Novel radical pelvectomy technique to treat chondrosarcoma in a large-breed dog.

Surgical management of chondrosarcoma with hemipelvectomy is well described, but there have been no reports on extensive excision involving bilateral pubis and unilateral ischium. This report describes a novel pelvectomy technique for the treatment of chondrosarcoma in a large-breed dog. A 12-year-old Labrador Retriever presented for tenesmus due to a large, intra-pelvic mass which was confirmed on computed tomography (CT). Surgery involved removal of the entire left ischium and both pubic bones with preservation of both hind limbs. Histopathology confirmed the diagnosis of a high-grade chondrosarcoma with tumour-free margins of less than 3 mm. The dog recovered well following surgery and regained ambulation within 9 days. Four months postoperatively, the dog had no ongoing pain or tenesmus and only a mild gait abnormality in the left hind limb. Pelvectomy involving the entire pubis and unilateral ischium was well tolerated in a large-breed dog. This technique may offer a novel surgical option to treat neoplasia previously considered too extensive for complete excision.

Nursing care for dialysis patients in Japan.

In Japan, the number of chronic renal failure patients requiring dialysis treatment is increasing by approximately 10,000 patients a year, totalling 229,538 or 1,801.2 patients per one million population at the end of December, 2002 according to the survey conducted by the Japanese Society for Dialysis Therapy. The primary disease is diabetic nephropathy (28.1% of patients), and with greater numbers of long-term and elderly patients, the incidence and severity of complications continue to increase. Dialysis units provide more diversified care, but budget cuts in health care make it difficult to secure sufficient personnel, and the workload on nurses has intensified. In this study, a survey of 157 out of 300 randomly selected dialysis facilities in Japan was made regarding nursing systems and nurses' concerns for medical care of dialysis patients.

Quantitative assessment of right ventricular structural abnormalities by right ventricular polar mapping of single photon emission computed tomogram.

The identification of right ventricular (RV) abnormalities is clinically important in the evaluation of arrhythmogenic substrates in right ventricular-originated ventricular tachycardia (RVT). The purpose of this study was to determine the diagnostic benefit of quantitative analysis in RV single photon emission computed tomography (SPECT) imaging with (99m)Tc-tetrofosmin/sestamibi in patients with RVT. Thirty patients with RVT (15 with idiopathic RVT and 15 with arrhythmogenic right ventricular cardiomyopathy (ARVC)) were compared with 27 control subjects (including 11 with right bundle branch block) with regard to the semiquantitative RV uptake score in each of six segments and the quantitative RV extent score in polar coordinate map displays by SPECT imaging. The RV total score and RV extent score were compared with the RV global function. Perfusion abnormalities were more frequently detected (P = 0.0001) in the ARVC group (59/90, 65.6%) than in the idiopathic RVT group (4/90, 4.4%) or controls (1/162, 0.6%). The RV extent score in the ARVC group (53.0 +/- 24.8) was significantly higher than that in the idiopathic RVT group (8.4 +/- 10.1) or controls (1.2 +/- 4.9). The RV extent score correlated well with the regional RV perfusion score (P < 0.0001) and with the RV ejection fraction (P < 0.0001). Non-invasive RV perfusion mapping using a (99m)Tc-labelled tracer is useful for the quantitative evaluation of RV substrates in patients with ARVC.

Process of apoptosis induced by TNF-alpha in murine fibroblast Ltk-cells: continuous observation with video enhanced contrast microscopy.

Apoptosis is originally defined by unique morphological changes of dying cells, and the biochemical hallmark associated with apoptosis is internucleosomal DNA fragmentation. However, few report has shown the precise time course of the apoptotic events. The present study was designed to try to clarify apoptotic processes using a video-enhanced contrast-differential interference contrast (VEC-DIC) microscopy. The morphological changes of murine fibroblast Ltk-cells treated with TNF-alpha were divided into four stages: (i) pre-apoptotic, (ii) cytoplasmic shrinkage, (iii) membrane blebbing, and (iv) ballooning. Almost of the cells underwent cytoplasmic shrinkage and membrane blebbing within 6 hours after TNF-alpha exposure, and at about 9 hours, they were in the ballooning stage. Based on these data, we investigated the relationship between morphological changes and other biochemical features. The earliest event was exposure of phosphatidyl-serine at the cytoplasmic membrane, which was already observed in the pre-apoptotic stage. Loss of mitochondrial membrane potential was observed in the cytoplasmic shrinkage stage. Caspase-8/-3 activities already started increasing in the pre-apoptotic stage, and reached their peak at 6 hours after TNF-alpha exposure. DNA fragmentation occurred in the late phase of the membrane blebbing.

[Usefulness of right ventricular Doppler index for predicting outcome in patients with dilated cardiomyopathy].

OBJECTIVES: Left ventricular Doppler index (LVDI) is believed to be a useful echocardiographic index of systolic and diastolic ventricular function. However, the usefulness of right ventricular Doppler index (RVDI) remains uncertain, especially in dilated cardiomyopathy. The predictive value of RVDI for estimating long-term cardiac events, including cardiac death, was investigated. METHODS: Fifty-nine consecutive patients with dilated cardiomyopathy (41 males and 18 females, mean age 52 +/- 15 years) were enrolled in this follow-up study. RVDI and LVDI were calculated as follows: DI = (isovolumic contraction time + isovolumic relaxation time)/ejection time. RESULTS: During a follow-up period of 3.7 +/- 3.0 years, 27 (46%) of the patients exhibited cardiac events, including cardiac death (n = 9), heart failure (n = 16) and tachyarrhythmias (n = 2) requiring in-hospital treatment. Patients with these cardiac events had higher LVDI and RVDI at the initial follow-up examination, and RVDI had a significant linear correlation with LVDI (LVDI = 0.550 + 0.452 x RVDI, r = 0.530, p = 0.0001). The 6-year survival rate was significantly lower in patients with both LVDI > or = 0.78 and RVDI > or = 0.49 than in other patients (50% vs 75%, respectively, p = 0.009). Cox proportional hazards model analysis showed that RVDI > or = 0.49 was the independent predictor of cardiac events (p = 0.0153) and cardiac death (p = 0.0003). CONCLUSIONS: RVDI is clinically useful for estimating the outcome of patients with dilated cardiomyopathy.

Combination of stereotactic radiosurgery and cytokine gene-transduced tumor cell vaccination: a new strategy against metastatic brain tumors.

OBJECT: To determine if the combination of radiosurgery and tumor cell vaccine would enhance the therapy of metastatic lesions of the central nervous system (CNS), the authors examined the antitumoral effects of radiosurgery and cytokine-transduced tumor cell vaccine. METHODS: Fifty-five rats underwent intracranial implantation of 5 x 10(3) MADB 106 cells. On Day 3 after tumor implantation, 34 rats were inoculated in the flank with nonirradiated MADB 106 cells that had been retrovirally transduced to express granulocyte-macrophage colony-stimulating factor or interleukin-4. Twenty-seven rats (17 animals that had received the vaccine and 10 that had not) underwent radiosurgery performed using a gamma knife at maximum doses of 32 Gy on Day 5. No animals in the untreated group or in the vaccine-alone groups survived longer than 21 days. Animals treated by ra diosurgery alone displayed prolonged survival in comparison with untreated animals (p < 0.0001), but only one of 10 animals survived longer than 55 days. In contrast, 14 of 17 animals that received the combination therapy of radiosurgery and vaccination survived longer than 55 days (p = 0.0003 compared with animals that underwent radiosurgery alone). On Day 55, the long-term survivors were challenged by parental MADB 106 cells, which were implanted in the contralateral hemisphere. All animals from the combination therapy groups survived longer than 50 days after this challenge, but the single survivor from the radiosurgery-alone group died of tumor growth in 27 days. CONCLUSIONS: The combination of radiosurgery and cytokine gene-transduced tumor cell vaccine markedly prolonged animal survival and protected animals from a subsequent challenge by parental tumor cells placed in the CNS. The data provided by this study indicate that this combination therapy represents a strategy that may have clinical applicability for single and/or multiple metastatic brain tumors.

Japanese patients not seeking kidney transplants.

In Japan, the number of patients seeking kidney transplants has declined in recent years. To investigate the reasons for this decline, a questionnaire was given to 73 haemodialysis patients treated at the Tokiwa-Tatsumi Clinic. The resulting data showed the percentage of patients seeking transplants declined from 61% in 1992 to 19.2% in 1999. The reasons given for not seeking transplants were the improvements of physical condition and resultant quality of life (QOL) due to progress in dialysis therapy, upgraded social welfare support, uncertainties of transplant medicine, loss of expectations due to limited availability of transplant kidneys and aging of patients. Meanwhile, the number of patients on dialysis continues to increase by approximately 10,000 a year, and the mean age of patients rises. To reduce this number, greater effort must be directed toward preventive medical care as well as educating the public regarding transplant medicine.

Detection of cardiac calcinosis in hemodialysis patients by whole-body scintigraphy with 99m-technetium methylene diphosphonate.

A noninvasive method for the diagnosis of cardiac calcinosis, a life-threatening complication in hemodialysis patients with end-stage renal disease (ESRD), has not, as yet, been firmly established. We tested whether whole body scanning with 99m-technetium methylene diphosphonate (MDP) might visualize cardiac calcinosis. In 19 consecutive chronic hemodialysis ESRD patients (13 males and 6 females, aged 40-81, mean 63 +/- 8 years) with cardiovascular disease [mitral annular calcinosis and/or calcified aortic valve (n = 4), hemodialysis cardiomyopathy (n = 1), coronary artery disease (n = 9) and peripheral artery atherosclerotic disease (n = 6)], MDP uptake in the heart was compared to that in 7 non-ESRD controls with hyperparathyroidism due to adenoma. Cardiac and lung field MDP uptake was confirmed in only 3 (16%) and 5 (26%) of the 19 ESRD subjects, respectively, but was absent in controls. Positive cardiac uptake was related to cardiac calcified complications (mobile intracardiac calcinosis, myocardial calcinosis and mitral annular calcification) and the duration of hemodialysis (p = 0.015). While it was statistically insignificant, subjects showing MDP uptake were elder and had higher serum Ca or Ca x P product and lower intact parathyroid hormone levels. These results suggest that cardiac calcinosis in ESRD patients can be detected noninvasively by myocardial scintigraphy with 99m-technetium MDP.

[Intracardiac floating thrombi in patients with acute pulmonary thromboembolism].

The mortality and morbidity associated with residual intracardiac floating thrombi in patients with acute pulmonary thromboembolism remain uncertain. Thirteen patients (2 men and 11 women, mean age 56 +/- 15 years) with pulmonary thromboembolism underwent echocardiography within 24 hours from onset of symptoms. Four patients (31%) had floating intracardiac thrombi in the right heart: 3 in the right atrium and one in the inferior vena cava. The time to evaluation by echocardiography was shorter than in the patients without thrombi. The thrombi disappeared shortly (3.2 +/- 2.4 hr) after thrombolysis without adverse effects in these patients. After thrombolysis, clinical symptoms improved and pressure gradient between the right ventricle and right atrium decreased significantly (p < 0.01) from baseline 47 +/- 6 to 26 +/- 5 mmHg. Major bleeding complications occurred in 3 (43%) of the patients who underwent thrombolysis. Right-side intracardiac floating thrombus was easily detectable by early echocardiography. Thrombolytic agents are likely to be effective in patients with intracardiac floating thrombi.

Hypoparathyroidism potentiates cardiovascular complications through disturbed calcium metabolism: possible risk of vitamin D(3) analog administration in dialysis patients with end-stage renal disease.

BACKGROUND/AIM: Progressive cardiovascular calcification in dialysis patients with end-stage renal disease (ESRD) is a serious complication; however, the precise mechanism remains uncertain. We tested whether metabolic calcium abnormalities and hypoparathyroidism might have a correlation with cardiovascular complications in ESRD patients. METHODS: A series of 48 ESRD patients with cardiovascular diseases and/or congestive heart failure, aged 36-82 (61 +/- 12) years, 23 male and 25 female, were enrolled in this study. Serum total calcium (Ca, mmol/l), inorganic phosphate (mmol/l), and intact parathyroid hormone (iPTH, pg/ml) levels were determined in all cases. RESULTS: Organic heart disease was confirmed in 28 patients (58.3%), including 15 with coronary artery disease: 8 with aortic aneurysm, 8 with stenotic valvular heart disease, 9 with excessive mitral annular calcification, 3 with dialysis cardiomyopathy, and 7 with obstructive arterial disease. Serum iPTH measurement revealed hypoparathyroidism (iPTH <60) in 20 of 48 (41.7%) and hyperthyroidism (iPTH >/=200) in 13 of 48 (27.1%) subjects. The 20 patients with low iPTH had a higher prevalence of valvular heart disease, a higher total Ca level corrected for serum albumin (2.70 +/- 0.30 in low iPTH vs. 2.47 +/- 0.30 in normal iPTH, 2.35 +/- 0.20 in high iPTH, p = 0.003) and a higher tendency of vitamin D(3) analog use (65% in low iPTH vs. 33% in normal iPTH and 46% in high iPTH, p = 0.078). Moreover, corrected serum Ca exhibited a negative logarithmic correlation with serum iPTH: corrected Ca = -0.284x log (iPTH) + 3.021 (r = 0.637, p = 0.0001). Multiple logistic regression analysis revealed diabetes and hypoparathyroidism (iPTH <60) as risk factors for cardiovascular complications in ESRD. CONCLUSION: These results suggest that hypercalcemia and hypoparathyroidism in conjunction with vitamin D(3) use might play an important role in cardiovascular complications of chronic dialysis patients.

Long-term site-related differences in the progression and regression of the idiopathic mitral valve prolapse syndrome.

The natural history of uncomplicated mitral valve prolapse (MVP) is not clearly understood. To determine the site-related differences in regression and progression of MVP, 112 patients with idiopathic MVP were enrolled in this echocardiographic follow-up study. Cardiovascular complications, including dysarrhythmias (n = 3, 2.7%), overt congestive heart failure (n = 4, 3.6%), progression of mitral regurgitation over one grade (n = 28, 25.0%), newly confirmed chordal rupture (n = 1, 0.9%), and surgical repair (n = 2, 1.8%), were observed in these patients during a follow-up period of 1-13 years (mean, 4.0 +/- 2.8 years). Multivariate analysis and Kaplan-Meier analysis revealed that posterior leaflet prolapse and significant mitral regurgitation (grade >/=2) were considerable risks for cardiovascular complications. Regression of MVP was seen in 17 (18.7%) of the anterior prolapse patients; however, new prolapse was observed in 40 (35.7%) patients, mainly in posterior prolapse patients. These results suggest that site-related differences exist in uncomplicated MVP prognosis and that MVP in the posterior leaflet has a poor outcome compared to that in the anterior leaflet.

Scintigraphic evidence for a specific long-chain fatty acid transporting system deficit and the genetic background in a patient with hypertrophic cardiomyopathy.

The mechanism of cardiac uptake of long-chain free fatty acids has not been fully determined. We encountered a hypertrophic cardiomyopathy patient who showed a lack of cardiac uptake of 2 different types of long-chain fatty acid analogues on the scintigraphic images. Flow cytometric analysis revealed no platelet or monocyte CD36 molecule expression (type I CD36 deficiency) and his CD36 gene showed homozygous mutation for 478C to T substitution, leading to an abnormal CD36 amino acid sequence. These findings strongly suggest that a specific transporting system rather than a simple diffusion is commonly involved in the cardiac uptake of long-chain free fatty acids in humans, and that the CD36 protein is the most likely candidate for the specific transporter and to explain scintigraphic defects on fatty acid imaging.

Fast spin-echo MR of the articular cartilage in the osteoarthrotic knee. Correlation of MR and arthroscopic findings.

PURPOSE: The objective was to assess the efficacy of fast spin-echo (FSE) imaging in the detection of articular cartilage abnormality in osteoarthrosis of the knee. MATERIAL AND METHODS: We studied 356 articular surfaces in 73 knees that had been examined by both MR imaging and arthroscopy. The MR images were obtained with FSE imaging (TR/TE 4200/100) on a 0.5 T unit. The surface abnormalities of the articular cartilage that were detected by MR imaging were compared with the arthroscopic findings. RESULTS: The overall sensitivity and specificity of MR in detecting chondral abnormalities were 60.5% (158/261) and 93.7% (89/95) respectively. MR imaging was more sensitive to the higher grade lesions: 31.8% (34/107) in grade 1; 72.4% (71/98) in grade 2; 93.5% (43/46) in grade 3; and 100% (10/10) in grade 4. The MR and arthroscopic grades were the same in 46.9% (167/356), and differed by no more than 1 grade in 90.2% (321/356) and 2 grades in 99.2% (353/356). The correlation between arthroscopic and MR grading scores was highly significant with a correlation coefficient of 0.705 (p < 0.0001). CONCLUSION: FSE sequence was less sensitive to mild cartilage abnormality but useful in detecting moderate to severe abnormality and in evaluating the degree of articular cartilage abnormality.

Reflections by the families of organ donors in Japan.

The number of kidney grafts in Japan is remarkably small compared to that in Europe and America. We conducted a questionnaire survey to donor families in order to examine problems surrounding kidney grafts, from their viewpoints. Thirty one families of post-mortem kidney donors responded and the majority perceived the donation positively. The survey also revealed that in most cases, donation was decided by the family without knowing the patient's wishes, families who made organ donations were apprehensive about Japanese society being critical of organ donations, and some families later regretted their decision of organ donation. In Japanese society, organ donation continues to face some resistance. It is important that medical professionals concerned with organ grafts understand with compassion the feelings of donor families, and make a greater effort in developing public understanding and support for organ grafts.

Multiple basilar trunk aneurysms and bilateral internal carotid artery hypoplasia.

We describe a case of a 32-year-old woman with bilateral hypoplastic internal carotid arteries who presented with subarachnoid haemorrhage and was found to have two basilar trunk aneurysms. Carotid angiography showed that both internal carotid arteries were narrowed at their origin and terminated at the cervical segment. Vertebral angiography demonstrated a dilated vertebrobasilar system which supplied sufficient blood flow for both cerebral hemispheres through the posterior communicating arteries. The patient was successfully treated by multiple operations.

Traction injuries of the brachial plexus: signal intensity changes of the posterior cervical paraspinal muscles on MRI.

PURPOSE: Our goal was to evaluate MR signal intensity change of the posterior cervical paraspinal muscles in brachial plexus traction injuries to determine the value of this finding in the diagnosis of nerve root avulsion. METHOD: MR images of 11 consecutive patients, 7 with nerve root avulsion and 4 without nerve root avulsion, were retrospectively analyzed, focusing on the signal intensity of the paraspinal muscles. RESULTS: Among the seven patients with nerve root avulsion, T2- or T2*-weighted MR images showed increased signal intensity in the deep posterior paraspinal muscles in five and traumatic meningocele in four. The signal intensity of the posterior paraspinal muscles was normal in all patients without nerve root injuries. CONCLUSION: MR signal intensity change in the deep posterior cervical paraspinal muscles is related to denervation and suggests the presence of nerve root avulsion.

Gadolinium-enhanced MR imaging of the wrist in rheumatoid arthritis: value of fat suppression pulse sequences.

OBJECTIVE: To determine the usefulness of fat-suppressed gadolinium (Gd)-enhanced MR imaging of the wrist in patients with rheumatoid arthritis (RA). DESIGN AND PATIENTS: Fat-suppressed Gd-enhanced T1-weighted spin-echo (SE) images were obtained and compared with other standard techniques in 38 wrists of 27 patients (22-77 years) with RA. Scoring based on the degree of synovial enhancement of each joint was developed and the total scores (J-score) were correlated with radiographic stage, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and symptomatic change in the follow-up study. RESULTS: Synovial proliferations showed marked enhancement in all the wrists. In addition, contrast enhancement in the bone marrow and tenosynovium was seen in 36 and eight wrists respectively. Fat-suppressed Gd-enhanced T1-weighted images demonstrated these abnormalities better than other techniques. The J-scores correlated well with values of CRP (P = 0.0034), but not with radiographic stages and ESR. CONCLUSION: Fat-suppressed Gd-enhanced T1-weighted SE images can clearly demonstrate most of the essential lesions in RA including the proliferative synovium, bone erosion, bone marrow inflammatory change, and tenosynovitis. Scoring based on the extent of Gd-enhancement of synovium can be useful in the assessment of the inflammatory status.

[Magnetic resonance imaging of sacral insufficiency fractures: characteristic features and differentiation from sacral metastasis].

Seven patients with sacral insufficiency fractures and seven patients with sacral metastasis were studied with MR imaging. The diagnoses were confirmed with other imaging modalities and clinical follow-up. The insufficiency fractures appeared as bands of abnormal signal: low signal intensity on T1-weighted images and slightly low to iso signal intensity on T2-weighted images. The lesions were delineated better on T1-weighted images than on T2-weighted images. The sacral alae were involved in all patients; five patients had bilateral lesions. The lesions that run across the sacral body were seen in three cases. Inclined coronal images were useful in demonstrating the pattern of distribution of the sacral insufficiency fractures. In three patients with follow-up MR studies, the lesions were markedly reduced or disappeared. The sacral metastatic tumors were of low signal in density on T1-weighted images and iso to high signal in density on T2-weighted images. The extent and distribution patterns of the lesions were various. It is possible to differentiate sacral insufficiency fractures from sacral metastases based on their distribution patterns on MRI. However, if the diagnosis is uncertain or if the symptoms persist or become worse, follow-up MR studies may be necessary.

Atypical appearance of adrenal pseudocysts.

We report 2 cases of adrenal pseudocysts that resulted from hemorrhage into a normal adrenal gland and that showed atypical imaging features on computerized tomography and ultrasonography. The presence of a solid component within the mass and/or central calcification, which is unlike the typical features of adrenal pseudocyst, suggested a diagnosis of adrenal tumor. The solid component diminished on computerized tomography in 26 days in case 1 and in 16 days in case 2, which seemed to represent resolving hematoma. The atypical appearance of these adrenal pseudocysts, especially the changeable pattern of the solid component within the mass, should be kept in mind to ensure a correct preoperative diagnosis.