Enhancing tuberculosis patient detection and care through community volunteers in the urban poor, The Philippines.

Setting: The Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association Philippines is a local non-governmental organisation (NGO) established in 2008 to improve access to tuberculosis (TB) services. Community health volunteers (CHVs) from NGO referring facilities were engaged to assist in local TB control activities. Objective: To describe the activities of the CHVs and the barriers experienced by patients with presumptive TB in seeking health care to treatment as documented on a master list, and to identify the CHVs' challenges in community TB care implementation. Design: This was a retrospective evaluation with a non-experimental design reviewing the presumptive TB master list and TB reports and conducting a free discussion session (FDS) in 2012. Results: Of the 78% (281/362) of referred presumptive TB patients who accessed a DOTS facility, 69% (194/281) underwent a diagnostic examination and 42% (81/194) were diagnosed with active TB. Of the 93% (75/81) initiated on treatment, 92% (69/75) were successfully treated. The CHVs contributed approximately 3% (75/2534) to the total TB cases diagnosed at the DOTS facilities. In the FDS, barriers evoked in seeking health care for treatment were transfer of residence and lack of interest in seeking a consultation. In 2012, the CHV attrition rate was 55% (80/145). Conclusion: The CHVs assisted in enhancing access to TB care and case detection. Sustainability of the CHVs' efforts should be explored to retain them in the programme.

Contexte : Le Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association Philippines, Inc, est une organisation non gouvernementale (ONG) locale créée en 2008 afin d'améliorer l'accès aux services de tuberculose (TB). Des travailleurs de santé communautaire (CHV) des structures de référence de l'ONG ont été engagés pour participer aux activités locales de lutte contre la TB.Objectif : Décrire les activités des CHV et les obstacles rencontrés par des patients présumés tuberculeux depuis la recherche de soins de santé jusqu'au traitement comme documenté sur la liste index, et identifier les défis auxquels sont confrontés les CHV dans la mise en œuvre de la prise en charge communautaire de la TB.Schéma : Evaluation rétrospective avec un schéma non expérimental par revue de la liste des cas présumés de TB, les rapports relatifs à la TB et l'organisation de séances de discussion libre (FDS) en 2012.Résultats : Soixante-dix-huit pour cent (281/362) des cas de TB présumés référés ont eu accès à un service de DOTS, puis 69% (194/281) ont eu un bilan diagnostique et 42% (81/194) ont eu un diagnostic de TB active. Quatre-vingt-treize pour cent (75/81) ont été mis sous traitement, puis 92% (69/75) ont été traités avec succès. Les CHV ont contribué à environ 3% (75/2534) du nombre total de cas de TB des services de DOTS. Lors des FDS, les obstacles rencontrés, de la recherche de soins jusqu'au traitement, ont été le changement de résidence et le manque d'intérêt à venir consulter. En 2012, le taux d'attrition des CHV a été de 55% (80/145).Conclusion : Les CHV ont contribué à améliorer l'accès à la prise en charge de la TB et à la détection des cas. La pérennisation de leurs efforts devrait être explorée afin de les garder dans le programme.

Marco de referencia: El Instituto de Investigación en Tuberculosis de la Asociación Japonesa contra la Tuberculosis, Filipinas, es una organización no gubernamental (ONG) local fundada en el 2008 con el fin de mejorar el acceso a los servicios relacionados con la tuberculosis (TB). Los voluntarios de salud de la comunidad (CHV) de los centros remitentes operados por las ONG se vincularon como asistentes a las actividades locales de control de la TB.Objetivo: Describir las actividades de los CHV, los obstáculos que encuentran las personas con presunción de TB al buscar atención de salud y tratamiento a partir de la información recogida con una lista modelo y reconocer las dificultades que afrontan los CHV cuando prestan servicios de atención comunitaria de la TB.Método: Se realizó en el 2012 una evaluación retrospectiva no experimental, mediante el examen de una lista modelo sobre la presunción de TB, los registros de TB y una sesión de discusión libre (FDS) con los CHV.Resultados: Setenta y ocho por ciento de los pacientes con presunción de TB remitidos (281/362) accedieron al establecimiento de DOTS, se practicó la investigación diagnóstica en el 69% de ellos (194/281), de los cuales en el 42% (81/194) se diagnosticó TB activa. El 93% (75/81) inició tratamiento y de ellos el 92% (69/75) logró un tratamiento exitoso. Los CHV contribuyeron con cerca de 3% (75/2534) del total de casos de TB de los centros DOTS. En la sesión de debate libre, los obstáculos referidos, desde la búsqueda de atención de salud hasta el tratamiento, fueron el cambio de residencia y la falta de interés en consultar. En el 2012, el índice de deserción de los CHV fue 55% (80/145).Conclusión: Los CHV contribuyeron a reforzar el acceso a la atención de la TB y la detección de casos. Es preciso examinar la sostenibilidad de la iniciativa de los CHV al propósito de conservar su presencia en el programa.

A review of tuberculosis contact investigations in the poor urban areas of Manila, The Philippines.

Setting: Socio-economically underprivileged areas in the Philippines. Objective: To review the implementation of tuberculosis (TB) contact investigations in the urban poor areas of Manila and Quezon City. Design: A descriptive cross-sectional study based on a review of data from household contact registries in local government unit (LGU) and non-government organisation (NGO) facilities during January-December 2012 in Manila and Quezon City. Free discussion sessions were also conducted among health-care workers. Results: Of 6161 children and adult household contacts listed in the LGUs and 1893 in the NGOs, 17% (n = 1086) in the LGUs and 95% (n = 1800) in the NGOs were evaluated. The yield of clinically diagnosed TB among children aged <15 years was 10.2% (127/1245) in the LGUs and 8.4% (63/752) in the NGOs. The yield of isoniazid preventive therapy (IPT) for those aged <5 years was 23.1% (124/537) in the LGUs and 28.0% (78/279) in the NGOs. The NGOs produced a high yield of IPT due to a better logistical system that ensured the availability of supplies and systematic home visits. Conclusion: Screening of household contacts in poor urban areas appears to be effective; it increased the number of children aged <15 years eligible for IPT and should be expanded as an intervention strategy for TB control in the Philippines.

Contexte : Quartiers défavorisés sur le plan socio-économique aux Philippines.Objectif : Revoir la mise en œuvre de la recherche des contacts de tuberculose (TB) dans les zones urbaines pauvres de Manille et de Quezon City.Schéma : Une étude descriptive transversale basée sur une revue des données des registres de contacts domiciliaires de janvier à décembre 2012 dans des unités publiques locales (LGU) et des structures d'organisations non gouvernementales (ONG) à Manille et à Quezon City. Des séances de discussion libre ont également été réalisées avec les prestataires de soins.Résultats : Sur les 6161 contacts familiaux des LGU et les 1893 contacts des ONG (enfants et adultes) listés, 17% (1086/6161) des LGU et 95% (1800/1893) des ONG ont été évalués. Le pourcentage de TB diagnostiquées cliniquement parmi les enfants âgés de < 15 ans a été de 10,2% (127/1245) dans les LGU et de 8,4% (63/752) dans les ONG. Le pourcentage d'enfants âgés de < 5 ans mis sous traitement préventif par isoniazide (TPI) a été de 23,1% (124/537) dans les LGU et de 28,0% (78/279) dans les ONG. Les ONG ont eu une meilleure mise en œuvre du TPI grâce à un meilleur système logistique qui a assuré la disponibilité des médicaments et des visites à domicile systématiques.Conclusion : Le dépistage des contacts familiaux dans les zones urbaines pauvres semble être efficace et il a augmenté le nombre d'enfants âgés de < 15 ans éligibles au TPI ; il devrait être étendu en tant que stratégie d'intervention pour la lutte contre la TB aux Philippines.

Marco de referencia: Las regiones desfavorecidas desde el punto de vista socioeconómico en las Filipinas.Objetivo: Evaluar la aplicación de la investigación de contactos de casos de tuberculosis (TB) en las zonas urbanas pobres de Manila y Ciudad Quezón.Método: Un estudio transversal descriptivo con análisis de datos de los registros de contactos domiciliarios de enero a diciembre del 2012, en los establecimientos de las Unidades del Gobierno Local (UGL) y de Organizaciones No Gubernamentales (ONG) en Manila y Ciudad Quezón. Se realizó además una sesión abierta de conversaciones con los profesionales de salud.Resultados: En las UGL se evaluaron 17% (1086/6161) y en los establecimientos de las ONG se investigaron 95% (1800/1893) de los contactos domiciliarios registrados (niños y adultos). El rendimiento (diagnóstico clínico) en los niños <15 años fue 10,2% (127/1245) en las UGL y 8,4% (63/752) en las ONG. El suministro del tratamiento preventivo con isoniazida en los niños de < 5 años alcanzó un 23,1% (124/537) en las UGL y un 28,0% (78/279) en las ONG. Las ONG lograron un resultado superior con respecto al tratamiento preventivo debido a su mejor organización logística, que procuraba la disponibilidad de los suministros y visitas domiciliarias sistemáticas.Conclusión: La investigación de los contactos domiciliarios en las zonas urbanas pobres resulta eficaz y aumenta el número de niños <15 años que cumplen con los criterios para recibir el tratamiento preventivo con isoniazida. Sería conveniente ampliar la escala de esta intervención, como una estrategia de control de la TB en las Filipinas.

The referral pathway of presumptive drug-resistant tuberculosis in an urban poor setting, The Philippines.

Setting: Socio-economically underprivileged urban areas in the Philippines. Objectives: To identify gaps in the referral pathway of presumptive drug-resistant tuberculosis (DR-TB) patients from initial consultation until initiation of treatment. Design: A retrospective study in which a masterlist of presumptive multidrug-resistant TB (MDR-TB) patients registered in 18 DOTS facilities in Tondo, Manila and Payatas, Quezon City, from October 2012 to September 2013, was analysed and reviewed. Results: Among 378 presumptive DR-TB patients identified and listed in the masterlist, 97% (368/378) were referred, of whom 90% (333/368) were screened at an MDR-TB treatment centre. Of the 368 patients, 35 (9.5%) were not screened, mainly due to loss to follow-up. Among those screened, 86.4% (288/333) were recommended for anti-tuberculosis treatment, of whom 98.2% (283/288) initiated treatment. The time between sample collection and examination was significantly longer at the laboratories of non-government organisations (NGOs) than at local government units (LGUs) (1 day vs. 0 day; P < 0.001). The time to the release of smear examination results to patients was significantly shorter at the NGOs than at the LGUs (4 days vs. 6 days; P = 0.009). Conclusion: The development of the presumptive MDR-TB masterlist facilitated tracking of patients for diagnosis and treatment. The NGOs should reduce delays in diagnosis and the LGUs should intensify patient follow-up to ensure early initiation of treatment.

Contexte : Quartiers défavorisés sur le plan socio-économique aux Philippines.Objectifs : Identifier les failles dans le parcours de référence des patients présumés atteints de tuberculose pharmacorésistante (TB-DR) depuis la consultation initiale jusqu'à la mise en route du traitement.Schéma : Nous avons revu et analysé rétrospectivement les patients enregistrés sur la liste des TB multirésistantes (TB-MDR) présumées de 18 structures offrant un traitement DOTS à Tondo, Manille et Payatas, Quezon City, d'octobre 2012 à septembre 2013.Résultats : Sur 378 patients TB-DR présumés identifiés et enrégistrés, 97% (368/378) ont été référés, puis 90% (333/368) dépistés dans un centre de traitement de la TB-MDR. Des 9,5% (35/368) qui n'ont pas été dépistés, ils avaient été perdus de vue en majorité. Parmi les patients dépistés, 86,4% (288/333) ont reçu une prescription de traitement de TB. Parmi eux, 98,2% (283/288) ont débuté le traitement. Le délai entre le recueil de l'échantillon et l'examen au laboratoire des organisations non gouvernementales (ONG) a été significativement plus long que dans les unités publiques locales (LGU) (1 jour contre 0 jour ; P < 0,001). Le délai de remise des résultats de l'examen du frottis au patient dans les ONG a été significativement plus court que dans les LGU (4 jours contre 6 jours ; P = 0,009).Conclusion : L'élaboration de listes de TB-MDR présumées a facilité la recherche des patients pour leur diagnostic et leur traitement. Les ONG devraient réduire les délais de diagnostic et les LGU devraient suivre leurs patients pour une mise en route rapide du traitement.

Marco de referencia: Las regiones desfavorecidas desde el punto de vista socioeconómico en las Filipinas.Objetivos: Reconocer las deficiencias en el sistema de derivación de los pacientes con presunción diagnóstica de tuberculosis farmacorresistente (TB-DR), desde la consulta inicial hasta el comienzo del tratamiento.Método: Se llevó a cabo un estudio retrospectivo de análisis y recapitulación de los pacientes registrados en la lista de referencia de casos con presunción de TB multirresistente (TB-MDR) en 18 establecimientos DOTS en Tondo, Manila y Payatas en Ciudad Quezón, de octubre del 2012 a septiembre del 2013.Resultados: De los 378 casos con presunción clínica de TB-DR detectados y registrados en la lista de referencia, se derivó el 97% (368/378) y se investigó el 90% (333/368) en un centro de tratamiento de la TB-MDR. La causa de la falta de investigación del 9,5% de los casos presuntos (35/368) consistió en primer lugar en la pérdida durante el seguimiento. Se recomendó el tratamiento antituberculoso a 86,4% de los pacientes examinados (288/333) y el 98,2% de estos comenzó el tratamiento (283/288). El lapso entre la recogida de las muestras y el examen de laboratorio en los establecimientos de las organizaciones no gubernamentales (ONG) fue significativamente más prolongado que en los establecimientos de las unidades del gobierno local (UGL) (un día contra 0 días; P < 0,001). El lapso hasta la entrega del resultado de la baciloscopia al paciente fue notablemente más corto en las ONG que en las UGL (4 días contra 6 días; P = 0,009).Conclusión: La creación de la lista de referencia de casos con presunción de TB-MDR ha facilitado el seguimiento de los pacientes con fines de diagnóstico y tratamiento. Se recomienda que las ONG acorten el lapso hasta el diagnóstico y que las UGL rastreen a los pacientes con el fin de comenzar oportunamente el tratamiento.

Impact of a training course on the quality of chest radiography to diagnose pulmonary tuberculosis.

SETTING: Socio-economically underprivileged urban areas in the Philippines. OBJECTIVE: To assess the performance of radiological technicians (RTs) 3 years after their participation in a training course to improve the quality of chest X-ray (CXR) and to test a monitoring visit after the course. DESIGN: A cross-sectional and observational study including on-site monitoring of X-ray facilities in Manila and Quezon City and assessment of CXR films taken by 23 RTs who previously attended a training course in 2009 or 2010. The sum of the assessment scores for each of six assessment factors at four points, i.e., before and after the training course that had been previously analysed, and before and after the monitoring visits that were currently analysed, were compared. RESULTS: Two assessment sum scores, identification mark or patient positioning, did not show significant differences. However, assessment of density, contrast, sharpness and artefact significantly improved after the training course, and before and after the monitoring visit, compared with before the training. There were no significant differences in any of the assessment factors before and after the monitoring visits. CONCLUSION: The training course appears to have had a long-term effect on maintaining CXR quality. The post-training monitoring visit did not significantly improve CXR quality.

Contexte : Zones urbaines de bas niveau socio-économique aux Philippines.Objectif : Evaluer la performance des manipulateurs radio (RT) dans les 3 années suivant leur participation à un cours de formation destiné à améliorer la qualité des radiographies pulmonaires (CXR) ainsi que l'effet d'une visite de suivi après le cours.Schéma : Etude transversale et d'observation incluant le suivi sur place des structures de radiographie à Manille et Quezon et l'évaluation des clichés de CXR pris par 23 RT qui avaient assisté au cours de formation en 2009 ou 2010. Les sommes des scores d'évaluation de chacun des six facteurs d'évaluation à quatre moments, c'est-à-dire avant et après le cours de formation qui avaient été évalués précédemment et avant et après les visites de suivi qui étaient en cours d'analyse, ont été comparées.Résultats : Deux sommes de scores d'évaluation­identification du cliché ou positionnement du patient­n'ont pas mis en évidence de différence significative. Cependant, en ce qui concerne la densité, le contraste, la définition et les artefacts, une amélioration significative a été constatée après le cours de formation et avant et après la visite de suivi, par comparaison avec les résultats préalables à la formation. Par contre, il n'y a eu de différence significative dans aucun des facteurs d'évaluation avant et après les visites de suivi.Conclusion : Le cours de formation a démontré un effet à long terme en termes de maintien de la qualité des RP. Par contre, la visite de suivi après la formation n'a pas significativement amélioré la qualité des RP.

Marco de referencia: Zonas urbanas en situación socioeconómica desfavorable en las Filipinas.Objetivo: Evaluar el desempeño de los auxiliares técnicos de radiología (RT) 3 años después de haber participado en un curso de capacitación destinado a mejorar la calidad de la radiografía de tórax (CXR) y la utilidad de una visita de supervisión después del curso.Métodos: Se llevó a cabo un estudio transversal y de observación, en el cual se realizó una supervisión directa de las instalaciones de radiología en Manila y Ciudad Quezón y se evaluaron las CXR realizadas por 23 auxiliares RT que habían atendido a un curso de capacitación en el 2009 o el 2010. Se calificaron seis criterios de calidad de las CXR y la suma de las puntuaciones de cada criterio se categorizó en cuatro niveles; se compararon las sumatorias de las puntuaciones en cada momento de evaluación antes y después de la capacitación y antes y después de las visitas de supervisión realizadas durante el estudio.Resultados: Las sumatorias de las puntuaciones de dos criterios­la marca de identificación y el posicionamiento del paciente­no exhibieron diferencias significativas en los diferentes momentos de evaluación. Sin embargo, las puntuaciones sobre la densidad, el contraste, la nitidez y la presencia de artefactos revelaron una mejoría significativa después de la capacitación y también antes y después de la visita de supervisión, comparadas con las calificaciones obtenidas antes del curso de capacitación. No se observaron diferencias significativas en los criterios de calidad evaluados antes y después de las visitas de supervisión.Conclusión: El curso de capacitación ofrece un efecto a largo plazo sobre el mantenimiento de la calidad de las CXR. Las visitas de supervisión posteriores al entrenamiento no tuvieron una repercusión importante sobre la calidad.

Prevalence and associated factors of depressive state among pulmonary tuberculosis patients in Manila, The Philippines.

SETTING: Both depression and tuberculosis (TB) are global public health problems that have a substantial impact on human health. However, depressive state among TB patients has not been well investigated in the Philippines. OBJECTIVE: To assess depressive state among pulmonary tuberculosis (PTB) patients and to identify factors associated with depressive state in Manila, the Philippines. DESIGN: A cross-sectional survey of PTB patients was conducted at 10 public health centres and two non-government organisation clinics providing directly observed treatment in District I, Tondo, Manila. Face-to-face interviews with 561 PTB patients using a structured questionnaire were conducted. RESULTS: Depressive state was observed in 16.8% of the participants. Logistic regression analysis indicated that body mass index < 18.5 kg/m(2), marital status of cohabitation compared with married, four or more symptoms, four or more adverse drug reactions, grade 3 or higher on the Medical Research Council dyspnoea scale and low perceived confidant social support were significantly associated with depressive state. CONCLUSION: Depressive state among PTB patients in economically depressed areas is common, and screening for depression in the primary care setting can identify patients who need support and treatment, especially for malnourished patients and those with poor social support.

Isolated colonic hernia through the esophageal hiatus.

We report on a 75-year-old woman with an isolated colonic hernia through the esophageal hernia. The patient had suffered from cough, palpitation and dyspnea. A chest X-ray showed a colon loop gas in the mediastinum. Simultaneous barium swallow and enema showed the herniation of the only transverse colon into the mediastinum and displacement of the distal esophagus by the migrated colon. The patient underwent an open-mesh cruroplasty and a Hill's posterior gastropexy. The postoperative clinical course was uneventful. The patient has cessation of the symptoms. To our knowledge, there are only five reports presenting patients with isolated colonic hernia through the esophageal hiatus, including our case.

Intraductal papillary tumors of the pancreas. Histopathologic correlation of MR cholangiopancreatography findings.

PURPOSE: To evaluate MR cholangiopancreatography (MRCP) findings of intraductal papillary tumors of the pancreas and correlate them with histopathology. MATERIAL AND METHODS: Seventeen patients with intraductal papillary tumor of the pancreas underwent MRCP before surgery. MRCP findings were correlated to histopathology with regard to the presence of septa and excrescent nodules in the cystic lesion, communication between the cystic lesion and the main pancreatic duct (MPD), degree of dilatation of MPD, and dilatation of the common bile duct (CBD). RESULTS: MRCP demonstrated septa in 17 cases (100%), excrescent nodules in 8 cases (47.1%), communication between the intraductal papillary tumor and the MPD in 14 cases (82.3%), dilatation of MPD over 50% in 6 cases (35.3%), and dilatation of CBD in 3 cases (17.6%). These findings showed excellent correlation with histopathology. The septum on MRCP corresponded with a layer of connective tissue with pancreatic duct epithelium. Excrescent nodules in the carcinomas consisted not only of malignant cells, but also of dysplasia and adenoma. Excrescent nodules in adenomas were consistent not only with minimal papillary growth of adenoma, but also with proliferation of fibrosis, and hematoma and organized fibrin with minimal fibrosis. Pancreatic tissue was affected by chronic pancreatitis in all cases. Cases with dilatation of CBD on MRCP were due to microscopic invasion by the carcinoma. CONCLUSION: MRCP appearances of intraductal papillary tumors are well correlated with the findings at histopathology.

Renal cell carcinomas in von Hippel-Lindau disease; tumor detection and management.

Twenty-seven renal cell carcinomas (RCCs) found in one family affected with von Hippel-Lindau disease were examined using ultrasound (US), CT, MRI and angiography. The sensitivity of the tumor detection using different imaging modalities was evaluated by macroscopic pathology (solid or cystic) and size (exceeding 2cm in diameter or not). In 18 of the RCC's exceeding 2cm in diameter (eight solid and ten cystic), all lesions were detected on US, CT, and MRI. However, on angiography, solid RCCs were detected in 88%, and cystic RCCs were detected in 60%. In nine RCCs less than 2cm in diameter (seven solid and two cystic), solid RCCs were detected in 86% on US, 86% on CT, 80% on MRI, and 43% on angiography, but cystic RCCs were detected in 50% on only CT and MRI. From the pathologic correlation, even renal simple cystic lesions in VHL are considered premalignant lesions and they had better be removed if the residual renal function after surgery is preserved. In case of the observation, they should be followed carefully using thin slice thickness dynamic CT to discover the wall irregularity, septation and irregular contour.

Outcome of liver transplantation for transthyretin amyloidosis: follow-up of Japanese familial amyloidotic polyneuropathy patients.

Since 1990, liver transplantation for familial amyloidotic polyneuropathy (FAP) has been carried out world-wide, and the outcome of the procedure seems to be promising. FAP is inherited systemic disease caused by mutated transthyretin. The most common cause is the valine to methionine substitution at position 30 (Met30). We have developed a scoring system for FAP Met30 that takes into account a variety of clinical symptoms of the disease. Six patients with FAP Met30 underwent extensive examinations according to our scoring system before and after transplantation. All patients survived the procedure and are alive after transplantation. Improvements of sensory and autonomic disturbances were observed during the initial 12 months after the procedure only, thereafter the patients' status remained unchanged. Following transplantation, no improvement of motor function and visceral organ damage were observed, but the modified body mass index improved in four of six patients after the operation. These results suggest that liver transplantation of FAP patients stops the progress of the disease, and that minor improvements are noted in several patients after the procedure. However, transplantation should be performed early after the onset of the disease in order to preserve the patients' functional status.

Correlation of 99mTc-GSA hepatic scintigraphy with liver biopsies in patients with chronic active hepatitis type C.

99mTc-DTPA-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy was performed in 230 patients with chronic active hepatitis type C, and its quantitative indices were compared with histological findings. 99mTc-GSA findings correlated well with four indices of the histology activity index (HAI), especially with the fibrosis score. Ninety patients were given interferon treatments, and 99mTc-GSA findings were compared with the results of the treatments. We classified the effects of interferon treatment into three groups according to clinical outcome: group 1: good effect (HCV-RNA negative, n = 34), group 2: moderate effect (HCV-RNA positive, but the value of GPT was normal for six months after the end of treatment, n = 19) and group 3: no effect (n = 37). Quantitative indices of 99mTc-GSA showed significant differences between groups. Follow-up study with 99mTc-GSA scintigrams was obtained in eight patients. The results of 99mTc-GSA improved in three patients in group 1 and deteriorated in five patients in group 3. There is a possibility that 99mTc-GSA scintigraphy can be used to predict the clinical outcome of chronic active hepatitis type C after interferon treatment.

Confirmation of yessotoxin and 45,46,47-trinoryessotoxin production by Protoceratium reticulatum collected in Japan.

Two different strains of the dinoflagellate Protoceratium reticulatum collected at Harima Nada and Yamada Bay in Japan were cultured and analyzed by fluorometric HPLC for yessotoxin production. Only the Yamada Bay strain produced yessotoxin. The toxin together with its analog, 45,46,47-trinoryessotoxin, were isolated from larger scale culture and unambiguously confirmed by (1)H NMR and MS measurements. This is the first confirmation of the biogenetic origin of yessotoxin in Japan, where the toxin was first reported. The results also indicate that the production of yessotoxins by P. reticulatum differs from strain to strain, in a similar way to that observed in many other toxigenic dinoflagellates such as Dinophysis spp. and Alexandrium spp.

[Evaluation of hepatic artery occlusion after intra-arterial infusion of SMANCS in patients with hepatocellular carcinoma].

Although intra-arterial infusion of SMANCS is effective for the treatment of hepatocellular carcinoma, injury of the hepatic artery is occasionally encountered. We analyzed 78 patients with hepatocellular carcinoma who received intraarterial infusion of SMANCS. Twenty-seven patients who were treated by epirubicin were used as a control. Complete occlusion of the right hepatic artery was induced in 15 patients who received SMANCS infusion. The average number of administrations was 1.9 in the occluded group, 1.5 in the non-occluded group, and 1.6 in the epirubicin group. There was no statistically significant difference in the dose of drugs in a single session between the three groups (3.5 +/- 1.5 ml in the occluded group, 3.6 +/- 1.5 ml in the non-occluded group and 4.2 +/- 1.2 ml in the epirubicin group), and there was no statistically significant difference in total dose between the three groups (6.8 +/- 2.6 ml in the occluded group, 5.5 +/- 3.6 ml in the non-occluded group and 6.8 +/- 4.3 ml in the epirubicin group). However, total dose per tumor volume was significantly larger in the occluded group (1.1 +/- 1.0 cm3) than in the non-occluded group (0.5 +/- 0.5 cm3) (p < 0.05). Excess infusion of SMANCS for small hepatocellular carcinomas appears to be an important factor in vascular injury.

Post-translational modification of transthyretin in plasma.

To determine the behavior of transthyretin (TTR) in blood circulation, TTR purified from normal subjects' plasma was injected to rats, and blood and urine were collected time dependently. Although TTR in plasma was proven to be a predominantly cysteine (Cys) conjugated form by electrospray ionization mass spectrometry (ESI-MS) analysis, it was gradually converted into free, 32 Da (dihydroxylation), 80 Da (phosphorylation), and 306 Da (glutathionylation), increased forms in molecular weight of TTR. The plasma levels of TTR were decreased in a time-dependent manner with the half life of 72.4 min. No secretion of TTR into the urine was observed by ESI-MS. In conclusion, this method can be simply performed without loading a radioactive molecule to the targeted protein. It offers a possibility to determine natural protein behaviors in the blood stream.

Visceral orthostatic hypotension in patients with severe autonomic dysfunction.

Although changes in the blood flow of the cerebral vessels and the peripheral vessels in the extremities after changing body postures have been well examined in patients with orthostatic hypotension (OH), such changes in visceral vessels have not been well investigated. To elucidate the effect of autonomic dysfunctions on changes in the abdominal blood flow, the blood flow velocity of the portal vein was measured by Doppler ultrasonography in 11 patients with familial amyloidotic polyneuropathy (FAP) (Met30), 3 with pandysautonomia, 1 with Shy-Drager syndrome, and 10 healthy controls, in the supine and at the upright position. Among the 15 patients with the above-mentioned autonomic disorders, 5 of the patients showed a marked decrease in blood flow after standing, and one of these 5 patients exhibited transient hepatic and intestinal ischemia during intensive rehabilitation because of a severe decrease in visceral blood flow. Another 7 patients exhibited moderate decreases in the blood flow after standing. In contrast, no such change was observed in the 10 healthy controls. The FAP patients with L-threo-3,4-dihydroxyphenylserine (L-threo-DOPS) administration showed no significant correlation between the degree of OH and the decrease in the blood flow of the portal vein, and the patients without the drug exhibited a weak correlation. On the contrary, the pandysautonomia and Shy-Drager syndrome patients exhibited a linear positive correlation. These results suggest that FAP is a disease for which this kind of ultrasonographic examination should be applied, and that Doppler ultrasonography may be a helpful tool to evaluate visceral OH.

Endoscopic and pathological manifestations of the gastrointestinal tract in familial amyloidotic polyneuropathy type I (Met30).

OBJECTIVES: To evaluate the characteristic changes in the gastrointestinal tract in familial amyloidotic polyneuropathy (FAP) (Met30), both fibre gastroscopy and colonoscopy studies were performed in FAP (Met30) patients. Microscopic changes were also examined in autopsied and biopsied materials from patients with FAP, and compared with data from autopsied samples from patients with AL amyloidosis, and secondary amyloidosis patients. DESIGN: Endoscopic and histopathological study. SETTING: Kumamoto University Hospital, Kumamoto, Japan. SUBJECTS: Nine patients with FAP (Met30) underwent fibre gastroscopy and colonoscopy. Six autopsied and 23 biopsied gastrointestinal samples from FAP patients, four from autopsied amyloidosis (including two myeloma associated form), and two from autopsied secondary amyloidosis patients were examined for histopathological study. MAIN OUTCOME MEASURES: Fibre gastroscopy and colonoscopy were employed for macroscopic study. Congo red and H-E staining were performed for histopathological study. Macroscopic changes in the gastrointestinal tract and microscopic differences in the amyloid distribution pattern were compared between the different types of amyloidosis. RESULTS: Fibre gastroscopy and colonoscopy for nine FAP patients revealed that four showed a fine granular appearance in the duodenum, three showed lack of lustre, and two showed mucosal friability in the gastrointestinal tract; however, no macroscopic abnormality was observed in four other FAP patients. Histopathological examination of tissue from FAP patients revealed that, although a small amount of amyloid was recognized in the submucosa perivascular layer, a significant amount of amyloid was seen in and around the nerves of the gastrointestinal tract, but very little in Auerbach's nerve plexus. In total, the amount of deposited amyloid in the tissues was small compared with that in other types of systemic amyloidosis, such as AL and secondary amyloidosis. CONCLUSION: These results suggest that the major reason why FAP patients show such severe gastrointestinal symptoms, compared with other types of systemic amyloidosis, may be because of the deposition of a significant amount of amyloid in the nerves in the gastrointestinal tract.

[Intra-arterial infusion of SMANCS for treatment of patients with hepatocellular carcinoma--adverse reactions and complications].

Although intra-arterial infusion of SMANCS has been demonstrated to be highly effective for treatment of patients with hepatocellular carcinoma, it is reported to cause critical adverse reactions and complications. We examined the adverse reactions of SMANCS on the hepatic artery in 78 patients with hepatocellular carcinoma, who were infused with SMANCS from right, left or proper hepatic artery at our hospital. SMANCS caused right hepatic artery occlusion in 15 patients (19%) and the average amount of infused SMANCS was 6.8 mg. The tumor volume in the artery occluded patients was smaller than that in the artery non-occluded patients. Then, the mechanism by which SMANCS caused arterial occlusion was its induction of arterial injuries by excess infusion. When SMANCS was infused to whole liver, it induced decreased hepatic functional reserve and liver atrophy, followed by delayed liver failure. Other adverse reactions were no different from those in patients infused with epirubicin-lipiodol emulsion.

Percutaneous microwave coagulation therapy: an experimental study.

PURPOSE: Microwave coagulation therapy (MCT) is a surgical alternative for inoperable hepatocellular carcinomas (HCCs). We have recently developed a percutaneous method for using MCT under ultrasound guidance. The purpose of this study was to investigate the feasibility of percutaneous MCT (PMCT) in an animal model and correlate the ultrasound findings with histological results. MATERIALS AND METHODS: Microwaves were administered for 30, 45, 60 and 90 seconds to 12 cadaveric porcine livers in vivo one hour after sacrificing them, to determine the most suitable coagulation time for the percutaneous method. The cadaveric livers were then subjected to histologic evaluation. The temperature around the electrode was measured in both cadaveric and living livers during PMCT. Ultrasound-guided MCT was also performed in nine rabbits. The histological findings after PMCT were evaluated in the cadaveric and living livers, and the areas of coagulation necrosis were correlated with the ultrasound findings. RESULTS: After microwave emission, coagulation necrosis of a spindle shape occurred primarily from the base of the electrode. The maximum area of coagulation was obtained at 60 seconds. The maximum temperature of cadaveric liver under PMCT was 95 degrees at 3 mm from the electrode; that of living liver was 85.1 degrees at 5 mm. Ultrasound revealed hyperechoic areas after PMCT in both cadaveric and living livers. On microscopy, parenchymal necrosis of the liver was observed only in living livers one month after MCT. Hyperechoic areas measured with ultrasound were significantly larger than the actual necrotic areas (p < 0.01), probably due to air bubbles which developed within the tissue. CONCLUSIONS: PMCT completely coagulated the liver tissue around the electrode. These preliminary results indicate that PMCT should be an effective treatment for hepatic neoplasms. In terms of clinical application, the hyperechoic areas observed during PMCT appear to be considerably larger than the areas actually treated.

Percutaneous microwave coagulation therapy in liver tumors. A 3-year experience.

PURPOSE: Percutaneous microwave coagulation therapy (PMCT) is an interventional alternative for inoperable malignant liver tumors. In this paper, we report the results of our 3-year experience of PMCT in order to establish suitable indications for this treatment. MATERIAL AND METHODS: We studied a total of 27 inoperable liver tumors in 24 patients. Histology of the tumors showed 20 hepatocellular carcinomas (HCCs) (13 well differentiated, 4 moderately differentiated, and 3 poorly differentiated) and 7 metastases. These tumors were treated by PMCT and were followed for 4-40 months (average 18 months). Under US guidance, the tumors were coagulated by microwaves emitted from an electrode. The changes of tumor size after PMCT were evaluated by CT. When the tumors disappeared or were reduced in size after treatment, PMCT was regarded as effective. Complications from PMCT were also evaluated. The patient survival rate was obtained by means of the Kaplan-Meier method. RESULTS: In tumors of 30 mm or less, treatment response was obtained in 70% of cases, while 55% of tumors larger than 30 mm responded. The tumor became smaller or disappeared in 85% of the well differentiated HCCs, and in 25% of the moderately differentiated HCCs, but none of the poorly differentiated HCCs responded. In metastatic tumors, PMCT was effective in 57% of cases. Slight pain (24%), fever (20%) and subcutaneous hematoma (8%) were experienced immediately after PMCT. In 2 poorly differentiated HCCs, needle tract seeding was observed. No case of liver dysfunction was seen after PMCT. The overall survival rate was 83.1% at 1 year and 68.7% at 2 years. CONCLUSION: Good therapeutic results were achieved with PMCT in lesions of 30 mm or less, and in well differentiated HCCs.

Small cell carcinoma of the stomach: a case report.

A case of a gastric small cell carcinoma discovered incidentally by screening ultrasonography is presented. Ultrasonography demonstrated a subcardial metastatic lymph node and multiple hepatic metastatic lesions. Upper GI series and gastroendoscopy revealed a large ulcerated tumor in the cardia of the stomach, and a Borrmann type II tumor, 4 x 2.5 cm, was found in the resected stomach. We describe the radiological findings of the upper GI series, ultrasonography, CT, and gastroendoscopy, and review the literature.

MR imaging enhancement with superparamagnetic iron oxide in chronic liver disease: influence of liver dysfunction and parenchymal pathology.

PURPOSE: To analyze the influence of liver dysfunction and parenchymal pathology on the accumulation of superparamagnetic iron oxide (SPIO). METHODS: We evaluated MR images of 13 patients having small hepatic neoplasms before and after administration of SPIO (10 micronol/kg). Biopsy and laboratory data confirmed the presence of severe cirrhosis in two patients, mild cirrhosis in four, chronic hepatitis in five, and normal livers in two. Degrees of liver dysfunction or liver parenchymal pathology were correlated with reductions in signal intensity of the liver and spleen after administration of SPIO. Signal intensity reduction was evaluated using a 1.5 Tesla MR unit. RESULTS: Response to SPIO of the liver and spleen did not correlate with liver parenchymal pathology, although reductions in signal intensity of the liver were somewhat small in severely cirrhotic livers. There were slight correlations between signal intensity alterations of the liver and laboratory data such as the indocyanine green retention rate (correlation coefficient 0. 47), albumin (0.36), total bilirubin (0.36), and serum glutamic oxaloacetic transaminase (GOT) (0.46). Signal intensity reduction of spleen did not correlate with liver function tests except for serum GOT. In patients with cirrhosis, heterogeneous structures were detected in the nontumorous portions of the liver. However, these did not prevent the diagnosis of small hepatomas. CONCLUSION: The uptake of SPIO showed some correlation with liver function but not with chronic liver parenchymal pathology. SPIO provided sufficient contrast between tumor and surrounding liver parenchyma among patients with chronic liver disease.