An unusual case of subclinical diffuse glucagonoma coexisting with two nodules in the pancreas: characteristic features on computed tomography.

A lesion was discovered in the tail of the pancreas by ultrasonography performed during a health checkup for a 59-year-old Japanese man. Abdominal contrast-enhanced computed tomography (CE-CT) revealed strong enhancement in a 4-cm tumor in the pancreatic tail and in a 1-cm tumor in the pancreatic body. Serum glucagon levels were elevated to 54,405 pg/mL and a preoperative diagnosis of glucagonoma was made. The pancreatic tail and spleen were resected en bloc, along with a protruding tumor in the pancreatic body. However, histopathological evaluation revealed diffuse glucagonoma throughout the pancreas. When we retrospectively reviewed abdominal CE-CT after the operation, the entire pancreas was seen to be enlarged and diffusely enhanced by strong spots. Immunohistochemical examination using anti-CD31 demonstrated rich microvessels in two solid glucagonomas as well as microglucagonoma throughout the entire pancreas, indicating hypervascularity. Enlarged pancreas and diffuse enhancement of the pancreas by strong spots may be characteristic features of diffuse glucagonoma on abdominal CE-CT.

Review: role of cerebral vessels in ischaemic injury of the brain.

This review discusses the pathological changes in the heart and vessels underlying brain ischaemic injury, with a major focus on atherosclerotic disease of the brain induced by lesions of the extracranial cervical and major intracranial arteries and small-vessel disease of the brain. The carotid bifurcation is the primary site for atherosclerotic changes, for which extensive clinical trials and pathological analyses on carotid endarterectomy specimens have been performed. Plaque rupture and erosion give rise to thrombus formation, which leads to brain ischaemic injury. These changes have much in common with atherosclerotic lesions of the subepicardial coronary arteries. Emboli of various types of particles are characteristics of brain ischaemic injury. Thrombi rich in fibrin and red blood cells (red thrombi) that develop in the cardiac chambers are common sources of cerebral emboli. Small-vessel disease of the brain induces fibrinoid necrosis, microaneurysm, fibrohyalinosis, lipohyalinosis and microatheroma, changes commonly associated with hypertension. The acute hypertensive small-vessel changes organize to create segmental arterial disorganization and deep small infarcts when they escape from rupture. Some specific vascular diseases responsible for brain ischaemic injury are briefly reviewed also.

A study on the neutron monitoring system of LHD based on Monte Carlo simulations.

Neutron monitoring is quite important because fusion neutrons are a direct evidence of fusion reactions. In calibration experiments of a neutron monitoring system, Monte Carlo calculations play an important role to correct various effects. To perform Monte Carlo calculations for a helical type fusion device, we make a program that can automatically generate an input file of a helical coil geometry for the MCNP code. The neutron spatial distributions and spectra for the helical devices are calculated in the geometries automatically generated by this program. We also discuss in calibration experiments.

Fusion product diagnostics planned for Large Helical Device deuterium experiment.

Deuterium experiment on the Large Helical Device (LHD) is now being planned at the National Institute for Fusion Science. The fusion product diagnostics systems currently considered for installation on LHD are described in this paper. The systems will include a time-resolved neutron yield monitor based on neutron gas counters, a time-integrated neutron yield monitor based on activation techniques, a multicollimator scintillation detector array for diagnosing spatial distribution of neutron emission rate, 2.5 MeV neutron spectrometer, 14 MeV neutron counter, and prompt γ-ray diagnostics.

Evaluation of H*(10) using the developed spherical type neutron dose monitor.

An instrument for evaluating the neutron ambient dose equivalent has been developed. It has the characteristic of uniform response to wide energy of neutrons. The monitor is four-layered spherically shaped, based on moderation and absorption of neutrons. Neutron dose can be evaluated from the linear combination of three specific responses of thermoluminescent dosimeters (TLDs), which are located at three depths in the moderator. TLDs were arranged between layers of two consecutive depths on 12 radial axes at even intervals so that the monitor is equally sensitive to all directions of neutrons. In order to verify the usefulness of dose evaluation by the monitor, irradiation experiments were conducted at the FRS, JAEA. The D2O-moderated 252Cf was used for the calibration of the monitor. Experiments were also conducted by using two neutron sources of 252Cf bare and 241Am-Be. As a result, the evaluated dose for each irradiation was obtained close to the actual irradiated dose. It was confirmed that the method of dose evaluation by the developed monitor can be applied to practical neutron fields where the distance of neutron source is unknown.

Hematological alterations in the Otsuka Long-Evans Tokushima fatty (OLETF) rats--a model of type 2 diabetes mellitus.

The OLETF rat develops microangiopathic complications similar to human diabetes and is considered a useful model of Type 2 DM. Erythrocyte, platelet and leucocyte abnormalities described in diabetic patients are thought to play a role in the development of diabetic microangiopathy. This study was designed to investigate whether OLETF rats show hematological alterations and the effect of sucrose treatment on metabolic and blood parameters. Hematological parameters, body weight, food and water intake, fasting and non-fasting blood glucose (BG) and HbA1c were measured in OLETF rats treated for two months with 30% sucrose added to drinking water. Non-treated OLETF rats and non-diabetic Long-Evans Tokushima Otsuka (LETO) rats were used as controls. In the control OLETF rats the number of platelets (Plt) and red blood cells (RBC) was higher, while the mean cell volume (MCV) and the mean cell hemoglobin content (MCH) were lower compared with LETO. Mean cell hemoglobin concentration (MCHC) was significantly higher in the diabetic rats. Sucrose administration decreased food intake and body weight and increased fasting blood glucose and HbA1c. It resulted in a decrease of RBC, Hb, Hct, MCV and MCH compared with control OLETF, while Plt count increased significantly. Our results point to significant alterations in erythrocyte count and morphology and Plt count in diabetic OLETF rats compared with non-diabetic LETO. Sucrose administration accelerated the development of diabetes, affected blood cells inducing the suppression of RBC and an increase in Plt count and some of its effects persisted after sucrose withdrawal.

Anti-prothrombin antibodies combined with lupus anti-coagulant activity is an essential risk factor for venous thromboembolism in patients with systemic lupus erythematosus.

Anti-prothrombin antibodies (anti-prothrombin) and anti-beta2-glycoprotein I antibodies (anti-beta2-GP I) are the most common and characterized anti-phospholipid antibodies (aPL) detected using specific enzyme-linked immunosorbent assay (ELISA) systems. Recently, lupus anti-coagulant (LA) activity detected by a phospholipid-dependent coagulation assay was reported to be associated with anti-prothrombin and/or anti-beta2-GP I. Here we show that the co-existence of IgG anti-prothrombin and LA activity might be an essential risk factor for venous thromboembolism (VTE) in patients with systemic lupus erythematosus (SLE). We examined not only the levels of antibodies to prothrombin and anti-beta2-GP I (both IgG and IgM isotypes) using an ELISA system, but also LA activity detected using both diluted Russell's viper venom time (dRVVT) and STACLOT LA test in 124 patients with SLE. The SLE patients were divided into four groups according to the results of ELISA and LA assay results for each aPL: group A, ELISA+ and LA+ group B, ELISA+ and LA-; group C, ELISA- and LA+ group D, ELISA- and LA-. Regarding IgG anti-prothrombin, the prevalence of VTE was significantly higher in group A (16/35 cases, 45.7%, P < 0.001, Fisher's exact probability test) than in the other groups (B, 2/30, 6.7%; C, 1/22, 4.5%; D, 1/37, 2.7%). With respect to IgM anti-prothrombin and IgG or IgM anti-beta2-GP I, the prevalence of VTE was higher in both groups A and C than in group D, but no statistical difference in prevalence was found between groups A and C. Multivariate logistic regression analysis of risk factors for VTE confirmed that the co-existence of IgG anti-prothrombin and LA activity was the only significant risk factor for VTE (odds ratio, 19.13; 95% confidence intervals, 4.74-77.18).

C-reactive protein is an independent predictor of the rate of increase in early carotid atherosclerosis.

BACKGROUND: An elevated plasma concentration of high-sensitivity C-reactive protein (hs-CRP) is a strong predictor of cardiovascular events. However, there have been no longitudinal studies of the relations between development of atherosclerotic lesions and hs-CRP concentrations. Furthermore, it remains unknown whether increased hs-CRP concentrations result in the development of atherosclerosis. METHODS AND RESULTS: The study included 179 outpatients 40 to 79 years of age who were treated at our institute for traditional risk factors for cardiovascular disease. The patients had no evidence of advanced carotid atherosclerosis at the time of baseline examination. Patients underwent repeated ultrasonographic evaluation of the carotid arteries for 35+/-10 months. Blood samples were collected for hs-CRP measurements. Based on focal intima-media thickening >/=1.1 mm representing plaque, plaque number (PN) and plaque score (PS; the sum of all plaque thicknesses) were calculated. The development of atherosclerosis was estimated by the formula Deltavalue/year=(last value-baseline value)/number of follow-up years. Multivariate linear regression analysis revealed that the log-transformed value for hs-CRP concentration was not related to baseline PN or PS but was related to DeltaPN/year and DeltaPS/year (beta=0.29 and 0.30; P<0.001 for both) independently of the effect of traditional risk factors. CONCLUSIONS: During the early stages of carotid atherosclerosis, the hs-CRP concentration is a marker of carotid atherosclerotic activity rather than extent of atherosclerosis.

Association between the prevalence of antibodies to beta(2)-glycoprotein I, prothrombin, protein C, protein S, and annexin V in patients with systemic lupus erythematosus and thrombotic and thrombocytopenic complications.

BACKGROUND: Anti-phospholipid (aPL) antibodies (Abs) frequently found in the plasma of patients with systemic lupus erythematosus (SLE) have been associated with thrombotic complications. Our aim was to clarify the roles in thrombosis of aPL Abs that react with complexes of phospholipids and plasma proteins such as beta(2)-glycoprotein I (beta(2)-GPI), prothrombin, protein C, protein S, and annexin V. METHODS: We determined the prevalence of aPL Abs to various phospholipid-binding plasma proteins in SLE patients with arterial thrombosis (30 cases), venous thrombosis (19 cases), thrombocytopenia (14 cases), fetal loss (14 cases), and patients without complications (91 cases). The aPL Abs were measured by an ELISA system in which human plasma proteins (beta(2)-GPI, prothrombin, protein C, protein S, and annexin V) were immobilized on gamma-irradiated or plain polystyrene plates. RESULTS: All types of aPL Abs were frequently observed in the patients with SLE when gamma-irradiated polystyrene plates were used (51 of 168 cases positive for anti-beta(2)-GPI, 94 of 168 cases positive for anti-prothrombin, 36 of 168 cases positive for anti-protein C, 47 of 168 cases positive for anti-protein S, and 50 of 168 cases positive for anti-annexin V), whereas no Abs to these plasma proteins were detected when plain polystyrene plates were used. Multivariate analysis confirmed that both anti-beta(2)-GPI and anti-prothrombin Abs were significant risk factors for arterial thrombosis [odds ratios (ORs), 8.8 and 14.5, respectively; 95% confidence intervals (CIs), 3.2-25 and 1.8-116, respectively] but not for venous thrombosis. The presence of anti-protein S Abs was a significant risk factor for venous thrombosis (OR, 30.4; CI, 3.3-281) but not for arterial thrombosis. The only significant risk factor for fetal loss was the presence of anti-annexin V Abs (OR, 5.9; CI, 1.4-14.8). CONCLUSIONS: Patients with SLE frequently have some aPL Abs to beta(2)-GPI, prothrombin, protein C, protein S, and annexin V. Thrombotic complications in SLE may depend on the antigenic specificities of these Abs, alone or in combination.

The effect of reaction temperature for nephelometric assays for rheumatoid factor.

Even using the same assay parameter, reagent and calibrator (N-latex RF kit II), the results of the assay for serum rheumatoid factors (RFs) with the Behring Nephelometer Analyzer (BNA) were higher than those with the Behring Nephelometer II Analyzer (BNII) ([BNII]=0.76 [BNA]-5.7 kIU/l, r=0.997, Sy/x=60.73, n=99). The mean bias (BNA minus BNII)+/-S.D. was 52.7+/-85.5 using the Bland and Altman plot method, and the bias was not constant. The only difference in the assay condition with the two methods was the reaction temperature with the BNA being performed at room temperature (25+/-1 degrees C) and the BNII being performed at 37 degrees C. The ratio of the results with the BNII to the BNA (BNII/BNA) ranged from 0.23 to 1.18. A significant difference was observed in the BNII/BNA ratio in patients with high levels of C-reactive protein (CRP) over 2.0 mg/l (mean BNII/BNA ratio; 0.78) in comparison to patients with normal CRP levels under 2.0 mg/l (mean BNII/BNA ratio; 0.65) (P<0.01). The RF concentrations with the BNA were reduced by addition of urea, which has been used as a mild protein-denaturing agent, and there was a significant correlation between the values calculated as (1-value treated with urea/original value without urea)x100 and the BNII/BNA ratio (r=0.652, P<0.01). These data suggested that the bias between the RF values obtained by the BNA and BNII might be caused by the variation in the reactivity of autoantibodies, which might be decreased in some inflammatory diseases.

Endoscopic resection of a pelvic neurogenic tumor through the retroperitoneal approach.

A pelvic neurogenic tumor resected endoscopically through the retroperitoneal approach is described. Close examination of a 62-year-old man who complained of dull pain in the lower abdomen revealed a tumor on the posterior surface of the iliacus muscle. The tumor was extracted endoscopically without the need for a laparotomy. This procedure involves a less invasive approach that may be useful for benign retroperitoneal pelvic tumors.

[A case report of gastric carcinoma with complete remission of paraaortic lymph node metastasis by 5'-DFUR and MMC administration after resection of primary tumor].

A 53-year-old man was referred to our hospital with Borrmann type 2 advanced gastric cancer with a Virchow's node metastasis. A CT scan revealed a paraaortic lymph node metastasis. Because the tumor was diagnosed as being a poor candidate for curative resection, only a total gastrectomy was done. After surgery, administration of 5'-DFUR and MMC was begun. As a result, the paraaortic lymph node metastasis disappeared and the Virchow's node metastasis was reduced. The patient is well with no sign of recurrence 20 months after the operation.

[Study of chronic graft-vs-host disease, infection and immune reconstitution in patients surviving more than one year after bone marrow transplantation from unrelated donors].

We studied the immune reconstitution and incidence of chronic graft-vs-host disease (GVHD) and infection in 25 patients who survived more than 1 year after bone marrow transplantation (BMT) from unrelated donors for treatment of leukemia. Of the 25 patients, 4 died after 1 year post-transplantation. The causes of death were relapse of leukemia (2 patients), obstructive bronchiolitis (1 patient), and hepatic failure (1 patient). Only 2 of 14 patients who were under 30 years of age at the time of their BMT developed chronic GVHD, however, 7 of 11 patients 30 years of age or older developed chronic GVHD. Lower karnofsky scores were displayed by 6 of the older patients with chronic GVHD but by none of the younger patients with chronic GVHD. These results underscored the importance of care for older patients with chronic GVHD.CD4-positive T cells, and especially CD4 * CD45RA-positive T cells, had not recovered to a normal range even 2 years after BMT. Longer follow-up will be necessary.

Bleeding through the fiber interstices of a knitted dacron graft 12 years after its implantation: report of a case.

We present herein the case of a 65-year-old man who suddenly developed fresh perigraft bleeding into the space between a knitted Dacron bifurcated graft and the aneurysmal sac, 12 years after undergoing graft replacement. Intraoperative findings did not show Dacron fiber degeneration at the nonanastomotic sites or a pseudoaneurysm at the anastomotic site. Widened Dacron fiber interstices resulting from graft dilation without sufficient graft healing was thought to have caused delayed hemorrhage through the macroscopically intact graft material, followed by massive clot retention between the graft and the aneurysmal sac. This case report serves to demonstrate that careful long-term follow-up is essential for patients who have undergone vascular graft replacement.

A double bifurcated graft for abdominal aorta and bilateral iliac artery reconstruction.

Revascularization of the hypogastric artery often tends to be neglected in aortoiliac reconstructive surgery; however, its incomplete revascularization can result in unfavorable complications such as buttock claudication or necrosis, vascular impotence, and colonic ischemia. Multiple vascular lesions in the abdominal aorta and bilateral iliac arteries were reconstructed using a newly designed double bifurcated graft in five male patients. All five patients demonstrated excellent graft limb patency and postoperative improvement of the ankle-brachial pressure index without any clinical signs of ischemia in regions of the hypogastric artery. Thus, we conclude that an aggressive approach toward hypogastric circulation maintenance is essential in aortoiliac reconstructive surgery. By using this double bifurcated graft, rapid and safe revascularization of the bilateral hypogastric arteries concomitant with the external iliac or femoral arteries can be performed.

Angle-adjustable sheath for a dual-stage venous cannula.

The dual-stage venous cannula is widely used but can obstruct the surgeon's view and interfere with operative procedures in the aortic root. We designed a new stainless steel sheath for a dual-stage venous cannula that enables the cannula to bend and maintain the appropriate angle for the surgical procedures. We suggest that operative procedures in the aortic root can be performed faster during safety cardiopulmonary bypass by use of a dual-stage venous cannula bent by application of this new sheath.

A new marrow T cell depletion method using anti-CD6 monoclonal antibody-conjugated magnetic beads and its clinical application for prevention of acute graft-vs.-host disease in allogeneic bone marrow transplantation: results of a phase I-II trial.

We established a simple method of T cell depletion using anti-CD6 monoclonal antibody-conjugated immunomagnetic beads. Preliminary experiments using this method demonstrated that CD3+ T cells could be partially depleted without depleting CD56+ NK cells. A phase I-II clinical study was performed to assess the safety and efficacy of this partial T cell depletion method for the prevention of acute graft-vs.-host disease (GVHD) in 10 leukemia patients at high risk for GVHD (defined as 1) unrelated transplant from MLC-positive or HLA-DRB1 mismatched donor or 2) related transplant from serologically HLA-A, -B, or -DR one-locus mismatched donor). Cyclosporine (CSP) and methotrexate (MTX) were used for additional prophylaxis against GVHD in all cases. Sustained engraftment occurred in 9 of the 10 patients. Although acute GVHD developed in 6 of the 9 evaluable patients, none developed more than grade III severe acute GVHD. Five patients were alive in remission at a median follow-up of 32 months after bone marrow transplantation, and no relapse of leukemia was observed. We conclude from this pilot study that selective T cell depletion with anti-CD6 monoclonal antibody coupled with CSP and MTX posttransplant immunosuppressive therapy is safe. Further analysis of the phase II-III study is needed to confirm the effectiveness of this protocol.

Clinical experiences of surgical repair for mitral regurgitation secondary to papillary muscle rupture complicating acute myocardial infarction.

Mitral regurgitation secondary to ischemic heart disease carries a significant mortality even after emergency open heart surgery. From 1993 to 1997, four patients were operated on for ischemic mitral regurgitation secondary to papillary muscle rupture. These patients were between 58 and 69 years of age and all were in class III or IV of the New York Heart Association Classification. The responsible infarction area was located in the lateral wall in 2 patients, and inferior in others. The interval between the onset of acute myocardial infarction and the appearance of mitral regurgitation was from 1 to 10 days. Three patients had partial rupture (defined as only one or several heads of papillary muscle ruptured), and one had total papillary muscle rupture. Primary mitral plasty was performed in 3 patients, including 1 patient who had undergone patch closure of ventricular septal perforation at the onset of acute myocardial infarction. Mitral plasty combined with coronary artery bypass grafting was performed in 1 patient. Only one case, who had total papillary muscle rupture, required reoperation for recurrence of mitral regurgitation. We suggest that even in the case of ischemic mitral regurgitation, when a papillary muscle rupture is partial, mitral repair is performed because of its potential for improving therapeutic results.

[Coronary artery bypass grafting to the left circumflex artery in the atrioventricular groove].

Coronary artery bypass graftings were performed to the left circumflex artery (LCX) system in the atrioventricular groove (#11 or #13) in addition to revascularization to the left anterior descending artery system using conventional technique in 10 patients with left main trunk lesion. Distal anastomosis was done at #11 of LCX in 6 patients using saphenous vein graft, and at #13 of LCX in 4 patients using 2 saphenous vein grafts and using 2 internal thoracic artery grafts. The mean flow rate of SVG operated by this technique showed larger values than that of SVGs by sequential bypass or individual bypass technique to #12 and/or #14 of LCX. Postoperative angiographies showed excellent graft patencies and symptomatic improvements were achieved. This technique of coronary artery revascularization is recommended and useful in patients whose #12 and #14 of LCX system is too small to make distal anastomosis.