterial sympathectomy in chronic ischaemic digits compared with intermediate-term results (3 years). Periarterial sympathectomy via the palm and volar wrist was carried out on 11 hands of seven patients with digital ischaemia but no gangrene or severe ulceration. The aetiology of ischaemia was Buerger's disease in four hands, collagen disease in three hands, and repetitive digital trauma in four hands. Subjective symptoms were evaluated at a mean follow-up period of 12 years. The efficacy of surgery was assessed objectively using thermography and plethysmography. Although five of seven patients continued on oral vasodilators and antiplatelet agents until the final follow-up, improvement of symptoms was maintained in all patients between intermediate- and long-term evaluations. Our results suggest that periarterial sympathectomy via the palm and wrist could prevent long-term aggravation of symptoms of chronic digital ischaemia when combined with adequate postoperative drug therapy.

Clear-cell adenofibroma can be a clonal precursor for clear-cell adenocarcinoma of the ovary: a possible alternative ovarian clear-cell carcinogenic pathway.

Several studies have reported that ovarian clear-cell adenocarcinoma can be derived from endometriosis. Although the clear-cell adenofibroma (CCAF), a major form of benign and borderline ovarian clear-cell tumour, has been suggested as another precursor for clear-cell adenocarcinoma (CCA), there is no supportive genetic evidence for this presumption. To examine the genetic linkage between CCAF and CCA of the ovary, we conducted allelotype analysis for both CCAF and adjacent CCA components in 14 cases of CCA associated with benign CCAF and/or borderline CCAF. DNA isolated from laser-microdissected tissue was subjected to polymerase chain reaction and analysis for loss of heterozygosity (LOH), using 17 polymorphic markers located on 11 chromosomal arms: 1p, 5q, 8p, 9p, 9q, 10q, 11q, 13q, 18q, 19p and 22q. For all informative loci, the frequency of LOH in adenocarcinoma was 49% (54/110 loci), and was significantly higher than those in the components of benign CCAF (22%, 20/92 loci) and borderline CCAF (30%, 25/83 loci) (chi(2) test; p<0.05, respectively). The concordance rate in allelic patterns at all informative loci was 74% between benign CCAF and adenocarcinoma components, 81% between borderline CCAF and adenocarcinoma components, and 95% between benign CCAF and borderline CCAF components. Furthermore, between CCAF and adenocarcinoma components, an identical LOH pattern, involving the same alleles, was found in 13 (93%) of 14 cases at one or more chromosomal loci, and estimation of probability indicated that these events were very unlikely to have occurred by chance. Among the markers examined, LOHs on 5q, 10q and 22q were frequent in both CCAF and adenocarcinoma components, whereas LOHs on 1p and 13q were rare in CCAF components but frequent in adenocarcinoma components. These findings suggest that CCAF can be a clonal precursor for ovarian clear-cell adenocarcinoma.

Prognostic analysis of pulmonary adenocarcinoma subclassification with special consideration of papillary and bronchioloalveolar types.

AIMS: The third edition of the World Health Organization (WHO) classification of lung tumours has been published and is expected to become the standard nomenclature. The aim of this study was to assess the usability and prognostic significance of the WHO classification in comparison with other recent classifications. METHODS AND RESULTS: One hundred and forty-seven resected pulmonary adenocarcinoma cases were reviewed and histologically classified according to the WHO classification (1999) and the classification by Noguchi (1995). Papillary carcinomas as described by Silver and Askin (1997) were also identified. Since the papillary type in the WHO classification is not strictly defined, we compared the following two kinds of WHO classification: (i) WHO-N; WHO classification adopting Noguchi Type F as the definition of the papillary type, namely, pure papillary adenocarcinoma without a bronchioloalveolar component; (ii) WHO-SA; WHO classification adopting papillary carcinoma by Silver and Askin as the definition of the papillary type, namely, tumour with papillary structure constituting at least 75% of the lesion. The bronchioloalveolar carcinoma of the WHO classification showed a better prognosis than other subtypes in both overall and Stage I disease limited survival analysis. In analysis limited to Stage III disease, only the papillary type of WHO-SA showed a significantly worse prognosis. CONCLUSIONS: WHO-SA is recommended for prognostic correlation.

The proximal form of mural thrombus in aortoiliac occlusive disease using computed tomography.

BACKGROUND: It is important to know the nature of proximal thrombus in patients with aortoiliac occlusive disease (AIOD) when juxtarenal aortic clamping is scheduled. This study was aimed to evaluate the shape and nature of thrombi at several sites of the abdominal aorta in patients with AIOD using enhanced computed tomography (CT). Final judgment was made according to the operative findings. METHODS: Between the years 1999 and 2001, 22 patients, who underwent aortobifemoral bypass, were enrolled. The shape and nature of their thrombi were examined at 4 points (superior mesenteric, suprarenal, juxtarenal and infrarenal arteries at the level of the 2 cm before the renal artery) and 88 slices of CT were examined retrospectively. RESULTS: There was mural thrombus in 31 slices, which could be classified into 4 shapes (crescent-shaped: 10 cases; magatama: 2; wavy: 12; circular: 6). The wavy and circular shaped thrombi were found to be atheromatous. Nine cases (40.9%) on operative findings were atheroma (wavy: 4; circular shaped: 5). The crescent shape might correspond to fibrin thrombus. Atheromatous thrombus clamping near the renal artery was thought to cause microthromboembolism to surrounding organs. CONCLUSIONS: It is recommended that the more proximal aorta or splanchnic arteries should be temporarily clamped during proximal procedures in patients with wavy or circular shaped thrombi at the juxtarenal aorta to prevent kidney or bowel infarction.

Lipoprotein analysis using agarose gel electrophoresis and differential staining of lipids.

We established a strategy to directly measure cholesterol and triglyceride levels of each lipoprotein fraction using a combination of agarose gel electrophoresis and differential staining. The cholesterol and triglyceride levels determined by electrophoresis correlated significantly with those of ultracentrifugation. The correlation coefficients between these methods were, for cholesterol levels 0.975(very low density lipoproteins, VLDL), 0.986(low density lipoproteins, LDL) and 0.965(high density lipoproteins, HDL) and for triglyceride levels 0.994(VLDL), 0.963(LDL) and 0.959(HDL) respectively. Both intra-and inter-assays showed low values of coefficients of variation (CV) (less than 3.57%). We observed a strong linearity between staining and triglyceride concentration. An increased VLDL-cholesterol was observed in type III subjects, a result which enabled distinction between type III and type IIb or type V lipoproteinemia. The method revealed lipoprotein patterns in some samples otherwise unexpected from their corresponding serum lipid parameters. Analyses of these electrophoretic patterns thus provide an effective technique to classify types of hyperlipidemia defined by the WHO. Furthermore, quantitative measurement of chylomicrons, usually difficult, proved to be achievable, providing an additional analysis of postprandial hyperlipidemia and the exact measurement of LDL-cholesterol after diet. Consequently, we recommend this simple and easy method for clinical evaluation of abnormalities in lipoprotein profiles.

Expression of L-type amino acid transporter 1 in a rat model of liver metastasis: positive correlation with tumor size.

The purpose of this study was to examine whether L-type amino acid transporter 1 (LAT1), one of the amino acid transporters, is related closely to tumor size in liver metastasis. Rat colon cancer cells (RCN-9) were injected into the capsule of the spleen of 12 male rats (inbred F344/DuCrj). Conversely, four rats received only phosphate-buffered saline (control group 1), and four rats underwent only laparotomy (control group 2). In each rat, the metastatic tumors, areas surrounding tumor nodules, or the livers of the control groups were immunostained with the antibodies to LAT1 C peptide antigen. In control groups 1 and 2, normal hepatocytes did not indicate a staining of LAT1. A total of 90 metastatic nodules were found in 12 livers with metastasis. Of the 90 metastatic nodules, 43 nodules indicated a positive staining of LAT1. Conversely, the remaining 47 metastatic nodules had a negative staining of LAT1. The average size in metastatic nodules in the group with positive staining of LAT1 was 1.6 +/- 0.4 mm2, which was significantly higher than that of the group with negative staining of LAT1 (0.6 +/- 0.2 mm2; P = .0007). The ratio of the average area of the metastatic nodule against the average largest section of the left lobe of the lateral segment (RML, %) was measured. The RML in the group with positive staining of LAT1 was 1.2 +/- 0.3%, whereas the RML in the group with negative staining of LAT1 was 0.4 +/- 0.1%. A significant difference was noted between the two groups (P = .0004). We concluded that LAT1 plays an important role in tumor cell growth of liver metastatic tumors.

Primary osteogenic sarcoma of a finger proximal phalanx: a case report and literature review.

Osteogenic sarcoma of the small bones of the hand is rare with only 15 cases documented. We describe a 12-year-old boy with an osteogenic sarcoma of the proximal phalanx of the middle finger. Wide excision in the form of ray amputation with a wide surgical margin was performed after neoadjuvant chemotherapy consisting of combined high-dose methotrexate, doxorubicin, ifosfamide, and cisplatin. To restore maximum function the index ray was transferred to the base of the third metacarpal. Adjuvant chemotherapy was administered subsequently. At 28-month follow-up evaluation there was no evidence of local recurrence of disease or distant metastasis and both function and appearance were good.

Clinical treatment reverses attentional deficits in congestive heart failure.

BACKGROUND: Congestive heart failure (CHF) is associated with cognitive deficits, particularly of memory and attention. The present study aims to clarify whether clinical treatment can reverse the attentional deficits of patients with CHF. METHODS: A convenience sample of 50 patients with CHF functional class IV and 30 elderly controls were recruited from a teaching hospital in Brazil. Participants received a clinical and cognitive examination that included the Mini-Mental State Examination (MMSE), Cambridge Cognitive Examination of the Elderly (CAMCOG), Digit Span, Digit-Symbol Substitution, and Letter Cancellation test. The cognitive performance of CHF patients was reassessed 6 weeks after the introduction of clinical treatment. RESULTS: Twenty-seven CHF subjects had MMSE<24, compared to only 10 of the controls (p = 0.07). CHF patients also had lower CAMCOG scores (mean = 71.8) than controls (mean = 82.0; p < 0.01). Digit Span, Digit Symbol and Letter Cancellation scores were lower for patients with CHF than controls (p < 0.01). Similarly patients with CHF took longer to complete the Trail Making A (p = 0.07) and B (p < 0.01). CAMCOG scores and left ventricular ejection fraction were moderately correlated (rho = 0.4, p < 0.01). Nineteen patients were lost for follow-up (11 deceased). Clinical treatment was associated with significant improvement of cognitive scores, particularly on the Digit Symbol (p < 0.01) and Letter Cancellation Tests (p < 0.01). Digit Span, Digit Symbol, Letter Cancellation and Trail Making scores of treated CHF patients and controls were similar (p > 0.10). CONCLUSIONS: CHF is associated with deficits in attention and psychomotor speed. These deficits improve with clinical treatment.

Clinical application of the reversed pedicled venous flap containing perivenous areolar tissue and/or nerve in the hand.

A reversed pedicled venous flap containing perivenous areolar tissue and/or nerve was used to cover traumatic skin defects of seven fingers in six patients. The series consisted of six men, ranging in age from 20 to 57 years (average: 39 years). The reconstructed sites were four dorsal skin defects and three volar skin defects of the finger. The flap was designed on the dorsum of the hand, in such a way as to place a vein at the centre of the flap and not to involve the dorsal metacarpal artery. The flap contained a dorsal vein, perivenous areolar tissue and fascia of the interosseous muscle. Cutaneous nerves were present in three of the seven flaps. The pedicle of the flap was dissected distally to the finger web space and the flap was transferred to the skin defect. The size of the flap ranged from 1.4x4.5 cm to 6.0x7.0 cm. The average length of the pedicle was 1.6 cm. Skin grafting was needed at the donor site in one case (flap size: 6.0x7.0 cm), but primary closure was possible in the remaining cases. Postoperatively, the largest flap showed superficial necrosis, although it survived. The remaining flaps survived completely. This suggests that in a large flap the skin should be attached to the pedicle to prevent congestion. The flap can be elevated without reference to the dorsal metacarpal artery at the ulnar side of the dorsum of the hand. The flap is an effective option to reconstruct skin defects of the finger, especially the little finger.

An experience of stereotactic radiation therapy for primary intracranial choriocarcinoma.

We report on a patient with choriocarcinoma in the pineal region who was successfully treated with stereotactic radiation therapy (SRT). The increased level of serum human chorionic gonadotropin (HCG) was lowered during chemotherapy with etoposide, cisplatin, and ifosfamide. However, HCG was not normalized and magnetic resonance images still showed an enhanced tumor mass with gadolinium. The patient underwent SRT of 40 Gy at an 80% isodose line per 10 fractions over two weeks, followed by conventional craniospinal irradiation of 32.4 Gy. The level of HCG dropped below the detection limit. The patient has been in good condition for more than four years after the completion of treatment, without any signs of recurrence. We propose SRT as a valid treatment option for malignant germ cell tumors in the pineal region.

Viability of ischemia/reperfused muscles in rat: a new evaluation method by RNA degradation.

The rat's skeletal muscle viability was evaluated using the muscle viability index (MVI) which reflects the mRNA degradation. To evaluate ischemic injury of the muscle, 24 hind limbs of Fischer rats (three subgroups of eight rats each) were preserved at normothermia for 1, 3 and 6 h and then tibialis anterior muscle was harvested. To investigate ischemia/reperfusion injury, another 48 limbs were transplanted to recipient Fischer rats after the ischemia at normothermia for 1, 3 and 6 h, respectively. The transplanted muscles were harvested on day 3 and day 7 after transplantation. Eight fresh muscles were also harvested and used as control. Total RNA isolated from each muscle was fractionated by electrophoresis and hybridized with 32P-labelled cDNA of GAPDH, and the radioactivity of intact and degraded GAPDH mRNA was measured. MVI was calculated as follows, MVI = [X/(X + Y)] x 100, where X and Y represent the radioactivities corresponding to intact GAPDH and degraded GAPDH mRNA band, respectively. In 1-h ischemia group, the MVI indices of both ischemic insult and ischemia/reperfusion group were comparable to control. In the 3-h ischemia group, the index of ischemia/reperfused group was comparable to control although the index of ischemic insult group was significantly lower than control. However, in the 6-h ischemia group, both indices of ischemic insult and ischemia/reperfusion group were significantly lower than control. These results show that the muscle damage was detected in ischemia at normothermia even after 3 h. However, this damage was overcome by reperfusion. There was no recovery from damage in muscles that had been preserved for more than 6 h which had resulted in irreversible degeneration. Therefore, in clinical muscle transplantation, one has to transplant the muscle at least within 3-h ischemia.

Evaluation of the longitudinal arch of the foot with hallux valgus using a newly developed two-dimensional coordinate system.

The purposes of the present study were to establish a method for the evaluation of the longitudinal arch, using a two-dimensional coordinate system, and to clarify the main point of flattening of the foot in patients with hallux valgus. Measurements on a weight-bearing lateral radiograph of the foot were performed in 186 feet of 110 women with symptomatic hallux valgus and in 93 normal feet of 72 women. A two-dimensional coordinate system was used to perform the measurements. In this coordinate system, the line connecting the lowest point of the first metatarsal head and the lowest point (O) of the calcaneus is fixed as the x-axis, and the line that is perpendicular to the x-axis and intersects the x-axis at point O is fixed as the y-axis. The mean values of the y-coordinates at the points of the medial longitudinal arch of the foot in the patients with hallux valgus were significantly lower than those in the normal subjects (P < 0.001). The values were noticeably lower at points on the navicular. However, no change was observed in the posterior talus body. The new coordinate system indicated that the main points of flattening of the foot in patients with hallux valgus were the plantar flexion of the talus and the sinking of the navicular.

Congestive heart failure and cognitive functioning amongst older adults.

BACKGROUND: Congestive heart failure is associated with decline in quality of life and, possibly, cognitive functions such as memory and attention. AIMS: The present study was designed to investigate the presence of cognitive impairment amongst patients with congestive heart failure (CHF). We hypothesised that CHF patients would have lower scores than elderly controls on general measures of cognitive functioning. METHODS AND RESULTS: We examined a sample of 50 consecutive patients admitted to hospital with CHF functional class III/IV and a convenience sample of 30 older adults assessed at the outpatient service of geriatric medicine of a teaching hospital in São Paulo, Brazil. All subjects were interviewed with the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX), as well as the neuropsychological battery of the CAMDEX (CAMCOG), Mini-Mental State Examination (MMSE), Trail Making A and B, Digit Span, Digit Symbol, and Letter Cancellation Test. All CHF patients had left ventricular ejection fraction (EF) below 45% and all controls above 65%. The cognitive performance of CHF patients was significantly worse than controls for all cognitive assessments. Twenty-seven of 50 CHF patients had a MMSE total score lower than 24, compared with only 10/30 controls (p=0.073). Similarly, 36/49 and 9/30 CHF subjects and controls respectively had CAMCOG scores below 80 (p<0.001). Cognitive scores were significantly associated with EF, which was the most robust predictor of cognitive impairment according to the CAMCOG in a logistic regression model. CONCLUSION: Our results indicate that CHF is associated with significant levels of cognitive impairment and show that mental performance is, at least partly, a consequence of EF. Physicians should be prepared to assess the mental state of patients, as poor cognitive functioning may interfere with treatment compliance and management plan.