Hepatic venous congestion after living donor liver transplantation: quantitative assessment of liver stiffness using shear wave elastography--a case report.

We report a 49-year-old right lobe liver transplant recipient, who developed a significant anastomotic stenosis of the right hepatic vein shortly thereafter. Shear wave elastography (SWE) was applied to investigate liver stiffness quantitatively. It showed increased stiffness in the anterior compared with the posterior segment of right lobe graft. The stenotic right hepatic venous anastomosis was then managed by angioplasty with stent placement. SWE after angioplasty showed a gradual decrease in stiffness of the anterior segment, which was almost equal to the posterior segment at 2 weeks thereafter. Our experience suggested that SWE may be a noninvasive tool to assess alterations in liver stiffness secondary to hepatic venous congestion after liver transplantation.

Brain infarction as the initial presentation of primary posterior mediastinal seminoma.

A 40-year-old man was admitted with acute onset of slurred speech and right hemiparesis. Cerebral infarction was diagnosed from magnetic resonance (MR) images. Chest X-ray incidentally revealed a posterior mediastinal tumour, which proved to be seminoma on CT-guided biopsy. The patient then received chemotherapy. Five months later, right upper limb weakness and slurred speech occurred again. Brain MR images revealed two metastatic lesions in the prior infarct areas, which on histology proved to be metastatic seminoma.

The management of papillary lesion of the breast by core needle biopsy.

BACKGROUND: The purpose of this study was to determine the accuracy of core needle biopsy (CNB) diagnoses of papillary breast lesions, and to identify the risk factors and histologic features, compared with excisional biopsy (EB). METHOD: We retrospectively reviewed 1,682 sonographically guided core needle biopsies performed at one single medical center from January 2001 through December 2005, and identified 41 papillary lesions. Surgical correlation was available for 35 cases, 2 cases were loss follow-up and 4 cases diagnosed as papilloma by core needle biopsy were followed up with imaging for at least 24 months. RESULTS: The pathologic diagnoses for the 35 papillary lesions obtained at core biopsy were benign in 24 cases, atypical in 7, and malignant in 4. Of those diagnosed as benign lesions at CNB, 7/24 turned out to be malignant. In the hyperplasia group, 5/7 were malignant. The total upgrade rate was 39%. The positive predict value was 100% and negative predict value was 61%. CONCLUSION: All papillary lesions of the breast diagnosed by CNB should be excised because a substantial number of lesions were upgraded of diagnoses at excision.

Uterine artery embolization: an effective treatment for intractable obstetric haemorrhage.

AIM: To present the findings of uterine artery embolization (UAE) in the management of obstetric haemorrhage. MATERIALS AND METHODS: From October 1999 to February 2003, 10 women with postpartum haemorrhage (n=7) and post-abortion haemorrhage with placenta accreta (n=3), were referred to our department for pelvic angiography and possible arterial embolization. RESULTS: Angiography revealed engorged and tortuous uterine arteries in all patients; and contrast medium extravasation in three patients. Eight patients (three with and five without detectable active bleeding) then underwent bilateral UAE. Medium-sized (250-355 microm) polyvinyl alcohol particles were injected via a coaxial catheter into the uterine arteries, followed by gelatin sponge pieces via a 4F Cobra catheter. Microcoil devascularization was also performed in the two patients with visible, active bleeding. The vaginal bleeding resolved in all patients, without any ischaemic complications. At follow-up, all patients who underwent UAE had normal menstruation; three of them subsequently gave birth to full-term healthy babies. CONCLUSION: Selective UAE by the coaxial method is safe and effective to control obstetric haemorrhage, with the potential to preserve fertility.

Endovascular aortic graft exclusion of abdominal aortic aneurysm.

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. This study reports the first successful case in Taiwan area of infrarenal abdominal aortic aneurysm treated with endovascular aortic bifurcational stent-graft. Minimally invasive surgery leading to early recovery, mobilization and shortened hospital day was promising. In addition, there were no local, remote or systemic complications during a 18-month follow-up. Thus, the procedure is an attractive alternative in its potential to reduce morbidity and mortality associated with open surgical repair, especially for patients who are not surgical candidates because of comorbidities. Careful patient selection and more experiences with refined endograft models will elucidate the feasible alternative to conventional surgical repair.

High resolution MRI of adrenal glands in patients with primary aldosteronism.

BACKGROUND: We studied the role of high-resolution magnetic resonance imaging (MRI) of the adrenal glands using a surface coil in patients with primary aldosteronism to differentiate aldosterone-producing adenomas (APA) from idiopathic hyperplasia of the adrenal gland (IHA). The data obtained were used to decide on surgical or nonsurgical treatment for patients. METHODS: High-resolution MRI with SE T1WI, FSE T2WI and paired in- and out-phase images of the adrenal glands of 41 patients with clinically documented primary aldosteronism were collected. The images were reviewed in comparison with other differentiating tests. RESULTS: Nineteen of the 41 patients were diagnosed with APA on MRI. Surgical and pathologic proof of APA was obtained in 10 cases and solitary macronodular hyperplasia was found in one case. Among these 11 cases, there were no false positive findings on MRI, while correct detectability of high-resolution computerized tomography (CT) was 62.5% (5/8); for adrenal venous sampling, it was 37.5% (3/8); and for NP-59 adrenal scanning, it was 42.9% (3/7). In eight cases with biochemically favored APA and no surgical proof, MRI and CT showed the same lesion detection rate, while there was no concordance with venous sampling, and concordance of only 33.3% (2/6) for adrenal scanning. In the remaining 22 patients without focal lesions on MRI, there was poor concordance among the four test modalities, with frequently conflicting results. CONCLUSIONS: In patients with definitive results of noninvasive biochemical tests for APA, and positive findings of unilateral, focal adrenal lesion on MRI or CT, unilateral adrenalectomy may be justified without further tedious and invasive examinations. CT should still be the first screening test; however, high-resolution MRI is a useful diagnostic supplement for patients with strong clinical evidence of APA and negative or equivocal findings on CT.

Concomitant chemoradiation treatment in the management of patients with extrahepatic biliary tract recurrence of gastric carcinoma.

BACKGROUND: The aim of this study was to determine the role of concomitant chemoradiation in the alleviation of obstructive jaundice in patients with extrahepatic biliary tract metastases from gastric carcinoma. METHODS: Thirteen patients with good performance status who had obstructive jaundice resulting from extrahepatic biliary metastases after gastrectomy for gastric carcinoma were treated with palliative intent. Treatment consisted of insertion of a percutaneous transhepatic choledochal drainage (PTCD) catheter followed by external radiation up to a total dose of 40-60 grays in combination with chemotherapy (cisplatin 20 mg/m(2)/day, 5-fluorouracil 600 mg/m(2)/day, and leucovorin 90 mg/m(2)/day for 96 hours during the first and fifth weeks) on an outpatient basis. RESULTS: The concomitant chemoradiation produced a good palliative effect in all 13 patients. Hyperbilirubinemia continued to improve after treatment, patients' clay-colored stool resolved within an average of 4 weeks (range, 2-6 weeks), and bilirubin levels returned to normal. The PTCD catheter could be removed after treatment was completed (the seventh week); the mean duration of PTCD placement was 2 months. The entire treatment course was performed on an outpatient basis; hospital admission was necessary only for PTCD insertion and chemotherapy. Ten patients died of their disease, with an average survival of 14.4 months (range, 4-31 months) from the time of PTCD insertion. Three patients are still alive at 16, 21, and 8 months. Biliary tract patency was maintained until death. No serious treatment-related complications occurred, and no endoprothesis or intraluminal brachytherapy was needed in this study. CONCLUSIONS: Satisfactory palliation can be achieved by concomitant chemoradiation for patients with obstructive jaundice resulting from extrahepatic biliary metastases from gastric carcinoma, providing an alternative treatment choice for these patients.

Managing a patient with presumed testosterone-secreting ovarian tumor.

We report the case of a 70-year-old woman who was presumed to have right ovarian testosterone-secreting tumor and was treated with long-acting gonadotropin-releasing hormone agonist therapy plus add-back hormone replacement therapy. The patient presented with various medical problems including hypertension, intracranial hemorrhage, myocardial infarction, unstable angina pectoris, and poor control of diabetic mellitus and had exhibited rapid symptoms of androgen excess such as progressive hirsutism and bilateral temporal balding for half a year. Tumor survey was negative except for an elevated testosterone level. Renal vein catheterization successfully detected a right ovarian androgen-secreting tumor. Because the patient was deemed medically unable to tolerate surgery, she received an alternative treatment consisting of 6 months of gonadotropin-releasing hormone-agonist (GnRH-a) and add-back hormone replacement therapy (HRT). Serum testosterone levels returned to normal limits after administration of the first dose of GnRH-a. A follow-up tumor survey was negative. The patient has been alive and free of disease for 8 months after six doses of GnRH-a. We conclude that this strategy might be used as urgent therapy in a medically compromised patient with presumed ovarian androgen-secreting tumor.

Dynamic MR imaging of hepatolithiasis.

BACKGROUND: To report the dynamic magnetic resonance (MR) imaging findings of hepatolithiasis. METHODS: Dynamic MR images (fast spoiled gradient echo sequence with intravenous injection of gadopentate dimeglumine) and computed tomography, cholangiography, or angiography of nine patients with hepatolithiasis are analyzed. RESULTS: All affected hepatic segments showed atrophic changes and contained dilated intrahepatic ducts. These segments showed either iso- or hypointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging. Preferential enhancement was noted throughout all phases of the dynamic study and persisted to delayed T1-weighted imaging in seven patients. In the last two patients, severe atrophic changes made evaluating signal intensity differences and enhancement patterns difficult. CONCLUSION: In addition to intrahepatic stones and biliary dilatation, segmental atrophy, signal intensity differences, and preferential and persistent enhancement are important MR findings of hepatolithiasis.

The effect of intravitreal injection of atropine on the proliferation of scleral chondrocyte in vivo.

Atropine was found to be effective in arresting the progression of myopia. However, the actual mechanism is still unclear. Thus, we tried to investigate the in vivo effect of atropine on the proliferation of scleral chondrocytes in chicks of form-deprivation myopia. Twenty chicks were equally divided into 4 groups which included intravitreal injection of normal saline (IVN), IVN with goggling (IVNG), intravitreal injection of atropine (1%) (IVA), and IVA with goggling (IVAG) groups. Intravenous injection of bromodeoxyuridine (BrdU) (30 mg/kg) from subaxillary vein was performed 2 hours before being sacrificed. The eyeballs were then fixed in 10% neutral-buffered formalin at 4 degrees C. Standard BrdU immunohistochemical staining was performed. The BrdU labeling index was obtained from the average of positive labelings of BrdU in scleral chondrocytes for every 100 counting cells in posterior poles and anterior scleral margins by two experienced technicians. The BrdU index on the anterior scleral margin of the IVAG group was less than that of the IVNG group. The index on the anterior scleral margin of the IVNG group was higher than the IVN group. Although the index on the posterior poles of the IVNG group was also higher than the IVN group, it was statistically not different. Also, no statistical difference was found between IVN and IVA on the anterior scleral margins or posterior poles. The index was significantly different on the anterior scleral margins, but not on the posterior pole among each group. Therefore, intravitreal injection of atropine could inhibit the proliferation of chondrocytes on the anterior margins of sclera, but not the posterior poles in form-deprivation myopia.

Normal and variant anatomy of hepatic arteries: angiographic experience.

BACKGROUND: Anatomic variation of hepatic arteries is reported to occur in 25-50% of the general population. Knowledge of the existing variations is important in planning and conducting surgical or radiologic procedures in the upper abdomen, such as liver transplantation and transarterial chemo-embolization (TACE). METHODS: Based on data from 321 patients undergoing upper abdominal arteriography, hepatic artery anatomy was analyzed and classified into three groups (single, double and multiple hepatic arteries at hepatic hilum) according to Suzuki's classification. Each group was subdivided into three types (celiac, mesenteric and mixed types) according to the origin of the hepatic arteries. The variations within each type were recorded. RESULTS: Two hundred and sixty one patients (68.%) had single hepatic arteries. One hundred and five patients (27.6%) had double hepatic arteries and only fifteen patients had multiple hepatic arteries. All of these variants, including twenty subtypes, were identified. CONCLUSIONS: This study, based on Suzuki's classification, provides basic data for the anatomic variations of hepatic arteries for the Chinese population in Taiwan.

Relapse of acute leukemia in childhood presenting as proptosis due to an orbital mass.

Extramedullary relapse of acute leukemia in sites outside the central nervous system or testes is rare. We report two children who developed proptosis due to an orbital mass as the initial presentation of leukemic relapse. The first patient was an 11-year-old girl with acute myelogenous leukemia who had undergone bone marrow transplantation 4 years previously. She had been in remission until 2 months prior to the present admission, when she developed isolated relapse of disease in the left orbit. The second patient, an 11-year-old girl with acute lymphoblastic leukemia, had been off chemotherapy for 2 years and in remission for 5 years. She suffered from concurrent orbital and central nervous system relapse. Both patients were treated with systemic chemotherapy and orbital radiotherapy. More than 1 year after the relapse, the proptosis was completely cured in both patients.

Anesthetics release unfreezable and bound water in partially hydrated phospholipid lamellar systems and elevate phase transition temperature.

A dimyristoylphosphatidylcholine multilamellar system with varied water content was prepared by dessiccating sonicated vesicles in vacuo. The water content in the sample was determined by gas chromatography after dissolving the multilamellar system in water-free benzene. Differential scanning microcalorimetry revealed several endothermic peaks in the heating scan at subzero temperature, ranging from -25 to -3 degrees. The peaks that appeared in the subzero temperature range indicate the existence of water molecules bound to the lipid head groups, differing from free water that freezes at 0 degrees. The difference between the amount of water molecules that froze in calorimetry and the total amount of water detected by gas chromatography indicates the presence of unfreezable, tightly bound water molecules. The relative amount of free, intermediate, and unfreezable water was estimated by comparing the differential scanning microcalorimetry data with gas chromatography measurements. The addition of halothane and 1-hexanol significantly decreased the intermediately bound water peaks. The anesthetics dehydrated the lamellar system. The phase polymorphism of partially hydrated phospholipid multilayers is well known, and the temperature that corresponds to the main phase transition of fully hydrated lipid membranes shifts to a higher temperature. The addition of anesthetics increased the phase transition temperature when the water content was less than 18 wt%. This result is the complete reverse of the depressant action of anesthetics in fully hydrated lipid membranes. The present anesthetic effect upon the elevation of the transition temperature is apparently caused by anesthetic-induced dehydration of the lipid-water interface at the present experimental condition.