Intestinal Perforation Caused by Lumboperitoneal Shunt Insertion Repaired with an Over-the-Scope Clip.

Lumboperitoneal or ventriculoperitoneal shunt insertion is a standard therapy for hydrocephalus that diverts cerebrospinal fluid from the subarachnoid space into the peritoneal cavity. Gastrointestinal perforations due to this procedure occur rarely; however, accepted treatment strategies have not yet been established. Hence, the most common treatment approaches are open surgery or spontaneous closure without endoscopy. We report the case of a small intestinal perforation in a 73-year-old-woman that occurred after the insertion of a lumboperitoneal shunt. A positive cerebrospinal fluid culture and high cerebrospinal fluid white blood cell count indicated a retrograde bacterial infection, and computed tomography revealed that the peritoneal tip of the shunt catheter was located in the lumen of the gastrointestinal tract. We repaired the perforation endoscopically using an over-the-scope clip, and the patient's recovery was uneventful. Use of an over-the-scope clip could be an effective and minimally invasive treatment for intestinal perforations caused by lumboperitoneal or ventriculoperitoneal shunt insertion.

Factors explaining the yearly changes in minimum bottom dissolved oxygen concentrations in Lake Biwa, a warm monomictic lake.

Vertical profiles of dissolved oxygen (DO) and water temperature (WT) measured bi-monthly for 36 years (1980-2015) near the deepest part of a warm monomictic lake were analyzed with special reference to yearly minimum DO at bottom (DOmin). DOmin changed yearly (3.0 ± 1.2 mg l-1) and significant differences in DOmin were not observed between Period I (1980-1993; cooler and worse in water quality) and Period II (1994-2015; warmer and better in water quality). This unclear trend in DOmin was probably due to the offsetting influences between warming induced by global warming and oligotrophication attempted by local governments etc. for the study period. DOmin was positively correlated with disturbance time (timing of last cold water intrusion observed from Mar to Aug), which could be related to the start of DO depletion at bottom. Thus, the linear model using this parameter could predict yearly DOmin fairly well for the entire study period (r2 = 0.60). In addition, DOmin and time of disturbance were correlated negatively with water density at bottom in Jan and positively with water density equilibrated to air temperature (AT) in Mar. Higher lake water density after full depth mixing advances the disturbance time. In contrast, lower AT in Mar and/or higher density of influent water after Mar delays the time likely due to the larger amount of snowfall in the watershed. Further, DOmin was positively correlated with maximum wind velocity in Sep which probably induced the recovery of DO. Multiple-regression models to predict DOmin using these meteorological and water quality parameters were developed (r2 ≥ 0.38, worse performances than the model using disturbance time) to forecast future trends of DOmin through global warming and/or climate change. Significant influences of water or sediment oxygen demands on DOmin were not detected. We also discuss the applicability of the proposed models.

Correction: Cost-efficient strategy for reducing PM 2.5 levels in the Tokyo metropolitan area: An integrated approach with air quality and economic models.

[This corrects the article DOI: 10.1371/journal.pone.0207623.].

Cost-efficient strategy for reducing PM 2.5 levels in the Tokyo metropolitan area: An integrated approach with air quality and economic models.

To attain cleaner air, it is important that authorities make informed decisions when selecting a strategy. Concentrations of particulate matter with an aerodynamic diameter of less than or equal to 2.5 µm (PM 2.5) are high in the Tokyo metropolitan area, even though concentrations of particulate matter with an aerodynamic diameter of less than or equal to 10 µm (PM10) have dropped dramatically since the implementation of the NOx-PM Act. Currently, monitored concentration levels continue to exceed the designated ambient air quality standard set by the Japanese Ministry of the Environment. To our knowledge, no study has investigated a cost-efficient strategy for reducing PM 2.5 concentration levels in the Tokyo metropolitan area. This is the first study to examine a proper control strategy for Japan by developing an integrated model that includes both aerosol and economic models. The simulation results show that prefectures in the Tokyo metropolitan area cannot achieve the standards by relying on their own efforts to reduce PM 2.5. That is, prefectural governments in the Tokyo metropolitan areas need to cooperate with prefectures outside of the area to improve their PM 2.5 concentration levels. Thus, we simulated policies under the assumption that emissions from other sources are reduced to levels such that the PM 2.5 concentration declines by approximately 18 µg/m3. We first simulated an efficient policy, i.e., the implementation of a pollution tax. We found that the total abatement cost to meet the air quality standard using the cost-efficient strategy is approximately 142.7 billion yen.

The scab-like sign: A CT finding indicative of haemoptysis in patients with chronic pulmonary aspergillosis?

OBJECTIVES: The aim of this study was to assess the CT findings that characterise haemoptysis in patients with chronic pulmonary aspergillosis (CPA). METHODS: We retrospectively identified 120 consecutive patients with CPA (84 men and 36 women, 17-89 years of age, mean age 68.4 years) who had undergone a total of 829 CT examinations between January 2007 and February 2017. In the 11 patients who underwent surgical resection, CT images were compared with the pathological results. RESULTS: The scab-like sign was seen on 142 of the 829 CT scans, specifically, in 87 of the 90 CT scans for haemoptysis and in 55 of the 739 CT scans obtained during therapy evaluation. In 48 of those 55 patients, haemoptysis occurred within 55 days (mean 12.0 days) after the CT scan. In the 687 CT scans with no scab-like sign, there were only three instances of subsequent haemoptysis in the respective patients over the following 6 months. Patients with and without scab-like sign differed significantly in the frequency of haemoptysis occurring after a CT scan (p<0.0001). Pathologically, the scab-like sign corresponded to a fibrinopurulent mass or blood crust. CONCLUSIONS: The scab-like sign should be considered as a CT finding indicative of haemoptysis. KEY POINTS: • Haemoptysis is commonly found in patients with CPA. • A CT finding indicative of haemoptysis in CPA patients is described. • Scab-like sign may identify CPA patients at higher risk of haemoptysis.

Shifts of radiocesium vertical profiles in sediments and their modelling in Japanese lakes.

Vertical profiles of radiocesium concentrations were measured in sediment cores collected at various times after the 2011 Fukushima nuclear accident in five Japanese lakes (Hinuma, Kasumigaura, Kitaura, Onogawa and Sohara) with different morphological and trophic characteristics in order to investigate the sedimentation-diffusion processes. In lakes where sediments had high porosities and experienced considerable wave action due to shallowness, we observed rapid penetration of radiocesium to a certain depth just after the accident, followed by downward movement of the peak depths. In contrast, gradual downward transfers of distinct peaks were found in other types of lakes. A one-dimensional differential sediment model with water-sediments interaction processes was constructed to describe the vertical shift of radiocesium profiles. Our proposed submodels relating to the length scales of the mixing using wind-induced stress and porosity of sediments were constructed based on one measurement of the vertical distribution of radiocesium in three lakes (Hinuma, Kasumigaura and Sohara). This model was then validated using samples from those lakes in different years, as well as from two other lakes. Good agreement was obtained. We discuss our findings, the limits of model application, and future research targets.

Single Amino Acid Polymorphisms of Pertussis Toxin Subunit S2 (PtxB) Affect Protein Function.

Whooping cough due to Bordetella pertussis is increasing in incidence, in part due to accumulation of mutations which increase bacterial fitness in highly vaccinated populations. Polymorphisms in the pertussis toxin, ptxA and ptxB genes, and the pertactin, prn genes of clinical isolates of Bordetella pertussis collected in Cincinnati from 1989 through 2005 were examined. While the ptxA and prn genotypes were variable, all 48 strains had the ptxB2 genotype; ptxB1 encodes glycine at amino acid 18 of the S2 subunit of pertussis toxin, while ptxB2 encodes serine. We investigated antigenic and functional differences of PtxB1 and PtxB2. The S2 protein was not very immunogenic. Only a few vaccinated or individuals infected with B. pertussis developed antibody responses to the S2 subunit, and these sera recognized both polymorphic forms equally well. Amino acid 18 of S2 is in a glycan binding domain, and the PtxB forms displayed differences in receptor recognition and toxicity. PtxB1 bound better to the glycoprotein, fetuin, and Jurkat T cells in vitro, but the two forms were equally effective at promoting CHO cell clustering. To investigate in vivo activity of Ptx, one µg of Ptx was administered to DDY mice and blood was collected on 4 days after injection. PtxB2 was more effective at promoting lymphocytosis in mice.

Low-dose CT scan screening for lung cancer: comparison of images and radiation doses between low-dose CT and follow-up standard diagnostic CT.

OBJECTIVES: This study aim to compare image quality and radiation doses between low-dose CT and follow-up standard diagnostic CT for lung cancer screening. METHODS: In a single medical institution, 19 subjects who had been screened for lung cancer by low-dose CT before going through follow-up standard diagnostic CT were randomly selected. Both CT image sets for all subjects were independently evaluated by five specialized physicians. RESULTS: There were no significant differences between low-dose CT screening and follow-up standard diagnostic CT for lung cancer screening in all 11 criteria. The concordance rate for the diagnoses was approximately 80% (p < 0.001) for all categories. Agreement of the evaluation of all categories in the final diagnosis exceeded 94% (p < 0.001). Five physicians detecting and characterizing the pulmonary nodules did not recognized the difference between low-dose CT screening and follow-up standard diagnostic CT. With low-dose CT, the effective dose ranged between 1.3 and 3.4 mSv, whereas in the follow-up diagnostic CT, the effective dose ranged between 8.5 and 14.0 mSv. CONCLUSION: This study suggests that low-dose CT can be effectively used as a follow-up standard diagnostic CT in place of standard-dose CT in order to reduce the radiation dose.

Evaluation of microscopic tumor extension in early-stage cervical cancer: quantifying subclinical uncertainties by pathological and magnetic resonance imaging findings.

We performed a detailed analysis of hysterectomy specimens of uterine cervical cancer to determine the appropriate length of uterine body to include within the clinical target volume. Between 2008 and 2011, 54 patients with uterine cervical carcinoma underwent hysterectomy. Those with quality pre-operative magnetic resonance imaging (MRI) data were included for analysis. Tumor sizes measured by MRI and microscopy were compared with regard to brachytherapy-oriented parameters. Detailed descriptive analysis focusing on the extent of tumor involvement was also performed. A total of 31 specimens were analyzed. The median maximal tumor length measured by MRI was slightly shorter than microscopic length (19 vs. 24 mm, respectively), while the maximal radius was almost identical. No tumors with a maximal size <2 cm by MRI (n = 6) extended to the uterine body ≥ 1/3. The majority of maximal tumor length underestimation on MRI was within 1 cm. Precise tumor delineation can be made by MRI. For patients with tumors <2 cm on MRI, treating the entire uterine body length may not be necessary. A 1-cm margin around an MRI-based gross tumor seems to be adequate to cover the actual tumor involvement.

Association of computed tomography-detected pulmonary interstitial changes with severe radiation pneumonitis for patients treated with thoracic radiotherapy.

We evaluated associations of interstitial changes with radiation pneumonitis (RP) for patients treated with thoracic radiotherapy. Between 2005 and 2009, patients who received thoracic radiotherapy of 40 Gy or more for lung cancer or thymic tumors and were followed-up for more than 6 months were eligible for this study. Possible risk factors for RP included the presence of interstitial changes on computed tomography before radiotherapy, and elevated C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels; these were compared with the incidences of severe RP. A total of 106 patients were included. The incidences of RP were 4 (4%), 0 (0%), and 5 (5%) for grades 3, 4, and 5, respectively. For those with interstitial changes, the incidence of RP ≥ grade 3 was significantly increased from 3% (2/79) to 26% (7/27) (p < 0.001). CRP and LDH levels were also associated with increased RP, as were pulmonary emphysema and performance status ≥ 2. Among 91 patients with RP ≥ grade 1, RP grade ≥ 3 occurred significantly earlier than grades 1 and 2. In conclusion, pulmonary interstitial changes, LDH and CRP levels, pulmonary emphysema, and performance status ≥ 2 were significantly associated with RP ≥ grade 3. RP grade ≥ 3 occurred significantly earlier than grades 1 and 2. The early appearance of interstitial changes requires careful management due to the possibility of severe RP.

Internal hernias after abdominal surgeries: MDCT features.

As less-invasive treatments for small bowel obstruction, such as laparoscopic surgery or small incision therapy, have become common, there is a growing demand for preoperative assessment of the cause and location of the small bowel obstruction. Thus, the role of computed tomography (CT) in the evaluation of small bowel obstruction is expanding. CT imaging of internal hernias (IHs) has been extensively described and is well established; however, CT imaging of IH after abdominal surgeries is not well recognized because of their anatomical complexity. The aims of this pictorial review are (1) to evaluate the causes of internal IHs in relation to previous abdominal surgery (e.g., IH associated with Roux-en-Y reconstruction, Billroth II reconstruction, peritoneal adhesive band, perineal hernia, and IH after gynecological procedures), (2) to demonstrate the spectrum of imaging findings on multidetector CT (MDCT), and (3) explain the key features for CT diagnosis of IHs related to previous surgical procedures, with emphasis on the multi-planar reformation (MPR) image. We also demonstrate the dynamic changes in the progression of mesenteric strangulation revealed by CT. Understanding the imaging appearance on MDCT can help radiologists guide therapy for patients with a small bowel obstruction after abdominal surgery.

Protective effects of vaccines against Bordetella parapertussis in a mouse intranasal challenge model.

Bordetella parapertussis causes typical whooping cough, as does Bordetella pertussis. However, current commercial vaccines are ineffective against B. parapertussis. In an effort to develop vaccines that are effective in protecting against both B. pertussis and B. parapertussis, we examined the protective effects of vaccines prepared from whole-cells and from recombinant proteins derived from B. parapertussis in a mouse intranasal challenge model. We confirmed current pertussis vaccines did not induce protective immunity against B. parapertussis in the mouse model. A whole-cell vaccine prepared from B. parapertussis induced protective immunity against B. parapertussis but not against B. pertussis, suggesting a combination of a current pertussis vaccine with a whole-cell parapertussis vaccine might prevent whooping cough caused by both species of Bordetella. We also found that filamentous hemagglutinin was a protective antigen of B. parapertussis. Our observations should lead to the development of new pertussis vaccines that can control the two prevalent forms of whooping cough.

Synergic effect of genotype changes in pertussis toxin and pertactin on adaptation to an acellular pertussis vaccine in the murine intranasal challenge model.

The Bordetella pertussis pertussis toxin and pertactin (Prn) are protective antigens and are contained in acellular pertussis vaccines. Polymorphisms in the A subunit of pertussis toxin (PtxA) and pertactin have been proposed to mediate vaccine resistance and contribute to pertussis reemergence. To test this hypothesis, previous studies compared clinical isolates expressing different alleles for the proteins. However, other virulence factors or virulence factor expression levels also may vary, confounding the analysis. To overcome these limitations, we constructed isogenic mutants of B. pertussis Tohama expressing the alleles ptxA1 or ptxA2 and prn1 or prn2 and compared the efficacies of an acellular pertussis vaccine against the mutants in a mouse model. While the vaccine was effective against all of the B. pertussis strains regardless of the allele expression pattern, the strain expressing ptxA1 and prn2 displayed a survival advantage over the other strains. These results suggest that an allele shift to the ptxA1 prn2 genotype may play a role in the emergence of pertussis in vaccinated populations.

Sarcoidosis associated with renal masses on computed tomography.

A 50-year-old woman was admitted to our hospital after computed tomography (CT) revealed renal masses and mediastinal lymphadenopathy. Uveitis had previously been diagnosed by a local ophthalmologist. Elevated levels of serum soluble IL2 receptor were observed. However, renal function was not compromised. Abdominal CT showed multiple low attenuation tumor-like nodules in both kidneys. As lymphoma was considered likely, CT-guided renal biopsy was performed; however, histological examination of the excised specimens revealed noncaseating granulomas. Analysis of bronchoalveolar lavage fluid demonstrated a sarcoidosis pattern. The final diagnosis was sarcoidosis with renal involvement.

Radiotherapy combined with transarterial infusion chemotherapy and concurrent infusion of a vasoconstrictor agent for nonresectable advanced hepatic hilar duct carcinoma.

BACKGROUND: The treatment of patients with advanced hepatic hilar duct carcinoma is a challenging problem. The current study was performed to evaluate the outcome of patients with advanced hepatic hilar duct carcinoma who received external beam radiotherapy (EBRT) combined with transarterial chemotherapy and infusion of a vasoconstrictor. METHODS: Between April 1993 and December 2002, 23 patients with histopathologically confirmed hilar duct carcinoma entered the study. The median total dose of EBRT was 41.4 grays (Gy). Transarterial chemotherapy was performed twice during EBRT. It was comprised of an infusion of a cocktail of 20 mg of epirubicin, 10 mg of mitomycin C, and 500 mg of 5-fluorouracil and was administered 1 minute after injection of epinephrine via a catheter introduced in the hepatic arteries. After the combined treatment, the patients underwent biliary endoprosthesis after evaluation of the initial response to treatment by percutaneous transhepatic cholangiography (PTC). The initial responses based on PTC were classified into four categories: CR, no stenosis; PR, relief of stenosis/obstruction; NC, no change; and PD, progressive stenosis/obstruction. The outcome parameters were survival rates and time, as well as frequency and type of complications. RESULTS: Excluding 1 patient who discontinued the treatment, the initial responses of 22 patients were 1 CR (5%), 8 PR (36%), 11 NC (50%), and 2 PD (9%). The response rate was 41%. The overall survival rates at 1 year, 2 years, and 3 years after treatment were 59%, 36%, and 18%, respectively. CONCLUSIONS: The combination of radiotherapy, transarterial infusion chemotherapy, and concurrent infusion of a vasoconstrictor can be delivered safely with good efficacy for patients with advanced hilar duct carcinoma.

CT and MR imaging findings of xanthogranulomatous cholecystitis: correlation with pathologic findings.

The aim of this study was to evaluate CT and MRI findings in xanthogranulomatous cholecystitis (XGC) and to correlate the imaging findings with various pathologic parameters. The study included 13 patients with histopathologically confirmed XGC. The CT ( n=13) and MRI ( n=5) obtained in these patients were evaluated retrospectively. On CT, low-attenuation areas in the wall of XGC correlated with foam and inflammatory cells or necrosis and/or abscess in XGC. Areas of iso- to slightly high signal intensity on T2-weighted images, showing slight enhancement at early phase and strong enhancement at last phase on dynamic study, corresponded with areas of abundant xanthogranulomas. Areas with very high signal intensity on T2-weighted images without enhancement corresponded with necrosis and/or abscesses. Luminal surface enhancement (LSE) of gallbladder wall represented preservation of the epithelial layer. The early-enhanced areas of the liver bed on dynamic CT and MR images corresponded with accumulation of inflammatory cells and abundant fibrosis. Our results indicate that CT and MRI findings correlate well with the histopathologic findings of XGC.

Symptomatic intrahepatic portosystemic venous shunt: embolization with an alternative approach.

OBJECTIVE: Intrahepatic portosystemic venous shunt is relatively rare and not well recognized. Awareness of intrahepatic communications is important because they can cause encephalopathy, and most of these shunts can be completely cured by transcatheter embolization. In this study, we describe the angiographic findings and transcatheter embolization techniques using several approaches for the treatment of intrahepatic portosystemic venous shunt. MATERIALS AND METHODS: Between 1989 and 2001, we treated 10 patients with symptomatic intrahepatic portosystemic venous shunt by performing transcatheter embolization with Gianturco coils, fibered platinum coils, detachable balloons, and detachable microcoils using one of three approaches to access the portal venous system: transileocolic obliteration (n = 2), percutaneous transhepatic obliteration (n = 4), or retrograde transcaval obliteration (n = 4). RESULTS: In all patients, complete obliteration or nearly complete obliteration was confirmed angiographically, and symptoms related to portal-systemic encephalopathy improved after treatment. Complications were observed in three patients: adhesive ileus in a patient treated by transileocolic obliteration and thrombosis of intrahepatic portal branches in two patients treated by percutaneous transhepatic obliteration. CONCLUSION: On angiography, two types of intrahepatic portosystemic venous shunt were seen: intrahepatic portal venous-hepatic venous communication and intrahepatic portal venous-perihepatic venous communication. Transcatheter embolization is effective for treatment of intrahepatic portosystemic venous shunt. Retrograde transcaval obliteration is the least invasive technique and is recommended as the first choice for treatment of portosystemic venous shunt except in patients with multiple shunts.

Mucin-producing carcinoma of the gallbladder: imaging demonstration in four cases.

We report four cases of mucin-producing carcinoma of the gallbladder (three papillary adenocarcinomas and one mucinous carcinoma), with an emphasis on imaging features. Our findings suggest that when a papillary protrusion or thickened wall, including cystic areas and/or calcifications, is seen radiologically in the enlarged gallbladder, mucin-producing carcinoma of the gallbladder should be included in the differential diagnosis.

Evaluation of efficacy in terms of antibody levels and cell-mediated immunity of acellular pertussis vaccines in a murine model of respiratory infection.

The efficacy of six acellular pertussis vaccines, prepared by various manufacturers in Japan, was investigated in a murine model of respiratory infection (aerosol challenge model) and a murine intracerebral (i.c.) challenge model. There was a good correlation between bacterial clearance from the lungs after aerosol challenge and the potency of vaccines as determined by i.c. challenge. The levels of antibodies against filamentous hemagglutinin were higher after immunizations with all tested vaccines than the levels of antibodies against pertussis toxin and pertactin. Spleen cells from mice immunized with each individual vaccine secreted interferon gamma (IFN-gamma) in response to stimulation by pertussis toxin, filamentous hemagglutinin and fimbriae. The production of interleukin-4 in response to each of the antigens tested was detected but was lower than that of IFN-gamma. However, antibody levels and cell-mediated immune responses were not correlated with the protective effects of the vaccines after aerosol challenge and after i.c. challenge.