Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate.

Background An introduction of the World Health Organization Surgical Safety Checklist (WHO SSC) is essential to promote surgical safety. Objective To obtain country-specific information regarding the checklist in a leading medical institution in Nepal. Method The present research was a cross-sectional study with a survey conducted among healthcare professionals working in the operation theatre at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal. A questionnaire was distributed to 150 healthcare professionals working in the operating theatre. Responses to the questionnaire were analysed descriptively and regression analyses used to identify factors associated with awareness of the checklist. Result In total, 127 healthcare professionals participated in the study, of whom 118 (92.9%) had been aware of the WHO SSC. A substantial proportion of participants (108, 91.5%) were not satisfied with the prevailing practice whereby the checklist was not routinely used during surgery. Lack of appropriate training was the most prevalent barrier to the checklist use (72, 67.9%), followed by unwillingness of staff to use the checklist (54, 50.9%), and lack of experience (42, 39.7%). The mean score on the survey was 6.0 out of 10. Regarding the results of the regression model on survey scores, surgeons had higher scores compared to nurses (unadjusted coefficient 0.80, 95% CI 0.20-1.40). Conclusion Most of the healthcare professionals were aware of the WHO SSC, however multiple barriers to the checklist use were identified. It is important to establish an effective use of WHO SSC in the operation theatre.

Indeterminate results of QuantiFERON TB-2G test performed in routine clinical practice.

The present authors assessed risk factors that can promote indeterminate results of QuantiFERON TB-2G (QFT-2G; Cellestis Ltd, Carnegie, Australia) tests. The subjects were 704 patients with suspected tuberculosis (TB) and latent TB infection between January 2005 and December 2007. The QFT-2G test and the tuberculin skin test (TST) were performed for all subjects. If the results of the QFT-2G test were indeterminate, the test was repeated within 1 month. In total, 72 (10.2%) patients showed indeterminate results on the QFT-2G test. Indeterminate results were due to positive control failure in 68 (88.9%) patients and negative control failure in four patients. The results of the TST were negative for 64 patients showing indeterminate results, the remaining eight patients showed a positive response to the TST. Indeterminate results were significantly associated with elderly and immunocompromised patients. Lymphocytopaenia and hypoalbuminaemia were significantly associated with indeterminate laboratory findings. When the QFT-2G test was repeated for all patients showing indeterminate results, 12 (16.7%) patients demonstrated determinate results on the subsequent test. Indeterminate results of the QuantiFERON TB-2G test under routine clinical practice are not infrequent. When scoring QuantiFERON TB-2G test results for elderly and immunocompromised patients, one must be careful because the possibility of obtaining determinate results may be low even if the test is repeated.

Cystic adenomyosis with florid glandular differentiation mimicking ovarian malignancy.

We report a case of cystic adenomyosis, presenting as a huge exophytic cystic mass with florid glandular differentiation. MR findings of the mass mimicked ovarian carcinoma associated with endometriosis. The presence of signal voids bridging the uterus and tumour should suggest a mass of uterine origin. Hyperintense protuberance in a hypointense loculus on T(2) weighted images may suggest benign disease. However, surgical exploration and resection is still required to exclude an ovarian malignancy.

Gynecologic malignancies accompanied by benign hormone-dependent diseases.

OBJECTIVE: To investigate the correlation between benign gynecologic diseases and hormone-dependent malignancies such as endometrial carcinoma in postmenopausal women. DESIGN: We retrospectively analyzed the prevalence of myoma uteri and adenomyosis uteri in 136 cases of endometrial carcinomas. We used 222 uterine prolapse cases as controls. RESULTS: The results showed that 21.6% and 9.9% of healthy postmenopausal women (control) had myoma uteri and adenomyosis uteri, respectively, after the cessation of menses. However, postmenopausal women with endometrial carcinomas had a 1.5- to 2-fold higher prevalence, respectively, for myoma uteri and adenomyosis uteri as compared with the postmenopausal control women. CONCLUSION: There was a higher prevalence of myoma uteri and adenomyosis uteri in postmenopausal patients with endometrial carcinomas than in the control population.

Carcinoma of the pancreas with endocrine component in childhood. A case report.

A case of pancreatic tumor in a six-year-old girl is presented. The tumor had histologic characteristics of acinar cell carcinoma with endocrine component. Grossly, it was encapsulated and attached to the tail of the pancreas, measuring 8 cm in the greatest diameter. Histologically, the tumor was composed of medium-sized tumor cells, with mild pleomorphism showing mainly acinar structures. Many of these tumor cell contained fine granules that were periodic acid-Schiff positive, diastase resistant, and positive with dimethylaminobenzaldehyde nitrite strain for tryptophan, and some contained granules that were positive with Grimelius stain and positive with peroxidase-antiperoxidase technic for gastrin. Electron microscopy revealed two types of membrane-bound granules in the tumor cells. The larger granules measured 400-700 nm in diameter and appeared to be zymogen granules, while the smaller ones measured 100-200 nm in diameter and appeared to be neuroendocrine granules. Some cells contained both granules. The postoperative course of the patient was excellent, and she was alive and well 13 years after operation. This may be the second reported case of acinar-endocrine cell tumor of the pancreas.

Angiotropic lymphoma with histologic features of neoplastic angioendotheliomatosis presenting with predominant respiratory and hematologic manifestations. Report of a case and review of the literature [corrected].

Neoplastic angioendotheliomatosis (NAE) is a rare fatal disease characterized by widespread intravascular proliferations of neoplastic mononuclear cells. Clinically, dermatologic and bizarre neurologic manifestations usually predominate. The origin of the neoplastic cells remains still undetermined. The authors report a patient with NAE peculiar with respect to the following points: (1) the patient predominantly manifested respiratory symptoms and hematologic findings and lacked cutaneous or neurologic manifestations; and (2) immunohistochemical and molecular genetic studies showed the B-cell nature of the neoplastic cells, although previous cases with predominant respiratory or hematologic manifestations were reported to be of endothelial origin. Despite the rarity, this type of NAE or angiotropic [corrected] lymphoma should be recognized because it is easily confused with other disorders, particularly vasculitis or thrombotic thrombocytopenic purpura.

Age-related changes in the reactivity of the rat jejunum to cholinoceptor agonists.

The contractile effects of barium, potassium, acetylcholine and acetyl-beta-methylcholine were studied in jejunum of 4, 12 and 20 month-old rats. The effects of age on the sensitivity and responsiveness of the jejunum to the agonists were examined using cumulative dose administration and measuring the pD2. The maximum contraction produced by the agonists and the sensitivity to barium and potassium were not modified by aging. In the middle-aged animals, the jejunum sensitivity to acetylcholine decreased while the sensitivity to acetyl-beta-methylcholine was not statistically different from that of 4 month-old rats. Since at this age (12 months) the acetylcholinesterase activity increased, the reduction in the sensitivity to acetylcholine could have been due to the increase in the activity of the metabolizing enzyme. Otherwise, in the jejunum from the older animals the sensitivity for both cholinoceptor agonists, acetylcholine and acetyl-beta-methylcholine, increased 5-fold when compared with the middle-aged animals. However, compared with the jejunum of 4 month-old rats the sensitivity to acetylcholine, to 20 month-old animals, was not altered while the sensitivity to acetyl-beta-methylcholine was increased. At this age (20 months), the jejunum acetylcholinesterase activity was increased when compared with that of 4 month-old rats and was not modified when compared with that of 12 month-old rats. The change in supersensitivity to cholinoceptor agonists could not have been due to an alteration in muscarinic receptor affinity, since the pA2 for atropine was not modified with increasing age. These results suggest that after an increase in acetylcholinesterase activity around month 12, the jejunum develops an adaptative supersensitivity to cholinoceptor agonists.

Pallido-nigro-luysian atrophy, progressive supranuclear palsy and adult onset Hallervorden-Spatz disease: a case of akinesia as a predominant feature of parkinsonism.

Few parkinsonian patients present with 'pure akinesia' or with severe akinesia accompanied by only mild rigidity, tremor and other manifestations such as ophthalmoplegia. Pathological examinations of such cases have rarely been conducted and have revealed findings compatible with progressive supranuclear palsy (PSP), pallido-nigro-luysian atrophy (PNLA) or Parkinson's disease. We report a parkinsonian patient whose main clinical feature was akinesia. A postmortem study of this patient showed findings corresponding to PNLA and PSP. Histochemical properties of the pallidal pigment granules were equivalent to those of Hallervorden-Spatz disease (HSD) and striatonigral degeneration. In addition to iron-positive pigment granules, spheroids, severe neuronal loss and gliosis in the globus pallidus and substantia nigra, formation of Alzheimer's neurofibrillary tangle (NFT) in the brainstem shares characteristics with PSP, adult onset HSD and PNLA. We suggest that the underlying pathology of 'pure' akinesia is most often situated in the globus pallidus substantia nigra and subthalamus (Luys), and that PSP, PNLA and adult onset HSD may constitute a spectrum of one disease.

Age-related changes in neuronal uptake of noradrenaline.

Age-related changes in the neuronal uptake of noradrenaline were studied in the vas deferens of 4-, 12- and 20-months old rats by determining the potentiating effect of cocaine on concentration-effect curves to noradrenaline and by evaluating the kinetic parameters (Vmax and apparent Km) of neuronal 3H-noradrenaline uptake. Since the neurotransmitters released by nerve terminals and the density of noradrenergic innervation are different in the epididymal and prostatic portion of the vas, the experiments were carried out in these two portions of the organ. In the epididymal portion, the ratio between EC50 for noradrenaline in the presence and in the absence of cocaine was reduced in tissues of middle-aged (12-months) and old (20-months) animals when compared with young (4-months) animals. The pD2 values for noradrenaline in the absence of cocaine and the kinetic parameters for neuronal 3H-noradrenaline uptake were not modified by ageing. Thus, in the epididymal portion there was no age-related change in neuronal uptake. The age-related decrease in the cocaine-induced supersensitivity to noradrenaline was due to an age-related decrease in the pD2 value for noradrenaline observed in the presence of cocaine, suggesting postsynaptic changes. In the prostatic portion, the ratio between EC50 for noradrenaline in the presence and in the absence of cocaine was also reduced in tissues of old animals (20-months) when compared with middle-aged and young animals. The pD2 value for noradrenaline in the absence of cocaine obtained in the prostatic portion of 20-months old rats was higher than that in the younger groups (4- and 12-months).(ABSTRACT TRUNCATED AT 250 WORDS)

Intraarterial infusion chemotherapy and radiotherapy with or without surgery for patients with locally advanced or recurrent breast cancer.

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

MR findings of subarachnoid dissemination of a pituitary adenoma.

Although pituitary adenoma is a benign tumour, subarachnoid dissemination occurs rarely. We describe a case of pituitary adenoma with subarachnoid dissemination. After the third operation for pituitary adenoma, an extraaxial mass was demonstrated on MR images. On T1 and T2 weighted images, the signal intensities of the extraaxial mass were similar to those of the primary pituitary adenoma. On dynamic contrast T1 weighted images, the time-intensity curve of the extraaxial mass, which showed early and persistent signal intensity, was also similar to that of the primary pituitary adenoma. These MR findings are considered to reflect the similar vascularity and stroma of the extraaxial mass and the primary pituitary adenoma.

Struma ovarii: MRI findings.

We describe the MRI findings in three cases of struma ovarii. In all three cases, MRI showed a multilocular cystic mass with a variable signal intensity within loculi. Some loculi or small cysts within septations showed low signal intensity on T1 weighted images and very low signal intensity on T2 weighted images, corresponding pathologically to gelatinous colloid material in large follicles. In one case, with Gd-DTPA enhanced T1 weighted images, the thick septations and locally thickened wall showed marked enhancement, corresponding microscopically to thyroid tissue.

Effects of sodium and calcium concentration on the barium chloride-induced electrical and contractile responses of the guinea pig vas deferens.

1. The mechanism of 10 mM barium chloride-induced electrical and contractile responses of the guinea pig vas deferens was investigated using calcium channel blockers and by modifying the Na+ and Ca2+ concentrations of the nutritional solution. Isometric contraction and membrane depolarization were measured simultaneously by the sucrose-gap technique. 2. In the absence of added Ca2+ there was a decay of the contractile but not of the depolarizing effect, which was independent of the frequency of 10 mM barium chloride administration. However, both barium-induced contraction and depolarization were reduced and the former more rapidly in a Ca2+-free solution (0.5 mM EGTA). 3. In low-Na+ solution (16 mM) there was a 3-fold increase in depolarization and no change in contraction, but in a low-Na+ Ca2+-free solution (0.5 mM EGTA), only contraction was reduced. 4. Nifedipine blocked both barium-induced contraction and depolarization in a dose-dependent manner when the organs were bathed in regular nutrient solution. In contrast, in low-Na+ solution only 50% of the depolarization was blocked by 10(-6) M nifedipine, which completely inhibited contraction. Both barium-induced contraction and depolarization in low-Na+ Ca2+-free solution were blocked by 10(-3) M LaCl3. 5. These data indicate that in the presence of calcium, barium mobilizes extracellular calcium through voltage-dependent channels and the contraction is due to the entry of calcium. In contrast, in the absence of added Ca2+ or in Ca2+-free solutions (0.5 mM EGTA), barium enters through the voltage-dependent channel and the contraction is reduced because the intracellular stores of calcium are limited.

Serum C-reactive protein as a prognostic factor in patients with epithelial ovarian cancer.

OBJECTIVE: It is well known that the serum level of Interleukin-6 (IL-6) correlates with the level of C-reactive protein (CRP). The purpose of this study is to determine the significance of CRP as a prognostic factor in epithelial ovarian cancer. STUDY DESIGN: The present study is comprised of 120 patients with epithelial ovarian cancer from 1985 to 1992. In this study, CRP levels above 50 mg/l were considered high CRP. Univariate and multivariate analyses were performed to identify clinicopathological variables associated with poor survival. RESULTS: The serum CRP value was significantly associated with the volume of ascites (P = 0.000004). Univariate analysis showed that the FIGO stage, primary tumour diameter, size of residual tumour, histologic grade, volume of ascites and high serum level of CRP were significant prognostic factors. Cox's multivariate proportional hazard model showed that histologic grade was the most important prognostic factor (P = 0.0026). FIGO stage and volume of ascites were also independent factors for 5-year survival (P = 0.0310 and P = 0.0216, respectively). However, the serum CRP value was not an independent prognostic factor. CONCLUSION: CRP is an adverse prognostic factor in univariate analysis, but not in multivariate analysis.

Clinical analysis of community-acquired pneumonia in the elderly.

OBJECTIVE: To evaluate the clinical features, etiology, and outcome of patients over 65 years old hospitalized for community-acquired pneumonia. PATIENTS: Eighty-four patients (50 males, 34 females) hospitalized for community-acquired pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1998 and March 2000. RESULTS: Most of the patients had respiratory symptoms or signs, but over one-third also had atypical symptoms of pneumonia such as dyspnea, consciousness disturbance, and gastrointestinal symptoms. The causative microorganisms were identified in 48% of these patients. Streptococcus pneumoniae (13%), respiratory viruses (13%), Haemophilus influenzae (8%) and Mycobacterium tuberculosis (8%) were frequently identified, but Mycoplasma pneumoniae was less frequently noted in the elderly. Double infection was recognized in 19 % and a combination of some virus and bacteria in 13%. Treatment consisted of the administration of second or third generation cephalosporin antibiotics intravenously, because antibiotics had already been preadministered in 39%. The prognosis was poor (mortality rate 9%) for the elderly with community-acquired pneumonia despite mechanical ventilation in 8%. CONCLUSIONS: Although the range of microorganisms causing community-acquired pneumonia differed slightly from that in previous reports; namely, lower frequency of Chlamydia pneumoniae and Legionella pneumophila, it is suggested that the initial antibiotic treatment should always cover S. pneumoniae and H. influenzae. In addition, since a prevalence of virus infections related to the increase in community-acquired pneumonia in the elderly was found in this study, the routine use of influenza vaccine and pneumococcal vaccines in the elderly is recommended to reduce the high mortality rate.

Clinical subgroup of autoimmune hepatitis type 1 sustaining remission without additional drugs.

BACKGROUND/AIMS: Many patients with autoimmune hepatitis type 1 need additional non-steroidal immunosuppressants to maintain remissions, but the indication should be limited to avoid the unnecessary side effects. The aim of this study is to clarify the clinical subgroups of autoimmune hepatitis type 1 sustaining remission without additional drugs. METHODOLOGY: We studied 20 patients with autoimmune hepatitis type 1, in whom complete remissions were achieved in the natural course or by prednisolone alone. Remissions were maintained with none or less than 10 mg/day of prednisolone. RESULTS: In the course (average: 6 years), 8 patients (40%) remained in remission for more than three years. In the remitted group, initial values of serum gamma-globulin (p<0.05) and serum immunoglobulin G (p<0.01) were lower than those in the relapsed group. The group with less than 30 mg/ml of gamma-globulin and 3000 mg/dl of immunoglobulin G showed a significantly lower relapse rate than the other one (p<0.01). CONCLUSIONS: There is a clinical subgroup of autoimmune hepatitis type 1 that sustains remission with low-dose prednisolone alone. Additional immunosuppressive drugs may not be needed to maintain remissions in such patients.

Salazosulfapyridine-induced angioimmunoblastic lymphadenopathy.

A 20-year-old man with ulcerative colitis was admitted because of fever, eruption and lymphadenopathy. He had started taking salazosulfapyridine one month previously. Lymph node biopsy revealed angioimmunoblastic lymphadenopathy. Autoantibody titers were all negative, and viral antibody titers were not increased retrospectively. Rearrangement of T-cell receptor beta and chromosomal aberration were not seen on the lymph node. This case is considered not to be a peripheral T-cell lymphoma but rather salazosulfapyridine-induced angioimmunoblastic lymphadenopathy (AIL), which is the second case in English language literature.

Rapidly progressive pneumonia due to Aeromonas hydrophila shortly after near-drowning.

An 87-year-old woman died of rapidly progressive pneumonia due to Aeromonas hydrophila shortly after a near-drowning event. Autopsy showed necrotizing pneumonia and postmortem cultures of both blood and lung revealed the organism. Fulminant pneumonia should be considered in patients of a near-drowning event.

Diffuse intrahepatic recurrence after resection of hepatocellular carcinoma.

BACKGROUND/AIMS: An early diffuse type in the pattern of the postoperative intrahepatic recurrence of hepatocellular carcinoma has been recognized. The purpose of this study was to elucidate risk factors for diffuse recurrence of hepatocellular carcinoma. METHODOLOGY: The subjects involved in the present study were 114 patients with hepatocellular carcinomas resected in Tenri Hospital during the past 12 years. Univariate analysis was used for retrospective determination of the factors related to diffuse recurrences after surgery in 10 cases among 114 patients. RESULTS: The risk factors linked to diffuse recurrence were microscopical portal infiltration (P < 0.01), elevated alpha-fetoprotein (more than 1000 ng/mL) (P < 0.05), the absence of preoperative transcatheter arterial embolization (P < 0.01), and two or more segmentectomies of the liver (P < 0.01). Six of 10 patients with microscopical portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL) had diffuse recurrence (P < 0.01). Six of 8 patients with two or more segmentectomies without preoperative TAE had diffuse recurrence (P < 0.01). CONCLUSIONS: When patients with the diagnosis of operable hepatocellular carcinoma have portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL), two or more segmentectomies of the liver without preoperative transcatheter arterial embolization should be avoided.