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We treated a patient with neurosarcoidosis, which caused the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), in whom diagnosis was performed using neuroendoscopy. The patient was a 56-year-old female who was hospitalized for hyponatremia and diagnosed with SIADH based on a detailed examination. During the course, she developed impaired consciousness due to acute hydrocephalus, which improved after ventricular drainage. Head magnetic resonance imaging (MRI) confirmed nodular lesions at the floor of the third ventricle and the cerebral aqueduct. Neuroendoscopic biopsy led to the diagnosis of neurosarcoidosis. Her hyponatremia improved after steroid therapy. Neurosarcoidosis can cause SIADH, and complication of hydrocephalus may lead to a poor prognosis. Neuroendoscopy appears to be effective for the diagnosis of neurosarcoidosis with hydrocephalus and helps in deciding the treatment modality.

Background N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in patients with acute coronary syndrome (ACS), and is a powerful predictor of long-term mortality. Differences in the clinical utility and pathophysiological implication of NT-proBNP and conventional cardiac markers in patients with ST elevation (STE) vs non-STE (NSTE) ACS were investigated in the present study. Methods and Results Ninety consecutive patients admitted with acute chest pain and a diagnosis of unstable angina or acute myocardial infarction were analyzed. Patients with ≥Killip class II were excluded to focus on the effect of myocardial ischemia on the release of cardiac markers. The markers were measured on admission and analyzed according to the time from onset. Conventional cytosolic marker (creatine kinase-MB) and myofibril marker (troponin T: TnT) were both significantly higher in STE-ACS patients compared with NSTE-ACS patients. Conversely, NT-proBNP was significantly higher in NSTE-ACS patients than STE-ACS especially within 3 h of onset, suggesting a larger ischemic insult despite the smaller extent of myocardial necrosis compared with STE-ACS patients. There was no significant correlation between NT-proBNP level and left ventricular ejection fraction (LVEF) obtained at acute-phase echocardiography in either NSTE-ACS patients (LVEF 57.7±11.2%) or STE-ACS patients (LVEF 55.1±12.7%). Comparison between NT-proBNP and TnT levels revealed a marked difference of elevations, with significantly augmented elevation of NT-proBNP (p

症例は51歳の男性. 7年前に他院で盲腸癌に対して結腸右半切除術(D3)を施行された. por, se, n1 (+), stage III aであった. 2004年11月頃より肛門部掻痒感を主訴に近医を受診した.直腸診で下部直腸前壁に可動性不良の粘膜下腫瘍を触知したため精査となった.直腸・前立腺に浸潤する40×50mmの腫瘍を認めた.経直腸生検では低分化腺癌であった. PET検査では他に遠隔転移は認めなかった.盲腸癌が孤立性転移をしたものと考え骨盤内臓器全摘術を施行した.術中ダグラス窩部腹膜にひきつれを認めたが腫瘍は腹腔内に露出していなかった.他に転移は認めなかった.術後4カ月目に陰茎転移が判明した.その後,再発は認めていない.骨盤内臓器全摘術は過大な侵襲を伴い慎重な手術適応の判断が必要となるが,本症のように根治切除可能なものに対しては積極的外科治療を行うべきと考えられた.

A 60-year-old man was admitted to the hospital because of constipation in July, 1993. With a diagnosis of rectal cancer (Rs) with synchronous multiple liver metastases (H3), an abdominal resection of the rectum, a right hepatic lobectomy and partial liver resections of the segment 3 and 4 were performed. After while, partial liver resections were performed twice for recurrences in the segment 4 of the liver in June, 1994 and September, 1995. In September, 1997, a left lateral segmentectomy of the liver and a partial resection of the gastric wall were performed for recurrence in the residual liver which directly invaded the stomach. At that time, No. 6 lymph node metastasis was observed. Histologically, the surgical margin of the stomach was positive, and a distal gastrectomy with D1 lymph nodes dissection was carried out in October, 1997. It is rare that metastatic tumor directly invades the stomach. We report the patient who is surviving for 5 years after the initial operation with aggressive liver resection.

A 50-year-old woman was admitted to the hospital because of an abnormal shadow detected incidentally by a routine chest X-ray, examination 4 years previously, when she was asymptomatic. The tumor gradually increased in size in those years. After admission, a partial resection of the lung including the tumor was performed. The tumor was attached to the visceral pleura of right lower lobe by a pedicle. Pathologically the tumor was solitary fibrous tumor of the pleura (localized fibrous mesothelioma). The histogenesis of solitary fibrous tumor is still controversial, but the mesencymal origin is preferred on the basis of immunohistochemical findings including CD34 positivity. In this case tumor cells also demonstrated positive for CD34.

A case of carcinoma of the pancreatic head associated with situs inversus (SI) and polycystic liver (PCL) is presented. The patient was a 71-year-old male with complaints of jaundice and general fatigue. Percutaneous transhepatic biliary drainage (PTBD) revealed complete obstruction of the lower end of the common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis of the main pancreatic duct (MPD) in the head of the pancreas. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated multiple cysts in the liver as well as SI. Pylorus-preserving-pancreatoduodenectomy (PPPD) was performed by an operator who took his usual position on the patient's right side. We had no particular difficulty during surgery, although we had to charge several procedures. We consider it reliable to take the usual positions during surgery, even in cases of SI.

A case of esophageal leiomyoma with remarkable calcification is presented. A 65-year-old man was admitted to the hospital, because esophagography on a health screening demonstrated extraesophageal compression and deformity of the esophagus. Endoscopy showed a protruding lesion, 3cm in diameter, in the anterior wall of the esophagus under the bifurcation of the trachea. Esophagography and computed tomography showed a massive calcification in the lesion. With endoscopic ultrasonography a tumor originating from the proper muscular layer of the esophagus was suspected. Enucleation of the tumor was performed. The resected specimen was a hard and saddle-like tumor, 4×3×1.5cm in size. Histological findings revealed leiomyoma. Nine of 20 cases of calcified leiomyoma of the esophagus reported in Japan were characterized by the location in the anterior wall of the esophagus near the bifurcation of the trachea.

SummaryBackgroundThe expanding role of cardiac markers – cytosolic [heart-type fatty acid-binding protein (H-FABP) and creatine kinase MB (CK-MB)], myofibril [troponin T (TnT)], and cardio-endocrine [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] – has been clarified in patients with acute coronary syndrome and those with heart failure. However, these applications for early risk stratification in the cardiac emergency, and the influence of renal function on these evaluations have not been fully investigated.Patients and methodsWe investigated the prognostic value of these representative cardiac markers and influence of renal function on these evaluations in 165 consecutive patients who were admitted for cardiac emergency because of chest pain or dyspnea.ResultsThere were significant correlations between TnT and CK-MB (r=0.512, p

A 19-year-old man was admitted for severe traumatic tricuspid regurgitation (TR) 4 months after a traffic accident. Transthoracic echocardiography revealed severe TR, with an abnormal chordal structure. Three-dimensional echocardiography showed widely lacerated right ventricular endocardium involving many subvalvular components. In this case of traumatic TR, three-dimensional echocardiography was useful not only for its diagnosis but also in providing important information for surgical decision making.

We describe a case of gastroduodenal ulcer in which pyloric vestibular stenosis exacerbated in a short time and we had difficulties in differentiation from advanced gastric cancer.The case was a 71-year-old male who had had head injury and was being medicated for sustaining headache. On October 16, 1989, the patient was admitted to our hospital because of melena. Upper gastrointestinal series revealed a probable advanced gastric cancer. Borrmann type 4. Biopsy cytology, however, showed no malignant findings. Because of markedly exacerbated stenosis at the pyloric vestibule, pyloric-side gastrectomy and duodenectomy were carried out on November 22. In the excised specimen, giant girdle ulcer (Ul-II) in 3 lines at the lesser curvature, anterior and posterior wall of lower body of stomach, and a whole-circumference stenosis 7 cm in length reaching to the duodenal bulb at the anal-side were observed. Histopathological findings included mild inflammatory findings at mucous membrane, submucosal proliferation of collagen fiber, and marked hypertrophy of intrinsic muscle layer at the whole-circumference stenosis site. This pyloric vestibular stenosis might be due to repeated chronic inflammation. Possible factors causing exacerbation can be medication and circulatory disturbance.

Two cases of adenoid cystic carcinoma in buccal mucosa were reported. The first case was a 56-years old woman having a buccal tumor since 20 years ago. The tumor was removed and neck dissection was performed. Her cheek was reconstructed by using a temporal flap prepared from the forehead. Tumor was 3×3×2cm in size, and histopathological study revealed a cribriform of adenoid cystic carcinoma. The other case was a 62 years old woman, who noticed a painless tumor at the cheek one year ago. Surgical procedure was performed, but margine positive was showed by histopathological sutdy. She rejected the additional surgery, it is unavoidable, and chemotherapy with Cisplatin was done. Recently only five cases have been reported in Japan. It seems that the prognosis relates with the histopathological type, and careful surgical resection is the best treatment.

To assess the feasibility and potential impact of routine three-dimensional (3D) echocardiographic assessment of left ventricular (LV) ejection fraction and volumes on clinical decision-making.Patients referred to three hospital-based echocardiography laboratories underwent 2D echocardiography (2DE) and 3D echocardiography (3DE). Feasibility was assessed in a group of 168 unselected patients and decision-making assessed within an expanded group of 220 patients. The time for acquisition and measurement was obtained. Feasibility was defined by ability to measure LV parameters. The potential of 3DE to alter clinical decisions based on 2DE was evaluated by the ability to identify four clinically relevant measurement thresholds: (1) LV end-systolic volume (LVESV)50 ml/m(2) (indication for surgery in regurgitant valve disease); (2) LVESV30 ml/m(2) (prognosis after infarction); (3) LV ejection fraction (LVEF)35% (indication for implantable defibrillator); and (4) LVEF40% (indication for heart failure treatment).3DE was technically feasible in 83% of unselected patients. The additional time for 3D acquisition and measurement was available in 184 patients and was 5.4 (SD 2.0) minutes. The use of 3DE changed categorisation in between 6-11% of patients. Within threshold categories, 3D reallocated 17.5% (11/63) of patients with LVEF35%, 16.1% (13/81) for LVEF40%, 12.4% (13/105) for LVESV30 ml/m(2) and 8.5% (5/59) for LVESV50 ml/m(2). Most of the impact of 3D was within 10 ml/m(2) of selected volume thresholds (or=75%) and 10% of EF thresholds (80%).Measurement of LV volumes and EF by 3DE is clinically feasible and has the potential to significantly alter clinical decision-making.

Background: Measurement of brain natriuretic peptide (BNP) has become a potent diagnostic aid as a means of identifying patients with systolic or diastolic dysfunction. Due to better stability in circulating blood, we reasoned that measurement of N-terminal proBNP (NT-proBNP) may be a more discerning marker for the detection and evaluation of chronic heart failure. Methods: The relationships between plasma concentrations of NT-proBNP and BNP, and aetiology, New York Heart Association (NYHA) classification, and left ventricular ejection fraction (LVEF) were analyzed in 105 patients with chronic heart failure. Sixty-seven healthy volunteers were studied as the controls. Results: Both NT-proBNP and BNP showed progressive increases (P

BackgroundResearch studies have shown 3D echocardiography (3DE) to be a feasible and more accurate method of assessing LV volumes and ejection fraction when compared to conventional 2D echocardiography (2DE). However, there is limited information regarding the feasibility and incremental value of 3DE in clinical practice.MethodsUnselected patients referred to two hospital-based echo laboratories underwent 2DE and 3DE with measurement of acquisition and analysis time. Feasibility was defined by ability to measure LV parameters. Potential of 3DE to alter clinical decisions based on 2DE was evaluated by the ability to identify four clinically relevant measurement thresholds: (1) LVEF l 40% (indication for heart failure treatment); (2) LVEF l 35% (indication for ICD); (3) LV end-systolic volume (LVESV) g30 ml/m2 (prognosis post-MI); and (4) LVESV g 50 ml/m2 (indication for surgery in regurgitant valve disease).ResultsOf 168 patients, 3DE was feasible in 150 (89.3%) with 2D and 3D data available in 148 patients (88.1%). Time for 3D sample acquisition was 5.3 p 1.9 min. The proportion of patients in which 3DE changed categorisation above or below a threshold as defined by 2DE was 5.4% (8/148) for LVEF l 40%, 2.7% (4/148) for LVEF l 35%, 11.5% (17/148) for LVESV g 30 ml/m2, and 2.7% (4/148) for LVESVi g 50 ml/m2, with 82% of impact for EF in range 30n45% and 75% for LVESV in 20n40 ml/m2.ConclusionMeasurement of LV volumes and ejection fraction by 3DE is clinically feasible and has the potential to significantly alter clinical decision making.Copyright c 2007 Published by Elsevier Ltd. on behalf of The Australasian Society of Cardiac and Thoracic Surgeons and The Cardiac Society of Australia and New Zealand

高creatine phosphokinase (CPK)血症を呈したMcArdle病の1例を経験したので報告する.症例は58才,女性.生来運動時に筋易疲労感,筋力低下をきたし,運動をそのまま持続すると筋力の回復をよく経験した.その他身体的には異常をきたしことはなかつた. 1975年8月頃に咳嗽発作,呼吸困難が出現,当院受診し気管支喘息の診断のもとに某病院入院.その加療中に血清のCPK, GOT, LDH値に異常を認め,筋疾患の疑いをもたれ当科に紹介され,同年11月11日に入院した.入院時検査では,血清CPKの高値, GOT, LDHの軽度上昇がみられ,それらの値は経過中平行して変動した.阻血下運動試験では,血清乳酸値の上昇がみられず,筋の嫌気的解糖系の障害を想定し筋生検を施行した.筋組織学的検査では,グリコーゲン蓄積と思われるPAS濃染部を筋鞘下に認め,ホスホリラーゼ活性を有する筋線維はみられなかつた.筋生化学的検査では,筋グリコーゲン含量が増加し,ホスホリラーゼ活性は極めて低値を示し,嫌気的解糖においてもグリコーゲン添加ではほとんど乳酸産生がなく,グルコース-1-リン酸(G-1-P),グルコース-6-リン酸(G-6-P)添加ではほぼ正常の乳酸産生量を示した.以上の結果より本症例をMcArdle病と診断した.なお運動負荷試験時の血清のK値並びにCa値の特異な変動と同時に血清CPKの高値は,筋細胞膜機能特に膜透過性異常が想像され, McArdle病の病態の一側面を表わしているものと考えられる.

From 1970 to 1982, 103 primary Borrmann type 3 gastric cancers were curatively resected in our department. The prognosis of these patients was investigated according to the location of the cancer, namely C (upper portion), M (middle portion), A (lower portion). The survival rate for patients with cancers located in M was best, and it was the worst if the cancers were located in C. However, there was no significance in the three groups in histopathological factors, such as depth of invasion and lymph node metastasis. Only the type of gastrectomy and combined resection of other organs showed a significant difference, but the difference was not enough to explain the defference in the prognosis. From this study, it has become apparent that more efforts in the treatment and earlier diagnosis are necessary to improve the prognosis for patients with gastric cancers located in C.

Effect of simvastatin on the lipid profile of hemodialysis patients. Background Simvastatin, a 3-hydroxy 3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, is used widely for treatment of hypercholesterolemia. Simvastatin may be a suitable treatment for dyslipidemia in hemodialysis (HD) patients. However, investigation of the side-effects and safety of long-term administration of simvastatin to HD patients has been limited. In this study, we investigated the effects and safety of simvastatin and its effects on lipoprotein metabolism in hypercholesterolemic patients on HD. Methods Simvastatin was administered at a dosage of 5 mg/day for 24 weeks to 38 HD patients with high serum total cholesterol (TC) levels (200 mg/dl) or low high-density lipoprotein cholesterol (HDL-C) levels (35 mg/dl). Every four weeks, serum lipids, apolipoprotein, lipoprotein(a) [Lp(a)] and malondialdehyde (MDA) levels were measured. In addition, lipid levels were determined in each lipoprotein fraction separated by ultracentrifugation. Results After 24 weeks of simvastatin administration, TC significantly decreased by 25.7%, and low-density lipoprotein cholesterol (LDL-C) was significantly decreased by 33.6%. Triglyceride (TG) and HDL-C showed no significant changes. Apolipoprotein (apo) B significantly decreased by 24.5% and apo E by 30.0%. No significant changes were observed in the other apolipoproteins. MDA was also significantly decreased, whereas Lp(a) was not significantly altered. In the lipoprotein fractions, very LDL cholesterol (VLDL-C), intermediate-density lipoprotein cholesterol (IDL-C), LDL1 cholesterol (LDL1-C), and LDL2 cholesterol (LDL2-C) showed significant decreases. No particular side-effects were observed during the 12 months of simvastatin administration. Conclusions These results suggest that simvastatin appears to be safe and effective in HD patients with hypercholesterolemia.

To elucidate the genesis and effect of atrial fibrillation (AF), 102 patients with acute myocardial infarction were studied. Eighteen patients had AF during the first 72 hours in the coronary care unit. The hospital mortality rate was 23%. Discriminant analysis was used to determine the important variables contributing to the genesis of AF and hospital mortality based on the following variables: cardiac output, pulmonary capillary wedge pressure, right atrial pressure, systolic blood pressure (at admission and before the onset of AF or most abnormal value), age, location of infarction, sex and pericarditis. Pulmonary capillary wedge pressure, right atrial pressure and age were the important factors contributing to AF, whereas pulmonary capillary wedge pressure and age were important for hospital mortality. Therefore, the hemodynamic change imposed on the left atrium and aging are the major factors related to the occurrence of AF and hospital mortality.