Endoscopic mucosal resection and endoscopic submucosal dissection for en bloc resection of superficial pharyngeal carcinomas.

BACKGROUND AND STUDY AIM: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are being used increasingly to treat superficial oropharyngeal and hypopharyngeal carcinomas. The aim of this study was to clarify whether ESD provided better results than EMR for en bloc and complete resection of superficial pharyngeal carcinomas. PATIENTS AND METHODS: A total of 76 superficial pharyngeal carcinomas in 59 consecutively treated patients were included. Patients underwent either conventional EMR (using a transparent cap or strip biopsy) (n = 45 lesions) or ESD (n = 31 lesions) between October 2006 and January 2011. The rates of en bloc resection, complete resection (defined as en bloc resection with tumor-free margins), major complications, and local recurrence were evaluated retrospectively as the therapeutic outcomes. RESULTS: ESD yielded significantly higher rates of both en bloc and complete resection compared with EMR (en bloc 77.4 % [24/31] vs. 37.8 % [17/45], P = 0.0002; complete 54.8 % [17/31] vs. 28.9 % [13/45], P = 0.0379). ESD was more frequently complicated by severe laryngeal edema (4/21 [19.0 %] vs. 1/31 [3.2 %], P = 0.1446) and was also more time-consuming (124.9 ± 65.1 minutes vs. 57.2 ± 69.6 minutes; P = 0.0014). Local recurrence was observed more often after EMR than after ESD (3/45 [6.7 %] vs. 0/31 [0 %]), although this difference did not reach statistical significance (P = 0.2658). CONCLUSIONS: ESD appears to be a superior method of endoscopic resection of superficial pharyngeal carcinomas for achieving both en bloc and complete resection, although these benefits were also associated with a higher incidence of complications and a significantly longer procedure time. Large prospective studies are needed to compare ESD with conventional EMR for superficial pharyngeal carcinomas.

A prolonged course of Group A streptococcus-associated nephritis: a mild case of dense deposit disease (DDD)?

We herein report the case of a 12-year-old boy with dense deposit disease (DDD) evoked by streptococcal infection. He had been diagnosed to have asymptomatic hematuria syndrome at the age of 6 during school screening. At 12 years of age, he was found to have macrohematuria and overt proteinuria with hypocomplementemia 2 months after streptococcal pharyngitis. Renal biopsy showed endocapillary proliferative glomerulonephritis with double contours of the glomerular basement membrane. Hypocomplementemia and proteinuria were sustained for over 8 weeks. He was suspected to have dense deposit disease due to intramembranous deposits in the first and the second biopsies. 1 month after treatment with methylprednisolone pulse therapy, proteinuria decreased to a normal level. Microscopic hematuria disappeared 2 years later, but mild hypocomplementemia persisted for more than 7 years. Nephritis-associated plasmin receptor (NAPlr), a nephritic antigen for acute poststreptococcal glomerulonephritis, was found to be positive in the glomeruli for more than 8 weeks. DDD is suggested to be caused by dysgeneration of the alternative pathway due to C3NeF and impaired Factor H activity. A persistent deposition of NAPlr might be one of the factors which lead to complement dysgeneration. A close relationship was suggested to exist between the streptococcal infection and dense deposit disease in this case.

Fabrication of SrGe2 thin films on Ge (100), (110), and (111) substrates.

Semiconductor strontium digermanide (SrGe2) has a large absorption coefficient in the near-infrared light region and is expected to be useful for multijunction solar cells. This study firstly demonstrates the formation of SrGe2 thin films via a reactive deposition epitaxy on Ge substrates. The growth morphology of SrGe2 dramatically changed depending on the growth temperature (300-700 °C) and the crystal orientation of the Ge substrate. We succeeded in obtaining single-oriented SrGe2 using a Ge (110) substrate at 500 °C. Development on Si or glass substrates will lead to the application of SrGe2 to high-efficiency thin-film solar cells.

Streptococcal origin of a case of Henoch-Schoenlein purpura nephritis.

We report the case of a 25-year-old man with abdominal pain, purpura on the legs and proteinuria occurring 2 weeks after acute tonsillitis, and admitted to our hospital with suspected Henoch-Schönlein purpura nephritis (HSPN). He had increased anti-streptolysin O (ASO) titer and hypocomplementemia. A renal biopsy specimen showed endocapillary proliferative changes, which are typical of acute poststreptococcal glomerulonephritis (APSGN). However, immunofluorescence study revealed predominant IgA and C3 deposits in mesangial lesions, indicating a diagnosis of HSPN. Because of massive proteinuria initially, the treatment with a combination of prednisolone, cyclophosphamide, dipyridamole and warfarin was started along with 3 plasma exchanges. Angiotensin-converting enzyme inhibitor was also given. Response to the treatment was favorable. A follow-up biopsy was performed 8 months after the first biopsy. The renal biopsy specimen showed a figure of typical HSPN. To further investigate the cause of glomerular changes in our patient, an immunofluorescent study of nephritogenic nephritis-associated plasmin receptor (NAPlr) of group A, beta-hemolytic streptococci was performed. NAPlr was significantly positive in the glomeruli in the first biopsy specimen, but not in the second. His clinical course and pathological findings suggest that NAPlr may be related to the pathogenesis in a part of patients with HSPN, especially in patients with high ASO titer and hypocomplementemia.

Coffee drinking and serum gamma-glutamyltransferase: an extended study of Self-Defense Officials of Japan.

PURPOSE: To examine the effect of coffee drinking on serum gamma-glutamyltransferase (GGT) level in relation to alcohol drinking, smoking, and degree of obesity in middle-aged Japanese men. METHODS: From 1986 to 1994, a total of 7,637 male officials of the Self-Defense Forces of Japan aged 48-59 years received a preretirement health examination. Coffee drinking was ascertained by a self-administered questionnaire, and serum GGT level was measured. After excluding 1,360 men with a possible pathologic condition influencing liver enzyme levels and 182 former alcohol drinkers, effect of coffee drinking on serum GGT was examined by a multiple linear regression model and analysis of variance adjusting for alcohol drinking, smoking, and body mass index (BMI). RESULTS: The adjusted percentage of difference in serum GGT was -4.3 (95% CI = -5.0; -3.5) per cup of coffee. The inverse coffee-GGT relation was most prominent among men drinking > or = 30 ml of ethanol and smoking > or = 15 cigarettes daily; and positive associations of alcohol and smoking with GGT were attenuated by coffee drinking, more clearly among men with BMI > or = 25.00 kg/m2. Adjusted percentages of difference in serum GGT were -2.6% (p = 0.0003) per cup of brewed coffee, and -5.1% (p = 0.0001) per cup of instant coffee, independently of each other. CONCLUSIONS: The present study suggests that coffee consumption may weaken GGT-induction by alcohol, and possibly by smoking. These effect modifications by coffee may differ according to the degree of obesity.

Involvement of neutrophil elastase in crescentic glomerulonephritis.

To elucidate the role of neutrophils in the tissue damage of crescentic glomerulonephritis (GN), we examined neutrophils infiltrated in renal tissues and the localization of neutrophil elastase (NE), as a neutrophil-derived tissue destructive mediator, using an immunohistochemical technique with antibodies specific for neutrophils and neutrophil elastase; the enzyme histochemical technique (chloroesterase staining) also was used to detect neutrophils. In normal controls, neutrophil infiltration was scarce, and NE was localized in neutrophil cytoplasm. Neutrophils were abundant in crescentic GN and infiltrated in the glomerulus and interstitium; the infiltrating neutrophils were often aggregated. NE was localized in the cytoplasm of neutrophils and also appeared extracellularly (in granular or diffuse patterns) in glomerular necrotizing lesions, crescents, ruptured portions of Bowman's capsules, and in periglomerular and perivascular sites of the interstitium. Moreover, urinary concentration of NE measured by enzyme-linked immunosorbent assay (ELISA) in crescentic GN patients was significantly higher than in normals (93.6 +/- 13.3 v 1.4 +/- 0.5 microg/g x Cr, respectively; P < .001). These data suggest that NE plays a significant role in renal tissue damage, especially in the formation of glomerular necrotizing and crescentic lesions and in periglomerular interstitial lesions of crescentic GN.

Coffee consumption and serum aminotransferases in middle-aged Japanese men.

We investigated the relation between coffee drinking and serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations among 7313 Japanese men receiving a health examination, excluding former alcohol drinkers and men with a history of chronic liver disease. Serum AST > 40 and/or ALT > 40 U/L was defined as liver inflammation. Adjustment was made for alcohol use, smoking, body mass index, serum marker for hepatitis virus infection, and other possible confounders. Adjusted odds ratios of liver inflammation were 1.00 (reference), 0.80, 0.69, and 0.61 for men drinking < 1, 1-2, 3-4, and > or = 5 cups of coffee daily, respectively. Among 6898 men without liver inflammation, serum AST and ALT were inversely associated with coffee consumption, and alcohol-related rise in AST was attenuated with coffee drinking. These findings suggest coffee may have an effect of suppressing the rise of serum aminotransferase, partly by inhibiting the alcohol-related elevation. Studies regarding biological mechanism are warranted.

Urinary type IV collagen as a marker for early diabetic nephropathy.

We investigated the urinary secretion of type IV collagen in 115 subjects with non-insulin-dependent diabetes mellitus (NIDDM) without macroproteinuria, 34 normal healthy subjects and 19 subjects with chronic glomerulonephritis (CGN). We examined the relation between the urinary level of type IV collagen and various clinical parameters. The urinary level of type IV collagen was significantly elevated in NIDDM subjects compared with normal subjects (4.88 +/- 3.12 vs. 1.7 +/- 1.25 micrograms/gCr, P < 0.001). The urinary level of type IV collagen was increased even in NIDDM subjects with normoalbuminuria. The ratio of urinary type IV collagen was significantly lower in subjects with chronic glomerulonephritis (CGN) than those in NIDDM subjects (P < 0.001), although there was no significant difference in the urinary level of type IV collagen between NIDDM and CGN subjects. The ratio of urinary type IV collagen to albumin was under 10.0 x 10(-6) in all subjects with CGN. Our results suggest that measurement of the urinary level of type IV collagen is useful for detection of early diabetic nephropathy and for the differential diagnosis of diabetic nephropathy and chronic glomerulonephritis.

Glomerular lesions in patients with Churg-Strauss syndrome and the anti-myeloperoxidase antibody.

We report here 4 patients with Churg-Strauss syndrome (CSS) who had classic symptoms including a history of bronchial asthma, severe eosinophilia and necrotizing vasculitis. The antineutrophil antibody (ANCA) against myeloperoxidase (MPO) titers was elevated (44-877 ELISA units), but the ANCA against proteinase-3 (PR3) was negative in all patients. One case was complicated with systemic inflammatory response syndrome (SIRS) and required plasmapheresis and continuous hemodiafiltration. One other patient clinically showed rapidly progressive glomerulonephritis and had hemodialysis 24 times. Two of 4 patients showed good responses with corticosteroid therapy alone, while 2 patients required the addition of cyclophosphamide. Urinary abnormalities such as proteinuria or microscopic hematuria were found in all patients. Three patients had a decreased glomerular filtration rate (GFR) and renal biopsy specimens obtained from these patients showed crescentic glomerulonephritis. One patient had mild to moderate mesangial-proliferative glomerulonephritis with interstitial eosinophilic infiltration. These findings suggest that renal involvements in CSS may not be as uncommon a disorder as previously considered, especially when MPO-ANCA is positive. MPO-ANCA may be associated with the onset of glomerular disorders in CSS.

Studies of glomerular permeability factor (GPF) in focal segmental glomerular sclerosis and the relationship between GPF and vascular permeability factor (VPF).

BACKGROUND: We previously demonstrated that the supernatants of cultured concanavalin-A (con-A) stimulated peripheral blood mononuclear cells (PBMC) from patients with minimal change nephrotic syndrome (MCNS) increased the urinary protein excretion in injected rats and suggested that PBMC released a factor, which we called glomerular permeability factor (GPF), changes in the glomerular permeability and thus resulted in proteinuria in MCNS. MATERIAL AND METHODS: In this study we investigated the GPF activity in focal segmental glomerular sclerosis (FGS) and other conditions of chronic glomerulonephritis (CGN), and also the relationship between GPF and vascular permeability factor (VPF). In experiment 1 the supernatants of the cultured con-A stimulated PBMC from patients with 10 FGS, 5 other CGN and 10 controls were tested regarding their ability to produce GPE The GPF activity was defined as positive when the 8-hour urinary protein excretion after the injection of the supernatant in Sprague-Dawley rats exceeded the mean value plus 2 standard deviations (M + 2 SD) of that before injection. RESULTS: Three out of 10 FGS patients and 1 membranous nephropathy patient out of the 5 other CGN patients were positive for GPF activity. In experiment 2 the relationship between GPF and VPF was analyzed using culture supernatants of PBMC from 10 nephrotic MCNS patients and 15 controls. The VPF activity was measured following the method developed by Ovary [1975]. All 7 cases that were positive for GPF activity were simultaneously positive for VPF activity. On the other hand, 16 cases that were positive for VPF activity were not always positive for GPF activity (7 cases were positive and 9 were negative for VPF activity). CONCLUSION: Experiments 1 and 2 thus suggested that GPF was not active in MCNS alone, but also in other CGN conditions and it was therefore not considered to be the same factor/substance(s) as VPF.

Impaired T-lymphocyte colony formation in lipoid nephrosis.

The T-colony-forming capacity was examined in 13 normal subjects and 14 patients with biopsy-proven lipoid nephrosis (LN). Eighteen additional patients with other well-defined forms of glomerulonephritis were studied as a disease control. Significantly fewer T lymphocyte colonies were found in LN patients and the nephrotic syndrome (NS) than in normal controls. A similar change could be observed in the groups with other types of NS. LN patients with NS had the lowest values of T-colony-forming cells (TCFC), but there was no statistically significant difference between the groups of nephrotic subjects. It was also of interest that peripheral blood lymphocytes (PBL) from 3 patients with lupus nephritis (SLE) produced significantly low levels of TCFC. The lower levels of TCFC in LN could be enhanced when exogenous interleukin 2 (IL 2) was added to the system. We also examined the production of T-colony-stimulating factor (TCSF). The TCSF production by stimulated PBL from LN patients was lower than in normal subjects. To explain our observations, we presumed that the T colony dysfunction seen in LN patients with NS might in part be due to the decreased TCSF activity.

A case report of mixed P- and C-ANCA positive patients with pauci-immune crescentic glomerulonephritis.

We describe 2 patients with pauci-immune crescentic glomerulonephritis and elevated titers of perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibody (P-ANCA and C-ANCA) which were associated with both 29 and 59 kD bands on Western blots. The presence of C-ANCA corresponds with a clinical and/or histological diagnosis of Wegener's granulomatosis, but although both patients suffered from pulmonary complications there was no clinical nor histological evidence of granulomatosis. Transbronchial lung biopsy showed only interstitial pneumonia and old hemorrhage. Therefore, the patients' conditions were interpreted as microscopic polyarteritis nodosa or hitherto undefined vasculitis associated with ANCA.

ANCA associated vasculitis allergica cutis (VAC) and mild proliferative necrotizing glomerulonephritis.

We report here the case of a 69-year-old male with vasculitis allergica cutis (VAC) accompanied by a nephrotic syndrome associated with serum perinuclear-staining anti-neutrophil cytoplasmic antibody (P-ANCA). Renal biopsy specimens showed mild proliferative glomerulonephritis with crescentic and necrotizing lesion in the glomeruli, while lesional skin biopsy specimens showed leukocytoclastic vasculitis in the deep dermis. Pauci-immune deposits were evident (deposits of immunoglobulins and complements were absent) by immunofluorescence microscopy in both tissues. The appearance of weakly positive P-ANCA associated with skin lesions and renal dysfunction occurred twice in this patient. Following corticosteroid administration, renal dysfunction was remarkably diminished and proteinuria decreased. P-ANCA titer were decreased, reaching the normal level. ANCA associated glomerulonephritis complicated by VAC has not been reported previously. In the present case, the vasculitis cutis and glomerulonephritis is assumed to be associated with the appearance of weakly positive P-ANCA.

Hemolytic uremic syndrome without hemolytic anemia: a case report.

Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. Most cases of HUS are caused by E. coli O157:H7 verotoxin. In the case reported here, diarrhea continued for twenty days after an E. coli 0157:H7 infection and was followed by acute renal failure and thrombocytopenia. Examination of percutaneous renal biopsy tissue showed typical HUS findings, e.g., mesangiolysis in glomeruli and thickening of capillary walls with prominent double outlines, but there was no indication of hemolytic anemia. LDH and haptoglobin, indications of hemolytic anemia, were in the normal range throughout the patient's clinical course. The patient's red blood cells had P1 antigen, which reportedly provides protection by adsorption of toxin into the red blood cells thereby preventing or limiting toxic damage to other organs. Therefore, we assumed that because of the expression of P1 antigen in this patient, the kidneys were not severely damaged and microangiopathic hemolytic anemia was thereby avoided.

Subclinical Fabry's disease occurring in the context of IgA nephropathy.

A 28-year-old male patient with both IgA nephropathy and an unusual case of Fabry's disease has been followed for 10 years. Diagnosis of both these diseases was made by histological examination of renal biopsy tissues and the enzyme activities of alpha-galactosidase A. Serial biopsies revealed the hithertofore unrecognized process of glomerular glycolipid accumulation peculiar to Fabry's disease at the initial stages of the disease. Physical examinations and routine laboratory analyses failed to show significant signs of Fabry's disease throughout the 10-year period. While alpha-galactosidase A activity is markedly decreased in the plasma of this patient as in classical Fabry hemizygotes, the activity in leukocytes and culture fibroblasts showed a considerable residual activity. Fabry's disease associated with IgA nephropathy apparently is extremely rare, and the present subclinical case is unique in that the early stages of substrate accumulation are demonstrable.

Asymptomatic acute poststreptococcal glomerulonephritis following upper respiratory tract infections caused by Group A streptococci.

During an observation period of 1-2 years in 2 different districts in Japan, 104 patients were found to have upper respiratory infections caused by group A streptococci. Fourty-nine of these patients were followed prospectively to determine if renal involvement would occur. Twelve patients developed transient serum complement (CH50) depression and urinary abnormality, and 2 of these developed mild hypertension. The latent period was from 1-8 weeks after the streptococcal infection. Renal biopsies of the 12 patients with "asymptomatic" of "subclinical" acute poststreptococcal glomerulonephritis (APSGN) were examined by light, immunofluorescent and electron microscopy. Glomerular lesions ranged from mild proliferative changes to the classical pathology seen in APSGN. The 12 patients were followed for 10 years. Two of them developed persistent or intermittent hematuria, and renal biopsies obtained 4 years after the initial infection revealed mesangial proliferative glomerulonephritis without IgA deposits. The remaining patients showed no abnormal findings after the acute episode. These findings suggested that glomerular involvement after group A streptococcal infection is frequent and mesangial proliferative glomerulonephritis, which was found to develop in some, may rank with IgA nephropathy as a major cause of unexplained microscopic hematuria.

Effective control of methicillin-resistant Staphylococcus aureus in a burn unit.

Methicillin-resistant Staph, aureus (MRSA) colonization and infection was studied in 231 patients who were admitted to our burn unit and remained for 3 days or more between 1986 and 1994 (patients with inhalation injury only and no burn wound were excluded). The study was divided into two periods: from 1988 to 1989 and from 1990 to 1994. MRSA was found in 80 patients. They increased from 1986 to 1988, slightly decreasing thereafter. In 1994 the incidence of MRSA was 4.3 per cent. The number of strains of MRSA isolated from burn wounds was significantly reduced in the later period. Comparing the two periods, isolation of patients from MRSA, prevention of contamination during care, and reduction in the number of patients initially given second- or third-generation cephem antibiotics were performed more strictly in the later period. The effectiveness of these measures was confirmed. Moreover, the first operation was carried out significantly earlier in the later period. Early excision and early closure of the wound was more effective in preventing and controlling MRSA colonization and infection.

Cranial defect and decrease in cerebral blood flow resulting from deep contact burn of the scalp in the neonatal period.

A case of cranial defect in the anterior fontanelle region is reported. The patient suffered a deep contact burn on the right parietofrontal region in the neonatal period. At age 3 years, a bone defect of 30 x 20 mm was observed in the right parietofrontal region, including the anterior fontanelle, and the pulsation of the brain was palpable. Moreover, scintigraphy of cerebral blood flow using SPECT with 99mTc-HMPAO demonstrated extensive decrease in blood flow in the right parietosquamosal region. Cranioplasty was performed at 3 years and 4 months using split ribs grafts and at age 5 years and 4 months using split-thickness calvarial bone grafts. After the cranioplasty, there was no bony defect and no region of reduced blood flow. The child is developing well.