Inhibition of PSA flare in prostate cancer patients by administration of flutamide for 2 weeks before initiation of treatment with slow-releasing LH-RH agonist.

BACKGROUND: A prospective randomized study was designed to determine whether flutamide (FLU) administered before treatment with a luteinizing hormone-releasing hormone agonist (LH-RHa) prevented prostate-specific antigen (PSA) flare in prostate cancer patients. METHODS: Prostate cancer patients were randomized into two groups and received either FLU (n = 11) or no pretreatment (n = 13) for 2 weeks before the initial injection of LH-RHa. LH-RHa (every 4 weeks) and FLU (every day) were administered throughout the period of this study. Blood samples, for the determination of PSA, testosterone (T), and luteinizing hormone levels, were collected before FLU administration, and before and 2, 7, 14, 28, 56, and 84 days after the first administration of LH-RHa. RESULTS: Treatment with FLU prior to LH-RHa induced an early decline in PSA level. The mean PSA level showed no significant secondary rise after LH-RHa administration in those patients with FLU pretreatment. Patients in both groups showed T flare after the first LH-RHa administration. However, the number of patients with PSA flare was significantly lower in patients with prior FLU administration than in those with LH-RHa alone. CONCLUSION: These results clearly demonstrate that, in patients with prostatic cancer, the administration of FLU for 2 weeks prior to the first LH-RHa administration is effective in preventing PSA flare, as well as in inducing an early decline in PSA levels.

Primary extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue type in the CNS.

Extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type has been reported in various internal organs. Here a case is reported of MALT lymphoma developing in the cerebellopontine (CP) angle in a patient with Sjogren syndrome, and the concept of MALT lymphoma of the CNS is introduced. Pathologically, the tumor showed inflammatory features of reactive lymphocytic infiltration with follicle formation, but there were slightly atypical lymphocytes and plasmacytes with B-cell markers. These cells invaded reactive follicles, showing follicular colonization, and showed aberrant expression indicating their neoplastic nature. A review of the literature revealed eight cases of MALT lymphoma originating from the dura mater and one from the CP angle. The average age of patients was 50 years (range 28-66 years), and all patients were female. The tumors were slow to develop and the patients were cured after surgical removal and/or additional therapies. It is proposed that MALT lymphoma should be considered as a differential diagnosis of inflammatory pseudotumor of the CNS.

[Interrelation between physical disease and chronic pain--importance of understanding myofascial pain syndrome].

Myofascial pain syndrome(MPS) is characterized by its unique pathology on developing the intramuscular trigger points. The author performed the psychological tests(Cornell Medical Index, Tokyo University Egogram, Minnesota Multiphasic Personality Inventory) on 46 MPS patients to clarify the psychological background. Results revealed that the MPS patients had remarkable hypochondriacal tendency with irrational way of thinking. The author concluded that it is necessary to be hypochondriacal and irrational for the formation of apparent MPS with outstanding TPs. This fact suggests that TPs in MPS are the result of deteriorated central pain control mechanism that should actually suppress the mechanical constriction of damaged muscles.

[A case of urachal abscess mimicking a tumor in the retrovesical space].

A 14-year-old girl was admitted to our hospital because of umbilical erythema and discharge. She had had an appendectomy at the age of twelve. Abdominal ultrasonography and cystoscopy revealed a large tumor-like mass at the posterior wall of the bladder. Computed tomography and magnetic resonance imaging revealed urachal sinus. The diagnosis of urachal abscess had been confirmed and conservative treatment had been continued by drainage via umbilicus and the administration of antibiotics. Total excision of the urachus was performed about one month later because the bladder mass was not reduced. Pathological findings revealed an inflammatory thickened wall of the urachus and no evidence of malignancy. We report this rare case of urachal abscess with a large mass in the retrovesical space.

[The difficulty of urethral anastomosis in sigmoid neobladder--the role of preoperative X-ray of an air-contrast barium enema].

BACKGROUND: Sigmoid neobladder (Reddy method) is one of the representative neobladder after radical cystectomy. Occasionally we experienced difficulty on urethral anastomosis in sigmoid neobladder. Here we investigated preoperative X-ray of air-contrast barium enema and clarified what type could be easily anastomosed in sigmoid neobladder. MATERIAL AND METHODS: We performed five cases of total cystectomy with sigmoid neobladder replacement. Of the five, we can easily make a urethral anastomsis in three cases but not easily in other two cases. We investigated sigmoid colon length, it's internal diameter, it's form and it's mobility that was substituted for elevation level of rectosigmoid using preoperative X-ray of air-contrast barium enema. We also studied seventy five cases of X-ray of air-contrast barium enema who visited our hospital with various complaints such as lower abdominal pain. RESULTS: The length of three cases with easily anastomosed were 45.7 cm in diameter other two cases 33.5 cm in diameter.(over all 47.5 cm) The internal diameter were 49 mm and 33.5 mm respectively.(over all 44.4 mm) It was considered that Reddy method was indicated who had at least averaged sigmoid colon length and internal size. Sigmoid colon form were classified into 3 groups (type N. type l and others). There were no difference on colon length regarding sigmoid form, but others was considered to be improper form because significant difference was observed between type N and others in internal diameter. Three cases with easily anastomosed demonstrated a positive correlation of the elevation of the sigmoid colon over promontorium in the air contrast barium enema, other two cases negative. The elevation cases of the sigmoid colon in X-ray of air contrast barium enema had long sigmoid colon than other types.(p < 0.0001) Tha mean length of them was 51.6 cm in diameter. CONCLUSION: Sigmoid neobladder was at least indicated in men who had averaged sigmoid colon length. The sigmoid colon elevation sign in X-ray of air contrast barium enema did not require the measurement of sigmoid colon length and that sign implied good indication for sigmoid neobladder.

[5'-DFUR chemoprophylaxis in superficial bladder cancer. Kanagawa Urology 5'-DFUR Study Group].

5'-Deoxy-5-fluorouridine (5'-DFUR), an oral fluorinated pyrimidine carbamate, is widely used in patients with gastrointestinal and breast cancers because of its effectiveness. However, in bladder cancer, response rates have only been reported in Phase II clinical trials. Therefore, we conducted a prospective randomized trial to investigate chemoprophylactic effect of 5'-DFUR against recurrence of superficial bladder cancer after transurethral bladder tumor resection (TUR-Bt). The subjects were grouped as follows: 1) 5'-DFUR group (n = 31), received 600 mg/day of 5'-DFUR starting 2-3 weeks after TUR-Bt for 2 years; and 2) control group (n = 31) received no 5'-DFUR. Although there was no significant difference between groups, the cumulative recurrence rates was more favorable in the 5'-DFUR group (p = 0.256) than in the controls. Results according to cancer factors showed that, in patients with G2 based on grading, those in the 5'-DFUR group tended to have a lower recurrence rate than the control group (p = 0.070). There was a 40% incidence of adverse drug reactions (12/30 patients), primarily slight gastrointestinal symptoms which disappeared or improved with drug discontinuation. The results of the present study suggest that 5'-DFUR might be the choice of treatment to prevent recurrence of superficial bladder cancer.

Sequence analysis of a total of three megabases of DNA in two regions of chromosome 8p.

Large-scale sequencing of genomic regions and in silico gene trapping together represent a highly efficient and powerful approach for identifying novel genes. We performed megabase-level sequence analyses of two genomic regions on human chromosome 8p (8p11.2 and 8p22-->p21.3), after covering those segments with sequence-ready contigs composed of 74 cosmids, 14 BACs, and three PAC clones. We determined continuous nucleotide sequences of 1,856,753 bases on 8p11.2 and 1,210,381 bases on 8p22-->p21.3 by combining the shotgun and primer-walking methods. In silico gene trapping identified four novel genes in the 8p11.2 region and, in the 8p22-->p21.3 region, six known genes (PRLTS, PCM1, MTAMR7, HCAT2, HFREP-1 and PHP) and three novel genes. The distribution of Alu and LINE1 repetitive elements and the densities of predicted exons were different in each region, and Alu-rich portions contained more exonic sequences than LINE1-rich areas.

[Long-term administration study of propiverine hydrochloride (BUP-4 tablets) in pollakiuria and urinary incontinence].

The safety and efficacy of one-year administration of propiverine hydrochloride (BUP-4 tablets) were assessed in facilities affiliated with the Department of Urology of Yokohama City University School of Medicine. Changes in subjective symptoms showed significant improvement in mean frequency of urination in the daytime from 10.3 +/- 4.0 times before administration to 7.1 +/- 2.9 times 1 year after the start of administration, in mean frequency of voiding at night from 4.2 +/- 1.7 times to 2.1 +/- 1.1 times and in mean incidence of urinary incontinence from 2.9 +/- 2.1 times to 0.7 +/- 1.0 times. The final degree of overall improvement rate was 82.0% (41/50 cases). Adverse effects were observed 26 times in 22 patients, the incidence being 15.6% (22/141 cases). They consisted of digestive symptoms in 9.9% (6 events of dry mouth, 4 of constipation, 2 of abdominal discomfort, 2 of diarrhea and 1 of gastritis), urinary tract symptoms in 3.5% (4 of dysuria and 1 of residual urine), abnormal laboratory findings in 1.4% (increase in glutamic-oxaloacetic transaminase, glutamic-pyruvic transaminase or lactate dehydrogenase levels) and others (1.4%). These results provide further evidence of the safety and efficacy of propiverine hydrochloride (BUP-4 tablets) even when administered for a long-term in the treatment of patients with pollakiuria and urinary incontinence.

[Bilateral renal cell carcinoma in a patient with chronic renal failure: a case report].

We describe a case of bilateral renal cell carcinoma associated with chronic renal failure. A 49-year-old man was admitted to our hospital to initiate hemodialysis. He was found to have multiple renal cystic changes and a left renal mass by ultrasound. Computed tomographic (CT) scan showed a tumor 4 cm in diameter in the left kidney and another one 2 cm in diameter in the right kidney. Left nephrectomy was first performed and histopathological examination revealed renal cell carcinoma of mixed type and granular subtype. Six months after the operation, CT scan showed the mild growth of the tumor in the right kidney. Right nephrectomy was performed and histopathological examination revealed renal cell carcinoma of papillary type and granular subtype. The patient remains well on hemodialysis, with no evidence of recurrence or metastasis for 13 months after nephrectomy.

Magnetic resonance imaging characteristics of choroid plexus papilloma in the fourth ventricle.

The computed tomography (CT) and magnetic resonance (MR) imaging characteristics of two cases of small choroid plexus papilloma within the fourth ventricle are reported. CT showed the tumors as high density areas with postcontrast enhancement. MR imaging showed the tumors as basically isointense areas with marked enhancement by gadolinium-diethylenetriaminepenta-acetic acid. Important MR imaging findings included clear evidence of tumor attachment to the normal choroid plexus, location in the lower part of the fourth ventricle, and separation from the fourth ventricular floor.

Auditory brainstem responses after out-of-hospital cardiac arrest: Are they useful for outcome prediction?

We evaluated whether we could predict the neurologic outcome in 55 out-of-hospital cardiac arrest patients using auditory brainstem responses (ABR). ABR patterns were classified into one of 3 types by evaluation of 5 components: type 1, with all 5 components; type 2, lack of at least one response between the 2nd and 5th components; type 3, with only the first component or no response. The relation between the ABR patterns on the 3rd day following resuscitation and the neurologic outcome on hospital discharge was evaluated. The specificity that the 5 awake patients had type-1 ABR was 38%. The sensitivity that the 10 brain dead patients had type-3 ABR was 60%. In the type-1 ABR patients, the negative predictive value that the patients were awake was 100%. In the type-3 ABR patients, the negative predictive value that the patients became brain dead was 90.9%. These results suggest that ABR on the 3rd post-resuscitation day may not be useful for predicting if patients are awake or become brain dead, although the loss of components may be a sign of morbidity, and the presence of the 2nd or later components indicates possible future prevention of brain death.

[Successful management for advanced renal cell carcinoma under combination therapy with human lymphoblastoid interferon-alpha and UFT (mixture of tegafur and uracil): a case report].

We report a case of renal cell carcinoma in a 76-year-old man with pulmonary metastasis and tumor thrombus in inferior vena cava. The patient responded to the combination therapy with a small amount of HLBI (human lymphoblastoid interferon-alpha) and UFT (1:4 mixture of tegafur and uracil). HLBI was administered intramuscularly at a dose of 3 x 10(6) IU two times a week. However, the administration of the same dose was discontinued, because of the severe side effects, such as depression, general fatigue, anorexia and high fever. Finally, the maximum dose was determined to be 2 x 10(6) IU/week. Nine weeks after the first treatment, UFT was simultaneously given orally at a dose of 100 mg/day for potentiating the antitumor effect. At 12 weeks, the patient registered complete response of pulmonary metastasis, and partial response (83% reduction) of renal tumor. About 60 x 10(6) IU HLBI was administered until the response was noted. After 34 weeks of administration of HLBI, nephrectomy was performed. Histological diagnosis was renal cell carcinoma of clear cell subtype, grade 2. Microscopically, many lymphocytes infiltrated into the cancer cells. This suggests the possibility of immunological response caused by HLBI.

Acute brain swelling after out-of-hospital cardiac arrest: pathogenesis and outcome.

OBJECTIVES: First, to examine factors that may be related to brain swelling, which was identified by the absence or compression of the lateral and third ventricles and perimesencephalic cisterns on brain computed tomography (CT) scans in the early postresuscitation period in patients who suffered an out-of-hospital cardiac arrest. Second, to characterize the neurologic outcome in those patients in whom cardiac arrest was followed by brain swelling. DESIGN: Prospective and retrospective analyses. SETTINGS: General ICU, tertiary care hospital. PATIENTS: Fifty-three patients (35 male, 18 female) who had an out-of-hospital cardiac arrest and who also had a brain CT examination on the third day after resuscitation. The 53 patients were divided into two groups: group A (25 patients) experienced brain swelling on postresuscitation day 3; group B (28 patients) did not experience noticeable brain swelling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There was a significant difference between the two groups in the etiology of the cardiac arrest. Twenty-three of 25 patients in group A had cardiac arrest due to respiratory distress, whereas this finding was true in only five patients in group B. In laboratory data, arterial pH was significantly lower in group A than in group B (6.93 vs. 7.09), as was base deficit (-21.0 mmol/L in group A vs. -13.7 mmol/L in group B). Neurologic outcome was evaluated 1 wk after resuscitation. There were significantly more patients in group A who were not awake and who were diagnosed as brain dead. CONCLUSIONS: The cause of brain swelling may be related to the development of the metabolic acidosis (possibly lactic acidosis) due to hypoxia before the resuscitation period. Brain swelling may be one of the indicators that predicts a poor neurologic outcome in the patients who suffer an out-of-hospital cardiac arrest.

[Vesicourethral dysfunction of diabetic patients].

In order to evaluate vesicourethral dysfunction in diabetic patients, urodynamic studies, IVP and urinalysis were performed on 173 diabetic patients (male 78, female 95) and 17 nondiabetic control cases. In addition to the classical findings as increased volume at the first desire to void and decreased maximum vesical pressure, diabetic patients showed varieties of vesicourethral dysfunctions such as overactive bladder (14.5%), low compliance bladder (11.0%) and loss of detrusor-external sphincter coordination (31.7%). Vesicourethral function of diabetics was classified in following 5 types by analysing the volume at first desire to void, volume at maximum desire to void, maximum vesical pressure, residual urine volume and bladder compliance. 1. Type 1, normal vesical function, 13 cases. 2. Type 2, vesical dysfunction with minimal residual urine, 49 cases. 3. Type 3, vesical dysfunction with residual urine, 66 cases. 4. Type 4, low compliance bladder, 20 cases. 5. Type 5, overactive bladder, 25 cases. Pyuria was observed in 59.8%, hydronephrosis was found in 10.9% and ectasia of lower ureter was found in 17.8% of diabetic patients. The highest incidence of pyuria and abnormality of the upper urinary tract were noted in Type 4 and followed by Type 3 and by Type 2 in decreasing order. Extent of pyuria and ectasis of the upper urinary tract showed statistically significant correlation with residual urine volume and detrusor-external sphincter coordination. When vesicourethral function was compensated by abdominal strain, the volume of residual urine is not elevated, but when the mechanism of compensation is lost or in the absence of detrusor-external sphincter coordination results in gradual accumulation of residual urine. In cases with long standing chronic urinary tract infection may results in fibrosis of the bladder wall with low compliance bladder. Fibrotic obstruction of uretero-vesical junction can cause hydroureteronephrosis and followed by renal function impairment. As vesical damage become irreversible at this end stage, proper management during early stage is crucial for management of diabetic patients. Cholinergic agent were effective to reduce residual urine volume in Type 3. alpha-blocking agent were effective to reduce residual urine volume in Type 3 and some cases of Type 4. In cases in which medication therapy failed to reduce residual urine, the clean intermittent catheterization was successful in control of urinary tract infection and upper urinary tract ectasis. Transurethral resection of the prostate and the bladder neck is indicated in the male patients with a large amount of residual urine in Type 3 and 4.

[Persistent primitive proatlantal intersegmental artery (PPPIA) presenting with cerebral infarction].

A case of persistent primitive proatlantal intersegmental artery (PPPIA) is reported. A 65-year-old male with treated hypertension was admitted to our clinic complaining of dysarthria and hemiparesis of sudden onset two days after the ictus. CT revealed spotty low-density lesions in the left corona radiata and bilateral thalami with bilateral watershed infarction. MRI findings were also compatible with cerebral infarction. Left common carotid angiography demonstrated a large anastomosis between the external carotid artery and the vertebral artery at the proatlantal region. Neither of the vertebral arteries were visualized on digital subtraction aortography. All the blood circulation of the vertebro-basilar system was through this anastomotic artery (PPPIA). A flow study revealed hypoperfusion in the territory of the left middle cerebral artery on 133Xe SPECT. Bone window CT of cervical vertebrae revealed hypoplasia of the left transverse foramen in C2, C3, C4, C5, C6 vertebrae. This case is very suggestive of an anaplasia or hypoplasia of the vertebral arteries. The etiology of his left frontal infarction seemed to be a blood-stealing phenomenon of long standing, from the anterior to the posterior circulation through the PPPIA.

New method of MVD using a vascular tape for neurovascular compression involving the vertebrobasilar artery--report of two cases.

In the treatment of hemifacial spasm and trigeminal neuralgia by microvascular decompression (MVD), lack of improvement or recurrence may occur because of the difficulties in positioning prostheses and the involvement of the large vertebrobasilar arteries, even with use of fenestrated aneurysm clips or adhesives. We have developed a new method of MVD, in which a vascular tape is anchored to the dura mater to transpose the responsible large artery. This method achieved successful results in our two patients with nerve compression involving the vertebrobasilar arteries.