Antinociceptive potentiation and attenuation of tolerance by intrathecal ß-arrestin 2 small interfering RNA in rats.

BACKGROUND: Tolerance to the analgesic effect of opioids complicates the management of persistent pain states. We tested whether the intrathecal infusion of small interfering RNA (siRNA) against ß-arrestin 2 would reduce tolerance to chronic morphine use and the severity of precipitated morphine withdrawal. METHODS: Intrathecal ß-arrestin 2 (2 µg siRNA per 10 µl per rat) was injected once daily for 3 days. Rats then received a continuous intrathecal infusion of morphine (2 nmol h⁻¹) or saline for 7 days. Daily tail-flick (TF) and intrathecal morphine challenge tests were performed to assess the effect of intrathecal ß-arrestin 2 siRNA on antinociception and tolerance to morphine. Naloxone withdrawal (2 mg kg⁻¹) was performed to assess morphine dependence. RESULTS: In the daily TF test, the antinociception of intrathecal morphine was increased and maintained in rats receiving ß-arrestin 2 siRNA compared with the control group (morphine alone). In the probe response test, rats receiving morphine infusion with ß-arrestin 2 siRNA treatment showed a significant left shift in their dose-response curve, as measured by per cent maximal possible effect (MPE), such that the AD50 was significantly decreased by a factor of 5.6 when compared with that of morphine-infused rats. In the naloxone-induced withdrawal tests, rats receiving ß-arrestin 2 siRNA injection with morphine infusion showed a significant reduction in four of the six signs of withdrawal. CONCLUSIONS: We show here that intrathecal ß-arrestin 2 siRNA in rats enhances analgesia and attenuates naloxone-induced withdrawal symptoms. This may warrant further investigation in the context of long-term use of intrathecal opioids for controlling chronic pain.

Retroperitoneal ectopic pancreas: imaging findings.

Ectopic pancreas is relatively uncommon and usually occurs in the stomach or duodenum. Retroperitoneal ectopic pancreas has not previously been documented. We report the case of a 48-year-old man with retroperitoneal ectopic pancreas that imitated bilateral adrenal tumours on ultrasound and MRI. Subsequent CT-guided biopsies confirmed an ectopic pancreas. The lesions remained stable during follow-up for 7 years. In retrospect, the similarity in signal intensities and enhancement pattern between the retroperitoneal masses and the pancreas may have been a clue to the diagnosis of this rare entity.

Development of malignant lymphoma subsequent to breast cancer.

The development of malignant lymphoma following breast cancer has not been described before. Here we report the development of malignant lymphoma at the ipsilateral chest wall subsequent to the surgical treatment of breast cancer. A 48-year-old woman underwent modified radical mastectomy due to breast carcinoma. Tamoxifen (10 mg twice daily) was given 3 years after the operation and continued for about 3 years. The patient was well until she recently (17 years after the initial operation) noted a small lump at her left anterior chest wall near the axilla. The local tumour mass was initially assumed to be a local recurrent lesion of breast cancer. Excisional biopsy was performed and eventually was histologically diagnosed to be malignant lymphoma. In view of the therapeutic implication, the development of second malignancy should not be mistaken as a progression of the known primary malignancy. Only with the awareness of such entity, can the prompt diagnosis and proper treatment be achieved.

Serum levels of soluble E-selectin in women with breast cancer.

BACKGROUND: Increasing evidence suggests that E-selectin contributes to tumour growth and metastasis, possibly by increasing angiogenesis and the adhesion of tumour cells to endothelial cells at distant sites. This study aimed to examine the relationship between preoperative levels of circulating soluble E-selectin and breast cancer. METHODS: Sixty-four consecutive women undergoing surgery for invasive breast cancer were studied prospectively. Venous blood samples were collected before the operation. A control group consisted of 16 patients with a benign breast tumour (eight with fibrocystic disease and eight with fibroadenoma). Serum concentrations of soluble E-selectin were measured by the quantitative sandwich enzyme immunoassay technique and compared with clinicopathological information. RESULTS: The mean (s.d.) serum level of soluble E-selectin in patients with invasive breast cancer was 73.7 (20.9) ng/ml, compared with 36.3 (5.6) ng/ml in the control group (P < 0.001). Furthermore, the serum levels of soluble E-selectin were significantly higher in women with oestrogen receptor-negative tumours (P = 0.001), poorly differentiated tumours (P < 0.001), more advanced primary tumour stage (P < 0.001), involved lymph nodes (P < 0.001), distant metastases (P < 0.001) and more advanced tumour node metastasis (TNM) stage (P < 0.001). On multivariate analysis, TNM stage (P < 0.001) was found to be an independent factor with regard to higher serum levels of soluble E-selectin. CONCLUSION: Preoperative serum levels of soluble E-selectin might reflect the severity of invasive breast cancer; further evaluation is warranted.

Temporal and spatial expression of bone morphogenetic proteins in extracorporeal shock wave-promoted healing of segmental defect.

Extracorporeal shock wave (ESW) is a noninvasive acoustic wave, which has recently been demonstrated to promote bone repair. The actual healing mechanism triggered by ESW has not yet been identified. Bone morphogenetic proteins (BMP) have been implicated as playing an important role in bone development and fracture healing. In this study, we aimed to examine the involvement of BMP-2, BMP-3, BMP-4, and BMP-7 expression in ESW promotion of fracture healing. Rats with a 5-mm segmental femoral defect were given ESW treatment using 500 impulses at 0.16 mJ/mm(2). Femurs and calluses were subjected to immunohistochemistry and RT-PCR assay 1, 2, 4, and 8 weeks after treatment. Histological observation demonstrated that fractured femurs received ESW treatment underwent intensive mesenchymal cell aggregation, hypertrophic chondrogenesis, and endochondral/intramembrane ossification, resulting in the healing of segmental defect. Aggregated mesenchymal cells at the defect, chondrocytes at the hypertrophic cartilage, and osteoblasts adjunct to newly formed woven bone showed intensive proliferating cell nuclear antigen expression. ESW treatment significantly promoted BMP-2, BMP-3, BMP-4, and BMP-7 mRNA expression of callus as determined by RT-PCR, and BMP immunoreactivity appeared throughout the bone regeneration period. Mesenchymal cells and immature chondrocytes showed intensive BMP-2, BMP-3, and BMP-4 immunoreactivity. BMP-7 expression was evident on osteoblasts located at endochondral ossification junction. Our findings suggest that BMP play an important role in signaling ESW-activated cell proliferation and bone regeneration of segmental defect.

Muscle force, motor nerve conduction velocity and compound muscle action potentials after parathyroidectomy for secondary hyperparathyroidism.

OBJECTIVE: We studied the motor nerve conduction velocity (MNCV) and the amplitude of compound muscle action potentials (CMAP) in patients with symptomatic secondary hyperparathyroidism at preoperative and 3 months post-operative period, to find the factors affecting muscle force after parathyroidectomy. METHODS: Twenty-six patients with symptomatic secondary hyperparathyroidism with levels of intact parathyroid hormone (iPTH) over 6.8 pmol/l who underwent total parathyroidectomy and autotransplantation of 60 mg of tissue were included in this research. Extension force of the quadriceps muscle was measured at 60 degrees of right knee flexion and expressed as Newtons (N) in peak force and average force. Nerve conduction studies of four limbs were checked and the MNCV and CMAP of right femoral and tibial nerves were analyzed and correlated with the muscle force. RESULTS: Three months after operation, the peak force increased from 272 +/-108 to 315 +/- 123 N (P=0.015) and the average force from 215 +/- 94 to 253 +/- 103 N (P=0.006). MNCV and latencies of femoral and tibial nerves did not show definite change, but the amplitude of CMAP increased significantly from 7.1 +/- 4.1 to 10.7 +/- 3.2 mV (P=0.005) at femoral stimulation and from 9.8 +/- 4.6 to 11.7 +/- 4.3 (P=0.007) and 13.2 +/- 5.9 to 14.9 +/- 6.0 (P=0.011) at proximal and distal tibial stimulation. CONCLUSION: The improvement of muscle force after surgery was found to be parallel to the increment of the amplitude of CMAP but not to nerve conduction velocity or latency. We propose that the weakness of the patients with secondary hyperparathyroidism is probably related to alteration of muscle fiber contraction.

Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta1.

Extracorporeal shock-wave (ESW) treatment has been shown to be effective in promoting the healing of fractures. We aimed to determine whether ESW could enhance the growth of bone-marrow osteoprogenitor cells. We applied ESW to the left femur of rats 10 mm above the knee at 0.16 mJ/mm2 in a range of between 250 and 2000 impulses. Bone-marrow cells were harvested after ESW for one day and subjected to assessment of colony-forming unit (CFU) granulocytes, monocytes, erythocytes, megakaryocytes (CFU-Mix), CFU-stromal cells (CFU-S) and CFU-osteoprogenitors (CFU-O). We found that the mean value for the CFU-O colonies after treatment with 500 impulses of ESW was 168.2 CFU-O/well (SEM 11.3) compared with 88.2 CFU-O/well (SEM 7.2) in the control group. By contrast, ESW treatment did not affect haematopoiesis as shown by the CFU-Mix (p = 0.557). Treatment with 250 and 500 impulses promoted CFU-O, but not CFU-Mix formations whereas treatment with more than 750 impulses had an inhibiting effect. Treatment with 500 impulses also enhanced the activity of bone alkaline phosphatase in the subculture of CFU-O (p<0.01), indicating a selective promotion of growth of osteoprogenitor cells. Similarly, formation of bone nodules in the long-term culture of bone-marrow osteoprogenitor cells was also significantly enhanced by ESW treatment with 500 impulses. The mean production of TGF-beta1 was 610 pg/ml (SEM 84.6) in culture supernatants from ESW-treated rats compared with 283 pg/ml (SEM 36.8) in the control group. Our findings suggest that optimal treatment with ESW could enhance rat bone-marrow stromal growth and differentiation towards osteoprogenitors presumably by induction of TGF-beta1.

Improvement of sexual function in male patients after parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: Clinically, the severity of uremia is known to be inversely proportional to sexual desire and activity in patients with chronic renal failure. We studied sexual function and sex hormones in male patients with symptomatic hyperparathyroidism before and 3 months after parathyroidectomy. STUDY DESIGN: From October 1998 to December 2000, 20 male patients with symptomatic secondary hyperparathyroidism were enrolled in this study. They underwent total parathyridectomy and autotransplantation of 90 mg of tissue to the subcutaneous tissue of the forearm or thigh. They all had regular sexual partners and were sexually active. Preoperatively, hemoglobin, hematocrit, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), prolactin, testosterone, leutenizing hormone (LH), and follicle stimulation hormone (FSH) were checked routinely. Three months after operation those data were checked again. Sexual function was evaluated with the International Index of Erectile Function (IIEF). Monthly frequency of attempted sexual intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse were individually analyzed preoperatively and 3 months postoperatively. RESULTS: Hemoglobin, hematocrit, testosterone, and LH were noted to have not significantly changed 3 months after surgery. Serum levels of calcium, phosphorus, alkaline phosphatase, FSH, and iPTH were significantly reduced, as were the levels of prolactin. But preoperative and postoperative FSH levels were within normal limits, and 70% of the postoperative alkaline phosphatase levels were above normal. Sexual function increased significantly 3 months after parathyroidectomy, as did monthly frequency of attempted intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse. CONCLUSIONS: Sexual function of male patients with symptomatic hyperparathyroidism can possibly be improved by parathyroidectomy and autotransplantation. Decreases in the levels of prolactin, calcium, phosphorus, and iPTH are also noticed after parathyroidectomy.

Progesterone receptor in patients with hepatolithiasis.

Altered gallbladder motility by progesterone has been recognized as an important factor in the development of gallstones. There are two types of hepatolithiasis, that occurs de novo in the intrahepatic ducts with an intact gallbladder (primary hepatolithiasis) and that which originates in the gallbladder and the stones migrate into the intrahepatic duct (secondary hepatolithiasis). This study was designed to evaluate the possible role of the progesterone receptor of gallbladder in the pathogenesis of hepatolithiasis. Eighty-four patients with hepatolithiasis (34 patients had primary hepatolithiasis and the other 50 patients secondary hepatolithiasis) were included. Paraffin-embedded specimens of gallbladder were processed to have an immunohistochemical staining for progesterone receptor. Positivity for progesterone receptor of gallbladder specimens was noted in eight patients (23.5%) with primary hepatolithiasis and in 23 patients (46%) with secondary hepatolithiasis. There is significant difference (P = 0.031) in positive rate for progesterone receptor between the primary hepatolithiasis and secondary hepatolithiasis groups. In conclusion, many more patients (46%) with secondary hepatolithiasis show positivity for progesterone receptor of gallbladder specimens than patients with primary hepatolithiasis (23.5%) (P = 0.031). This phenomenon is intriguing and should be of further evaluation and elucidated.

Serum levels of matrix metalloproteinase 2 in patients with breast cancer.

Matrix metalloproteinases (MMPs) have been reported to be associated with invasive and metastatic behaviors of human malignant tumors. However, there is still limited knowledge about the role of matrix metalloproteinases-2 (MMP-2) in breast cancer. This study was designed with the aim to elucidate the possible relationship between the preoperative circulating MMP-2 and breast cancer. Fifty-seven consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. Venous blood samples were collected before the surgery. Sera were obtained by centrifugation, and stored at -70 degrees C until assayed. The control group consisted of 12 patients with benign breast tumor (six with fibrocystic disease and six with fibroadenoma). Serum concentrations of MMP-2 were measured by the quantitative sandwich enzyme immunoassay technique. The data on primary tumor stage, age, estrogen receptor, lymph node status, and TNM staging were reviewed and recorded. The mean value of serum MMP-2 in patients with invasive breast cancer was 694.3+/-140.5 ng/ml and those of control group were 593.3+/-134.0 ng/ml and the difference was significant (P=0.026). Furthermore, there were significantly higher serum levels of MMP-2 in the patients with more advanced primary tumor staging (P=0.005), in the patients with more advanced lymph node status(P=0.011) and in the patients with more advanced TNM staging (P<0.001). In multivariate analysis, TNM staging (P<0.001) appeared as independent factor regarding the significant higher serum levels of MMP-2. Patients with more advanced TNM staging were shown to have higher serum MMP-2 levels. Thus preoperative serum MMP-2 levels might reflect the severity of invasive breast cancer and deserve further evaluation.

Computed tomography and angiography in hepatic tuberculosis mimicking liver tumor.

Tuberculosis is one of the most common and well-documented infectious diseases, with a vast variety of clinical manifestations. A case of isolated hepatic tuberculosis mimicking liver tumor is presented. The patient was a 44-year-old man who had suffered from intermittent epigastralgia for about 2 years. Abdominal computed tomography demonstrated a low density mass with internal calcification over the left lobe of the liver. Celiac angiography showed encasement of the hepatic propia and occlusion of the left hepatic artery. Abnormal tortuous vascular structures were found at the hepatic hilar region. The patient underwent surgical intervention under the impression of left liver tumor. Microscopically, the resected liver tissue specimen revealed tuberculosis.

Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism.

HYPOTHESIS: The recovery of osteoporosis or bone mineral density (BMD) after parathyroidectomy and autotransplantation can be improved in patients with symptomatic secondary hyperparathyroidism. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Forty-five patients with symptomatic secondary hyperparathyroidism who underwent total parathyroidectomy and autotransplantation were included. They were divided into an osteoporotic group (n = 20) and a nonosteoporotic group (n = 25) according to preoperative T scores less than -2.5 at either the lumbar spine (L1-L4) or the femoral neck (FN). INTERVENTIONS: Serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were checked before surgery and 1 day, 1 week, and 3 months after surgery. The BMDs of the FN and L1-L4 were measured using dual-energy x-ray absorptiometry before surgery and 6 months after surgery. RESULTS: Patients with osteoporosis were older (mean +/- SD, 50.2 +/- 14.0 years) than those without osteoporosis (42.7 +/- 9.1 years) (P =.04). Except for bone fractures found in 2 women in the osteoporotic group, there were no significant differences between the 2 groups in sex, clinical manifestations, duration of dialysis, weight of removed parathyroid tissue, and types of dialysis. Also, serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were similar in both groups. Both 1 day and 1 week after total parathyroidectomy and autotransplantation, serum levels of calcium and intact parathyroid hormone decreased rapidly and then gradually increased 3 months later; however, serum levels of alkaline phosphatase increased rapidly and then gradually decreased 3 months later. Six months after parathyroidectomy, BMD, T score, and Z score at L1-L4 and the FN increased significantly (P<.001). The increment was much better in the osteoporotic group than in the nonosteoporotic group (P<.001). Also, osteopenia or osteoporosis improved significantly after parathyroidectomy at both L1-L4 and the FN (P<.001 for both). CONCLUSION: Parathyroidectomy and autotransplantation can improve BMD of symptomatic secondary hyperparathyroidism at L1-L4 and the FN.

Serum levels of transforming growth factor beta1 in patients with breast cancer.

HYPOTHESIS: Transforming growth factor beta1 (TGF-beta1) may be related to breast cancer progression. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Sixty consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. The control group consisted of 14 patients with benign breast tumors (7 with fibrocystic disease and 7 with fibroadenoma). INTERVENTION: Venous blood samples were collected before the surgery. Sera were obtained by centrifugation and stored at -70 degrees C until assayed. Serum concentrations of TGF-beta1 were measured by quantitative sandwich enzyme immunoassay. Data on primary tumor stage, age, estrogen receptor status, lymph node status, distant metastases, and TNM staging (according to the Union Internationale Contre le Cancer) were reviewed and recorded. MAIN OUTCOME MEASURES: Measurements of preoperative serum TGF-beta1 levels in patients with breast cancer. RESULTS: The mean +/- SD value of serum TGF-beta1 in patients with invasive breast cancer was 498.7 +/- 249.7 pg/mL and in the control group was 495.2 +/- 225.5 pg/mL (P =.96). However, there were significantly higher serum levels of TGF-beta1 in patients with more advanced lymph node status (P =.04), more advanced TNM stage (P =.005), and poorer histological grade (P =.02). In multivariate analysis, TNM staging (P =.02) was demonstrated to be the independent factor related to significantly higher serum levels of TGF-beta1. CONCLUSIONS: Patients with more advanced TNM stages were shown to have higher serum TGF-beta1 levels. Thus, serum TGF-beta1 levels may reflect the severity of invasive breast cancer.

Paget disease of the breast--an easily overlooked disease?

BACKGROUND AND OBJECTIVES: Paget disease of the breast has long been recognized as a distinct clinical disease. The clinical manifestations and outcomes of Paget disease of the breast were reviewed to understand its earlier diagnostic clues and achieve an optimal treatment plan. Patients and Methods Thirty-one patients with Paget disease of the breast were included in this study. The postoperative outcomes and possible related prognostic factors were reviewed and analyzed. RESULTS: The 5-year overall survival was 69%. Nineteen patients (61%, Group A) did not have a palpable breast mass and 12 patients (39%, Group B) had a palpable breast mass. There was significant difference (P < 0.01) in the 5-year overall survival between Group A (94%) and Group B (19%). Group A patients had significantly higher incidences of underlying noninvasive breast carcinoma (73% vs. 8%, P < 0.01) and n0 lymph nodes status (84%vs. 50%, P = 0.043) than those of Group B. CONCLUSIONS: Paget disease of the breast without a palpable breast mass carries a more favorable prognosis. Patients with any nipple complaints deserve a detailed evaluation even in the absence of a palpable breast mass in order not to overlook a favorable disease.

Total pelvic exenteration for primary local advanced colorectal cancer.

Total pelvic exenteration (TPE) is an ultraradical operative procedure for locally advanced pelvic tumors with high morbidity and mortality rates. We retrospectively reviewed the results of TPE for primary locally advanced colorectal cancer in terms of mortality, morbidity, and long-term survival. Of 2952 patients with colorectal cancer, 50 underwent TPE for primary locally advanced colorectal cancer between 1986 and 1995. There was one operative death (2%). The other 49 cases were entered into a retrospective study. Thirty-two cases (65%) showed involvement of one or more adjacent organs. Thirty-one patients (97%) had urologic organs invaded by tumor. The overall 5-year survival rate was 49% and the overall morbidity was 37%. The survival rate for stage II was 62%, and that for stage III was 35%; there was no survival in stage IV. Early morbidity was noted in 24% of patients; late morbidity, in 15%. TNM stage appeared to be the only independent factor for survival (p = 0.022). Our study showed that TPE can be performed with relatively low operative mortality and acceptable morbidity. With thorough preoperative evaluation and adequate surgical dissection, satisfactory outcomes for a primary locally advanced colorectal cancer can be achieved, especially at the earlier stages.

Synchronous and "early" metachronous colorectal adenocarcinoma: analysis of prognosis and current trends.

PURPOSE: We evaluated the accuracy of preoperative diagnostic examinations and determined whether patients with synchronous colorectal cancers differ from patients with a single colorectal malignancy in clinicopathologic factors, the possibility of early metachronous colorectal cancer, and postoperative outcome. METHODS: A retrospective evaluation of 1,780 patients with primary colorectal adenocarcinoma from 1987 to 1993 was performed. We divided patients into three groups: Group 1, single colorectal adenocarcinoma; Group 2, synchronous colorectal adenocarcinoma; and Group 3, early metachronous colorectal adenocarcinoma. RESULTS: There were 52 cases (3 percent) in Group 2 and 13 cases (1 percent) in Group 3 (<3 years from the index colorectal cancer operation). Differences in age, gender, and cancer-free rate among the three groups did not reached statistical significance. Compared with cancers in Group 1, significantly more proximal tumor locations and early cancer stage were noted for the second and third cancers in Group 2. In Group 3 a significantly more proximal tumor site was noted for the index colorectal cancer but cancer stage showed no significant difference from cancers in Group 1. Better histologic type was also noted in the index and second cancers in Group 2 than in cancers in Group 1. There was a higher incidence of associated benign adenoma in Group 2 (35 vs. 15 percent in Group 1). The positivity rate of Group 2 was significantly higher by preoperative colonoscopy (71 percent) and incidental findings at surgery (58 percent) than barium enema examination (30 percent). CONCLUSION: Preoperative barium enema examination was an unsatisfactory tool for detecting synchronous tumors. Preoperative colonoscopy demonstrated a higher positivity rate, but it still failed to detect nearly 30 percent of cases with synchronous tumors. Intraoperative palpation of the whole colorectum could detect nearly 60 percent of unexpected synchronous tumors. We believe both colonoscopy and intraoperative palpation of the whole colorectum are crucial to the early detection of synchronous colorectal cancer.

Pregnancy complicated by concurrent primary hyperparathyroidism and arrhythmia.

Primary hyperparathyroidism during pregnancy results in a high rate of fetal complications and maternal morbidity. Maternal hypercalcemia in pregnancy results in fetal hypercalcemia, which leads to suppression of fetal parathyroid function. Spontaneous abortion and stillbirth can occur, and the loss of maternal calcium after birth leads to neonatal hypocalcemia. It is essential to detect primary hyperparathyroidism during pregnancy because early diagnosis and management can decrease the rate of fetal and maternal complications. We present the case of a 27-year-old gravida 1, para 0 woman whose pregnancy was complicated by hyperparathyroidism and arrhythmia. The patient complained of dyspnea and palpitations in the seventh and 15th weeks of gestation. Electrocardiography showed ventricular premature contraction bigeminy and trigeminy in association with hypercalcemia (3.3 mmol/L). A parathyroidectomy in the second trimester revealed parathyroid adenoma. Hypercalcemia and arrhythmia resolved completely and the patient delivered a term baby without any maternal or fetal complications. The simultaneous occurrence of arrhythmia with ventricular premature contractions and hyperparathyroidism in pregnancy is rarely reported. Palpitations and dyspnea due to arrhythmia may be associated with primary hyperparathyroidism in pregnancy and should be considered in the differential diagnosis. In the management of symptomatic primary hyperparathyroidism during pregnancy, surgical intervention is preferable in the second trimester when organogenesis is completed and the risk of spontaneous abortion is low.

Treatment of complicated hepatolithiasis with intrahepatic biliary stricture by ductal dilatation and stenting: long-term results.

A group of 190 cases of hepatolithiasis with postoperative residual stones located proximal to the stricture sites were managed with the aim of complete clearance of stones and relief of bile stasis to decrease the potential risk of recurrence. All procedures were performed through a T-tube track with gradual dilatation and stent placement through the stricture sites, creating a channel that allows cholangioscopy and electrohydraulic lithotripsy. Complete clearance of intrahepatic duct (IHD) stones was achieved in 88.4% of cases. Multiple sharply angulated IHD strictures in right-sided hepatolithiasis constituted a major cause of failure. Recurrent stone formation and repeated cholangitis, subsequent drainage, and liver resection are associated with high mortality rates particularly if there is late development of a cholangiocarcinoma. We concluded that postoperative ductal dilatation and stenting through the T-tube track combined with endoscopic electrohydraulic lithotripsy is effective and safe for managing complicated hepatolithiasis. Persistent irreversible aneurysmal dilatation of IHD and atrophic change of the affected hepatic lobe at follow-up were ominous signs of recurrence and cholangiocarcinoma development. Early drainage with stone extraction combined with surgical intervention can prevent subsequent morbidity and mortality.

Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends.

BACKGROUND: In adenocarcinoma of the colon and rectum, obstruction and perforation may occur either alone or together at the site of the neoplasm or proximally. Both events carry a poor prognosis. This retrospective study sought to determine whether a correlation exists between perforation and obstruction, and between these conditions and different clinicopathological factors in colorectal adenocarcinoma. METHODS: The medical records of 1950 patients with colorectal adenocarcinoma treated in our hospital during a 7-year period were retrospectively analyzed. One hundred patients (5%) were excluded from this study because of a loss of follow-up. Data on clinicopathological factors including age, sex, tumor location, surgical mortality, pathological type, stage, and long-time cancer-free rate were simultaneously analyzed. Patients were grouped as follows: Group 1, complete colonic obstruction without perforation (n = 120). Group 2, complete obstruction with perforation at the site of the cancer (n = 35); Group 3, complete obstruction with perforation proximal to the cancer (n = 13); and Group 4, nonobstructing, nonperforated cancers (n = 1682). RESULTS: When compared with Group 4, Group 1 had a more advanced Dukes' stage, older age, greater incidence of colonic versus rectal cancers, and a poorer cancer-free survival (P < or = .005). Groups 2 and 3 had a greater incidence of colonic versus rectal cancers (P < or = .004), and Group 3 had a greater operative mortality (P < .001). No significant differences were found between Groups 1, 2, and 3. Multivariate analysis revealed that the independent factors favorable to cancer-free survival (> 5-year survival) were female gender (P = .035), well-differentiated pathology (P < .001), uncomplicated cases (P = .004), colon versus rectal location (P < .001), and early stage (P < .001). CONCLUSIONS: The perioperative mortality rate for perforated colorectal cancer at the site of the cancer was 9%; for obstructive colorectal cancer, 5%. Perioperative mortality was much greater for perforations of the colon and rectum occurring proximal to the cancer (31%). Survival was worse (P < .001) for patients with obstruction (33%) or perforation proximal to the cancer (33%). The site of perforation did not appear to impact the 5-year survival, although the numbers are relatively small.

A study on pruritus after parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: The effective therapy for uremic pruritus remains a clinical challenge, and the factors affecting the pruritus before and after parathyroidectomy have not been defined. STUDY DESIGN: Thirty-seven patients were operated on for secondary hyperparathyroidism. Their ages ranged from 14 to 73 years, and the duration of dialysis from 12 to as long as 168 months. Indications for surgery were skin itch in 22 patients and other reasons in 15 patients. Serum levels of calcium, phosphorus, intact PTH (i-PTH), and alkaline phosphatase were checked at two different intervals-before surgery and 1 week after operation. Immunohistochemical stain of mast cells, antihuman macrophage (CD68), antihuman dendritic reticulum cell (CD35), and i-PTH (IHPTH) were performed on skin specimens. Skin samples were prepared into tissue homogenates and analyzed for concentrations of interleukin-2 (II-2) and tumor necrosis factor-alpha (TNF-alpha). II-2 and TNF-alpha were measured by sandwich enzyme-linked immunosorbent assay. The extent of pruritus was evaluated on a visual analog scale (VAS) ranging from 0 to 10 and a behavior rating scale (BRS) ranging from 0 to 5, at a preoperative stage and 1 week after operation. RESULTS: Serum levels of calcium, phosphorus, the product of calcium and phosphorous (Ca x P), alkaline phosphatase, and i-PTH changed significantly after parathyroidectomy. The VAS decreased from 5.4 +/- 3.2 to 1.8 +/- 1.5 (p < 0.001). Significant improvement of BRS was achieved 1 week after surgery (p < 0.001), and in the followup period. Before surgery, there was no correlation between serum levels of calcium, phosphorus, Ca x P, alkaline phosphatase, i-PTH, number of mast cells, CD68, CD35, and IHPTH, and the scale of itch estimated with either VAS or BRS. The tissue levels of Il-2 and TNF-alpha were not detectable in any of them. We noted that high levels of phosphorus and Ca x P affected the postoperative extent of pruritus. But a linear regression test showed Ca x P was the only factor affecting postoperative itch. CONCLUSIONS: Pruritus in patients with secondary hyperparathyroidism can be reduced by parathyroidectomy. Apparently, high-level Ca x P is the only factor that seems to affect the postoperative extent of pruritus.