bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes in resistive index following extracorporeal shock wave lithotripsy
Authors: Aoki Yoshitaka , Ishitoya Satoshi , Okubo Kazutoshi , Okada Takashi , Maekawa Shinya , Maeda Hiroshi , Arai Yoichi
Published: March 2003

Abstract
Background
: Extracorporeal shock wave lithotripsy (ESWL) has replaced most surgical and endourologic forms of therapy for upper urinary tract stone disease. Despite its proved safety and efficacy, its adverse effects on renal function are still to be identified. A newer diagnostic technique, color Doppler ultrasonography, has brought a new insight into renal function. It enables precise evaluation of the renal vascular supply. Changes in intrarenal vascular resistance after ESWL were studied with Doppler ultrasound techniques.

Methods
: In 70 consecutive patients the resistive index (RI) was measured at an interlober artery before and 30 min after ESWL in the treated and contralateral kidneys. In 17 patients, a follow‐up Doppler study was performed 1 week after ESWL.

Results
: In the treated kidneys, the RI significantly increased from 0.656 ± 0.053 (mean ± SD) at baseline to 0.682 ± 0.053 (P < 0.0001). There was no significant correlation of increase in RI with patient age (r = 0.010) or with pre‐ESWL blood pressure (r = 0.002). Elderly patients (≥ 60 years old, n = 31) had higher RI levels on baseline than younger patients (< 60 years old, n = 39). In 18 of the 31 (58.1%) elderly cases the RI were elevated to greater than 0.7, indicating pathologic changes. In younger patients, only 9 (23.1%) experienced increase in RI up to 0.7 or greater. The contralateral untreated kidneys showed significant change in RI before (0.664 ± 0.045) and after (0.679 ± 0.049) lithotripsy in elderly patients (P < 0.005). A follow‐up Doppler study showed that the mean RI returned to pretreatment levels after 1 week.

Conclusions
: Because of higher RI levels on baseline, elderly patients have a higher risk of post‐ESWL renal tissue damage than younger patients. Clinical implication of RI change in the contralateral kidneys in this study remains to be answered. The measurement of changes in RI with Doppler ultrasound techniques after ESWL may provide useful information for clinical diagnosis of renal tissue damage.
Immunohistochemical finding of α‐1‐antichymotrypsin in tissues of benign prostatic hyperplasia and prostate cancer
Authors: Tanaka Masashi , Suzuki Yoshio , Takaoka Katsuyuki , Murakami Shino , Suzuki Noriyuki , Shimazaki Jun
Published: March 2003

Background
: Ratio of free to total (F/T) prostate‐specific antigen (PSA) is higher in the blood of patients with benign prostatic hyperplasia than those with prostate cancer. To clarify the difference between ratios in these two, α‐1‐antichymotrypsin, the major component of the bound PSA in the blood, was immunohistochemically examined.

Methods
: Tissues were obtained surgically via a retropubic approach from patients with benign prostatic hyperplasia (nine cases) and prostate cancer (27 cases). These samples were processed in paraffin blocks, cut into 5 mm sections and stained with antibodies against α‐1‐antichymotrypsin and PSA.

Results
: The percentage of α‐1‐antichymotrypsin‐stained cells in prostate cancer was higher than that in benign prostatic hyperplasia (P < 0.05). Almost all of glandular and cancer cells were stained with PSA antibody. The percentage of α‐1‐antichymotrypsin‐stained cells in prostate cancer did not correlate to histologic grade, although α‐1‐antichymotrypsin‐stained cells were more widely scattered in high grade tissues. No correlation was found between α‐1‐antichymotrypsin‐stained cells and ratio of F/T in the blood of cancer patients. In about 20% of cancer tissues, histiocytes with positive α‐1‐antichymotrypsin staining were found in stroma but not in that of benign prostatic hyperplasia.

Conclusions
: Prostate cancer tissues are shown to have a richer environment of α‐1‐antichymotrypsin than those of benign prostatic hyperplasia. Some cancer tissues contained α‐1‐antichymotrypsin‐stained histiocytes. These local events may correlate to a high amount of the bound form among total PSA in the blood of prostate cancer patients.
Malignant fibrous histiocytoma of the spermatic cord: A case report
Authors: Uchida Kohsuke , Oda Toshiro , Adachi Hideki , Wakabayashi Junichi , Hisasue Shinichi , Takagi Yoshio
Published: March 2003

We present a case of malignant fibrous histiocytoma of the spermatic cord. An 86‐year‐old man was admitted to the hospital with a right painless scrotal mass. Under the diagnosis of a testicular tumor, right radical orchiectomy was performed. Grossly, the tumor firmly adhered to the spermatic cord. The right testis and epididymis were normal. The histologic diagnosis was malignant fibrous histiocytoma. There was local recurrence 2 months after surgery. The recurrent tumor was resected with the surrounding soft tissue, but the patient died 5 months after the initial operation.
A comparative study of endoscopic trigonoplasty for vesicoureteral reflux in children and in adults
Authors: Okamura Kikuo , Kato Norio , Tsuji Yoshikazu , Ono Yoshinari , Ohshima Shinichi
Published: March 2003

Background
: Endoscopic trigonoplasty is an experimental therapy for vesicoureteral reflux. We investigated differences in surgical results between children and adults.

Methods
: Endoscopic trigonoplasty was performed on 51 patients and 15 pediatric and 21 adult patients were included in this study. The children accounted for 27 cases of refluxing ureter (grade II, 8; III, 14; IV, 4; V, 1) and the adults for 28 cases (I, 4; II, 18; III, 4; IV, 2). There was a greater proportion of bilateral disease and a higher average degree of reflux in the children’s group.

Results
: We found no significant differences in operative time, complications, analgesics usage, the duration of the indwelling catheter and hospital stay. Our follow up at 3 months showed that the reflux had ceased in 19 of 27 cases (70%) in the children’s group and in 27 of 28 cases (96%) in the adults’ group. The next follow up at 12 months showed that there was no reflux in 16 of 27 cases (59%) in 15 children and in 17 of 23 adult cases (74%). Trigonal splitting caused recurrence of reflux greater than grade II, in two children (13%) affecting four ureters and in three adults (14%) affecting four ureters.

Conclusions
: Endoscopic trigonoplasty has proved to be equally less invasive in children and in adults, but vesicoureteral reflux was less often resolved in children. This suggests that the greater original distance between the ureteral orifices and the greater thickness of the detrusor muscle favor the adult patient. For children, a new surgical concept is needed to increase cessation rate of vesicoureteral reflux.
Conservative treatment of childhood phimosis with topical conjugated equine estrogen ointment
Authors: Yanagisawa Naoko , Baba Katsuyuki , Yamagoe Masanari , Iwamoto Teruaki
Published: March 2003

Purpose
: To assess the application of topical conjugated equine estrogen for the treatment of boys with phimosis.

Methods
: Fifteen boys with phimosis were included in the study. Conjugated equine estrogen (Premarin®) 0.1% ointment was applied on the prepuce once daily. The treatment was continued until the prepuce was fully retractable. The patient was examined each second week up to a maximum treatment of 8 weeks. Retractability and the appearance of the foreskin were graded before and after treatment.

Results
: Thirteen of 15 boys (87%) referred with phimosis were successfully treated with conjugated equine estrogen ointment. An adverse effect of gynecomastia was seen in one boy (7%). Conclusion: Conjugated equine estrogen ointment application for phimosis may be an alternative to surgery.
Calcium supplement necessary to correct hypocalcemia after total parathyroidectomy for renal osteodystrophy
Authors: Nakagawa Masayuki , Emoto Akio , Nasu Nobuyoshi , Hirata Yuji , Sato Fuminori , Li Wenping , Imagawa Masaharu , Nomura Yoshio
Published: March 2003

Background
: Prediction of the extent of calcium supplement will facilitate safe and efficient management of hypocalcemia in the early postoperative stage of total parathyroidectomy with autotransplantation (PTXa) in patients with renal osteodystrophy.

Methods
: The correlation between the extent of calcium deficiency, estimated by the amount of calcium supplement over 48 h after PTXa and using various parameters such as carboxy terminal parathyroid hormone (c‐PTH), intact PTH (i‐PTH), alkaline phosphatase (ALP), serum calcium, serum phosphorus, duration of hemodialysis, total weight of resected parathyroid glands and degree of subperiosteal resorption of the middle phalanx was examined in 49 patients who underwent PTX with subcutaneous autotransplantation. Bone mineral density (BMD) was also determined before, 3 months and 1 year after PTXa with dual energy X‐ray absorptiometry (DEXA) in 13 patients.

Results
: There was a positive correlation between pre‐operative i‐PTH level (r = 0.56, P < 0.0005) or ALP level (r = 0.50, P < 0.0005) and the amount of calcium supplement over 48 h after PTXa in these patients. Furthermore, the degree of subperiosteal resorption, determined by Jensen’s classification, was significantly correlated with the amount of calcium supplement after PTX (P < 0.05). Bone mineral density 3 months after (P < 0.0005) and 1 year after PTXa (P < 0.001) significantly increased compared with BMD before PTXa in all patients examined.

Conclusion
: These findings suggest that the pre‐operative determination of i‐PTH, ALP levels and degree of subperiosteal resorption allow the management of hypocalcemia safely and efficiently in renal osteodystrophy patients after PTXa.
Microsurgical epididymovasostomy
Authors: Matsuda Tadashi
Published: March 2003

Epididymal obstruction is found in about 30% of obstructive azoospermic patients. Half of these obstructions are due to unknown etiologies, followed by obstruction due to epididymitis. The development of a specific, mucosa‐to‐mucosa anastomosis of the epididymal tubule to the vasal mucosa using a surgical microscopy has greatly improved the outcome of epididymovasostomy. The patency and natural pregnancy rates in this study were 79% and 38%, respectively. Side‐to‐end anastomosis also decreases the technical difficulty in comparison to the end‐to‐end anastomosis procedure. An anastomosis at the epididymal caput generally results in a poorer outcome than at the corpus or cauda epididymis.
Oral estramustine phosphate and oral etoposide for the treatment of hormone‐refractory prostate cancer
Authors: Sumiyoshi Yoshiteru , Hashine Katsuyoshi , Nakatsuzi Hironori , Yamashita Yokihiko , Karashima Takashi
Published: March 2003

Background
: The purpose of the present study was to evaluate the antitumor activity and toxicity of oral estramustine phosphate (EMP) in combination with oral etoposide in patients with hormone‐refractory prostate cancer.

Methods
: Twenty patients with adenocarcinoma of the prostate that progressed after one or more regimens of androgen‐deprivation therapy were enrolled into this trial. Oral EMP was administered twice daily, for a total daily dose of 560 mg, and oral etoposide (50 mg/bodyweight per day) was given on days 1–21 and was stopped on days 22–35. Treatment was continued until evidence of disease progression appeared or two consecutive rises in the prostate‐specific antigen (PSA) value were observed.

Results
: Ten of 20 patients showed a decrease of 50% or greater in the PSA value from initially elevated PSA levels after therapy. The median progression‐free duration and 2 year cause‐specific survival rate of these 10 patients were 208 days (range 71–693 days) and 67.5%, respectively. There were no significant differences in age, pretreatment PSA value, duration from initial treatment to relapse, prior therapy or survival between patients who had a decrease of 50% or greater in PSA values after this combination therapy and those who did not. The main toxicities (≥ grade 2) were anemia, leukocytopenia, thrombocytopenia, gastrointestinal and hepatic disorders, which occurred in 40, 15, 10, 15 and 5% of patients, respectively.

Conclusions
: The combination of oral EMP and etoposide is considered to be a well‐tolerated outpatient treatment regimen for patients with hormone‐refractory prostate cancer and the therapy deserves further investigation.
Bilateral testicular tumors in androgen insensitivity syndrome
Authors: Sakai Naoki , Yamada Tetsuo , Asao Takeshi , Baba Masaya , Yoshida Minoru , Murayama Tetsuo
Published: March 2003

We report on a case of complete androgen insensitivity syndrome with bilateral testicular tumors and a point mutation in the androgen receptor gene. A bilateral gonadecotmy was performed and both of the resected tumors were histologically diagnosed as pure seminoma. Direct sequencing of amplified exons E–G of the androgen receptor gene from the resected tumor identified a CGA to CAA substitution in exon E, resulting in arginine to glutamine replacement at codon 752. To our knowledge, this is the first reported case of androgen insensitivity syndrome with bilateral testicular tumors.
Urological management of cloacal anomalies
Authors: Shimada Kenji , Hosokawa Syozo , Matsumoto Fumi , Johnin Kazuyosi , Naitoh Yasuyuki , Harada Yasunori
Published: March 2003

Background:

A cloacal anomaly results from incomplete urorectal division and is frequently associated with genitourinary abnormalities. Experience of the urological reconstruction of this entity is reported.

Methods:

Nine girls with cloacal malformation have been treated at the Osaka Medical Center in the past 9 years. Seven patients were detected by prenatal ultrasonography as having: megacystis (two patients); hydronephrosis (two patients); or hydrometrocolpos (three patients). Two patients underwent prenatal shunt placement between the enlarged bladder and the amniotic space.

Results:

For neonatal urinary diversion, four patients received cystostomy. Six of seven patients with associated hydrocolpos required intermittent catheterization to decompress an enlarged vagina. Vesicoureteral reflux was detected in 12 ureters of seven patients. Antireflux surgery was indicated in four patients before definitive repair. Definitive reconstruction was performed on eight patients. The posterior sagittal approach was used in all patients. Vaginal reconstruction was done utilizing a perineal skin flap (one patient), a tubularized vaginal flap (three patients), distal rectum (three patients) and total urogenital mobilization (one patient). Postoperatively, urethrovaginal fistula was created in one patient and complete occlusion was seen in one patient.

Conclusion:

The anatomical variety of this entity determines the management options from in utero. It involves not only the creation of three perineal orifices, but also a continent, catheterizable urethra under the stabilization of renal function. Accomplishment of the definitive repair requires the combined expertise of experienced pediatric surgeons and pediatric urologists.
Chrono and clinical pharmacokinetic study of tacrolimus in continuous intravenous administration
Authors: Satoh Shigeru , Tada Hitoshi , Tachiki Yutaka , Tsuchiya Norihiko , Shimoda Naotake , Akao Toshiya , Sato Kazunari , Habuchi Tomonori , Suzuki Toshio , Kato Tetsuro
Published: March 2003

Abstract Background: The circadian variation of clinical pharmacokinetics of tacrolimus in kidney transplant recipients receiving continuous intravenous administration has not been clarified. The aim of this study was to evaluate the circadian variation of this drug in continuous intravenous administration, with regard to the dosing scheme for conversion from intravenous to oral therapy.

Methods: The blood concentration–time curve was studied in 10 living‐related kidney transplant recipients, aged 18–51 years (mean, 36.5 years), 1 day before operation for preoperative oral administration, the third postoperative day for continuous intravenous administration and the sixth postoperative day at the conversion from intravenous to oral therapy.

Results: Although the total body clearance of daytime was slightly higher than that of night‐time, the intravenous tacrolimus infusion maintained an adequate therapeutic blood concentration for 24 h. There were significant differences between the preoperative and the postoperative state in the area under the curve, total body clearance and bioavailability for the oral administration. The mean absolute bioavailability was 17.7% in preoperative and 11.1% in postoperative state, respectively and a large interindividual variation was confirmed in this parameter, which was 7.0–27.2% for preoperative and 6.4–22.0% for postoperative area under the curve, respectively.

Conclusion: This study proposes that intravenous administration is a safe and appropriate method to achieve the required blood concentration in patients with various tacrolimus metabolism in the early post‐transplant period. As the oral tacrolimus absorption was found to be variable between preoperative and postoperative states in identical patients, the conversion dosage cannot be calculated from preoperative oral or postoperative intravenous pharmacokinetics. Frequent blood concentration monitoring is needed to ensure safe treatment.
M1 prostate cancer with a serum level of prostate‐specific antigen less than 10 ng/mL
Authors: Yamamoto Shinya , Ito Takaaki , Akiyama Akihito , Aizawa Taku , Miki Makoto , Tachibana Masaaki
Published: March 2003

Abstract Background: M1 prostate cancer, which is invasive, is usually associated with a serum level of prostate‐specific antigen (PSA) greater than 10 ng/mL, but cases are occurring where the serum PSA level is less than this. The present study investigated the clinical and pathologic characteristics of these cases of M1 prostate cancer.

Methods:

Between April 1989 and March 1998, 167 cases of M1 prostate cancer were diagnosed by transrectal needle biopsy and eight of these with a serum PSA level less than 10 ng/mL were investigated. The patients' ages ranged from 57 to 79 years (median, 73) and the serum PSA levels ranged from less than 4.0 to 9.8 ng/mL. In all cases except one, the distal metastasis was to bones only. All cases had received hormonal therapy as the initial therapy. Immunostaining of PSA, chromogranin A, neuron‐specific enolase, carcinoembryonic antigen and vimentin were performed in five of the eight cases.

Results:

Four cases were poorly differentiated, two were undifferentiated, one was a mixture of poorly differentiated and undifferentiated and one case was moderately differentiated. Of the five cases in the immunohistochemical study, three cases with an undifferentiated carcinoma component showed negative staining reactions for PSA and all cases were positive for carcinoembryonic antigen. Four of the patients died of prostate cancer. In two of these four cases, hormonal therapy was ineffective, but systemic chemotherapy and irradiation therapy had been moderately effective. The overall 3‐year survival rate was 33.3%.

Conclusions:

The cases of M1 prostate cancer with a serum PSA less than 10 ng/mL are almost always poorly differentiated or undifferentiated and have a poor prognosis compared with the usual M1 prostate cancer. Because hormonal therapy is ineffective in these cases, systemic chemotherapy and irradiation therapy should be chosen as the initial therapy.
Androgen deprivation in combination with radical prostatectomy for localized prostate cancer
Authors: Naito Seiji
Published: March 2003

Abstract Radical prostatectomy is the only potential modality for cure in patients with localized prostate cancer. However, the lack of reliable and accurate clinical staging frequently leads to incomplete excision of tumor, with the consequences of early local recurrence or distant metastasis. Thus, the role of neoadjuvant or adjuvant hormonal treatment has been investigated in improving disease‐free or cause‐specific survival. This review reports the current status and problems of such androgen deprivation in combination with radical prostatectomy for localized prostate cancer.
Renal artery aneurysm causing hydronephrosis
Authors: Miyagawa Yasushi , Oka Toshitsugu , Takano Yuji , Takaha Minato , Choi Soomi , Isobe Fumitaka
Published: March 2003

Abstract A 42‐year‐old man presented with left hydronephrosis incidentally discovered on abdominal echogram during a routine health examination. Color Doppler ultrasonography, intravenous pyelography and angiography revealed a non‐calcified renal artery aneurysm of 30 mm in size compressing the pyeroureteral junction and causing hydronephrosis. Three‐dimensional computed tomography (3‐D CT) using spiral CT clearly displayed the aneurysm located at the first bifurcation of the left renal artery and involving the anterior segmental artery. Decompression was successfully obtained via in situ revascularization of the renal artery after aneurysmectomy. A literature search revealed 12 cases of renal artery aneurysm causing hydronephrosis reported in Japan, although only three cases were documented in other countries, and these reports are reviewed. Use of 3‐D CT for evaluation of renal artery aneurysm is advocated.
Testis sparing surgery for the treatment of a sequential bilateral testicular germ cell tumor
Authors: KIRKALI ZIYA , TÜZEL EMRE , CANDA A ERDEM , MUNGAN M UGUR
Published: March 2003

Abstract Standard therapy of sequential bilateral testis cancer is generally considered to be orchiectomy. We present a case of sequential bilateral testicular germ cell tumor treated with testis sparing surgery. The patient was disease free 50 months after surgery without local recurrence or distant metastases. Testis sparing surgery provides a better quality of life and may be considered a safe, feasible alternative in the treatment of carefully selected patients with bilateral testicular germ cell tumor.
New concept parameters of RigiScan in differentiation of vascular erectile dysfunction: Is it a useful test?
Authors: BASAR M MURAT , ATAN ALI , TEKDOGAN ÜMIT Y
Published: March 2003

Abstract Background: The aim of this study is to investigate the value of new nocturnal penile tumescence recording parameters, such as tumescence activity unit and rigidity activity unit values, total erection number and erection times, in differentiating between psychogenic erectile dysfunction and organic erectile dysfunction. We also aimed to determine the role of these parameters in differentiating arterial erectile dysfunction from veno‐occlusive dysfunction.

Methods: Eighty‐seven consecutive patients were allocated into three groups as psychogenic,
arterial and venous erectile dysfunction after investigations. Nocturnal penile tumescence
recording parameters between psychogenic and vascular erectile dysfunction and arterial
and veno‐occlusive dysfunction were compared. Mann–Whitney U‐test,
Pearson's χ2 test and correlation coefficient tests were used for statistical analysis.

Results: Depending on intracavernous injection, penile Doppler ultrasonography and cavernosometry tests, 37 patients (43%) had psychogenic impotence while 50 (57%) had organic pathologies. Of the 50 patients diagnosed with vascular impotence, 29 (48%) had arterial failure and 21 (42%) had veno‐occlusive dysfunction.

Nocturnal penile tumescence recording revealed psychogenic erectile dysfunction in 34 patients (39%) and vascular erectile dysfunction in 53 patients (61%). Nocturnal penile tumescence recording has been regarded as the gold standard and, in our series, it showed 90.6% sensitivity and 88.2% specificity in differentiating the cause of erectile dysfunction.

Values of rigidity activity unit and tumescence activity unit were significantly higher in patients with psychogenic impotence (P < 0.001), when compared
with vascular impotence. In patients with a vascular cause, no difference was found
between arterial failure and veno‐occlusive dysfunction with regard to tip tumescence
activity unit, base tumescence activity unit, tip rigidity activity unit, base rigidity
activity unit and erection time (P > 0.001). However, patients with arterial
failure had less erection than patients with veno‐occlusive dysfunction (P < 0.001).

Conclusion: New recording parameters of nocturnal penile tumescence can differentiate organic and psychogenic erectile dysfunction more precisely. However, these recording parameters cannot distinguish subgroups with a vascular cause of erectile dysfunction.
Flexible video cystoscope with built‐in high‐frequency cauterizing element for transurethral resection of bladder tumor
Authors: KAWAKAMI MASAKO , ISHIKAWA MASAKUNI , KONTANI KAZUHIKO , IIJIMA KAZUYOSHI , KOBAYASHI SHINYA , NISHIZAWA OSAMU
Published: March 2003

Abstract The major advantage of the flexible video cystoscope is that a digital signal can be obtained while high frequency cauterization is carried out. Cauterization while observing a digital signal picture was not possible before this new model was developed. We decided to use this new cystoscope to resect a bladder tumor and coagulate the bleeding because the patient could tolerate only local anesthesia due to severe heart disease complications. We successfully treated the patient with this technique and no complications were noted. This new flexible video cystoscope was found to be safe for resecting bladder tumor under local anesthesia.
Embryonal carcinoma of the testis associated with prostate cancer in a 72‐year‐old man
Authors: GOHJI KAZUO , WATSUJI TOSHIKAZU , UBAI TAKANOBU , UEDA HARUHIKO , KATSUOKA YOJI
Published: March 2003

Abstract A 72‐year‐old Japanese man presented with a painless swollen left scrotal mass with elevated levels of serum α‐fetoprotein and prostate specific antigen. The patient underwent high orchiectomy under diagnosis and a final pathological examination revealed embryonal carcinoma of the left testis. A systematic needle prostate biopsy under guidance of transrectal ultrasound revealed prostate cancer (Gleason score, 8) on the left lobe (T2aN0M0). Systemic chemotherapy was given for retroperitoneal lymph node metastasis of testicular cancer and hormonal therapy (LH‐RH analog) was given for prostate cancer. The patient was well with no evidence of metastasis from the testicular cancer or prostate cancer and with no elevation of serum α‐fetoprotein or prostate specific antigen 26 months after the orchiectomy.
Clinical utility of ursodeoxycholic acid in preventing flutamide‐induced hepatopathy in patients with prostate cancer: A preliminary study
Authors: KOJIMA MUNEKADO , KAMOI KAZUMI , UKIMURA OSAMU , FUJITO AKIRA , NAKAO MASAHIRO , TANAKA SHIGEKI , MIYASHITA HIROAKI , IWAMOTO NORIYUKI , OHE HIROSHI , KITAMORI TOMOHITO , DATE SEIKI , KITAMURA KOJI , ARAKI HIROTAKA , AOKI TADASHI , IMADA NAOKI , TAKADA HITOSHI , IMAIDE YOICHIROH , MIKAMI KAZUYA , UCHIDA MUTSUMI , SAITOH MASAHITO , MIKI TSUNEHARU
Published: March 2003

Background:

The present study was designed to ascertain retrospectively the validity of ursodeoxycholic acid (UDCA) in the treatment of prostate cancer in terms of prophylactic effects on the occurrence of flutamide‐induced hepatopathy in a large number of patients surveyed in a multi‐center cooperative study.

Methods:

One hundred and eighty‐one patients (74.1 ± 4.9 years) with prostate cancer treated with flutamide with (n = 70) or without (n = 111) UDCA were retrospectively evaluated and the occurrence of hepatopathy was compared between these two patient groups.

Results:

Between patients treated with UDCA and those without it, no significant differences were noted in age, clinical stage, grade, duration of flutamide administration and serum prostate‐specific antigen (PSA) levels before treatment. However, there were significant differences in the presence or absence of previous treatments and treatments used together with flutamide. The incidence of hepatopathy was 11.4% (8/70) in patients with UDCA and 32.4% (36/111) in those without it, showing a statistically significant difference (P < 0.05). The hepatopathy‐free rate obtained by

the Kaplan–Meier method was also significantly higher in patients with UDCA

(88.4% 1 year following flutamide administration) than that in those without

it (59.6%) (P < 0.005).

Conclusion:

These results suggest that UDCA has a prophylactic effect against flutamide‐induced hepatopathy in patients with prostate cancer.
Fate of tetraplegic patients managed by ileal conduit for urinary control: Long‐term follow‐up
Authors: Kato Haruaki , Hosaka Kyoko , Kobayashi Shinya , Igawa Yasuhiko , Nishizawa Osamu
Published: March 2003

Background:
A study was conducted to evaluate our experience of ileal‐conduit formation in tetraplegic patients with special reference to late complications due to upper urinary tract stones and pyocystis.

Methods:
Ileal‐conduit formation was performed in 16 patients with tetraplegia to improve urinary management. The mean age at operation was 46 years (range 19–70) and the mean follow‐up period was 8.7 years (range 2–17). We evaluated the results retrospectively from patients’ medical records.

Results:
Two patients died 2 years after the procedure and one patient died 8 years after the ileal‐conduit formation. Five patients suffered from repeated renal or ureteral stone. In three of these cases, serious urinary tract infections developed whenever the stone caused an obstruction. Three patients received a cystectomy at the time of the ileal‐conduit formation. Eight patients suffered from empyema of the bladder and in two of these cases a subsequent cystectomy was required.

Conclusions:
Ileal‐conduit formation should be cautiously considered as an option in the urinary management of tetraplegic patients, particularly when more conservative management strategies have proved unsuccessful. However, an antirefluxing mechanism for the ileal conduit may be necessary, and a simultaneous cystectomy may improve the results.
Increased transforming growth factor‐β1 and tubulointerstitial fibrosis in rats with congenital hydronephrosis
Authors: ZHOU YUN , TAKAHASHI GO , SHINAGAWA TOSHIHITO , OKUHARA TOSHINI , YONAMINE KYOKO , AIDA YOSHIO , TADOKORO MAMORU
Published: March 2003

Abstract Objectives: Most of our knowledge concerning renal obstruction has been derived from experimental animal models, and it is not yet well defined in spontaneous hydronephrosis. The aim of our study is to evaluate the roles of transforming growth factor‐β1 (TGF‐β1) and apoptosis in congenital hydronephrotic kidneys in comparison with experimental models.

Methods: We made histological studies on kidneys from 6‐week‐old Wistar‐Imamichi rats with congenital unilateral hydronephrosis as well as surgical models of complete or partial unilateral ureteral obstruction. The severity of hydronephrotic kidneys was evaluated on routine hematoxylin and eosin (H&E) stained sections, and the tubulointerstitial fibrosis analyzed morphometrically on Masson's trichrome stained sections. Renal tubular atrophy was assessed on periodic acid Schiff (PAS) stained sections, and tubular cell apoptosis assessed with TUNEL technique. The renal TGF‐β1 level was determined by a sandwich enzyme‐linked immunosorbent assay (ELISA).

Results: We observed a significant loss of kidney weight with profound compensatory growth of the contralateral kidney in rats with congenital hydronephrosis. Most of the hydronephrotic kidneys were markedly enlarged with dilatation of the collecting system, renal parenchymal thinning, tubular atrophy, interstitial infiltration and fibrosis. The renal TGF‐β1 level was markedly elevated in hydronephrotic kidneys as compared with normal controls (326.01 ± 30.64 pg/mg protein vs 227.81 ± 11.07 pg/mg protein, P < 0.01). The tubular apoptotic score in hydronephrotic kidneys was also significantly higher than normal controls (2.17 ± 0.50/HPF [high power field]vs 0.14 ± 0.04/HPF, P < 0.01). The increased TGF‐β1 and apoptotic status paralleled the histological changes of tubulointerstitial fibrosis and tubular atrophy. Similar findings were also obtained in experimental obstructive models.

Conclusion: In comparison with surgical models of partial and complete ureteral obstruction, our data provide solid morphological and molecular evidences of renal obstruction in rats with congenital hydronephrosis.
Nerve‐sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy
Authors: NONOMURA NORIO , NISHIMURA KAZUO , TAKAHA NATSUKI , INOUE HITOSHI , NOMOTO TAKESHI , MIZUTANI YOUICHI , NAKAO MASAHIRO , OKUYAMA AKIHIKO , MIKI TSUNEHARU
Published: March 2003

Background: Nerve‐sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular germ cell tumors to preserve postoperative ejaculation. The indications for nerve‐sparing procedures have been extended to patients who have residual retroperitoneal tumor postchemotherapy with an increase in the incidence of local recurrence. Here, we report on 26 Japanese men with advanced testicular cancer who underwent nerve‐sparing RPLND after partially successful chemotherapy.

Methods: Between January 1995 and December 2000, 26 patients with metastatic or recurrent testicular cancer underwent nerve‐sparing RPLND after chemotherapy. Eight patients had seminoma and 18 had non‐seminoma. Three patients received high‐dose chemotherapy with carboplatin (250 mg/m2 per day × 5 days), etoposide (300 mg/m2 per day × 5 days) and ifosfamide (1.5 g/m2 per day × 5 days) in combination with peripheral blood stem cell transplantation.

Results: In all cases, lumbar splanchnic nerves were preserved macroscopically during the operation, at least unilaterally. Twenty‐two patients (84.6%) achieved antegrade ejaculation during a mean follow‐up at 3.9 months (range: 1–7 months). Three patients have fathered children. Only one patient suffered a retroperitoneal recurrence during a median follow‐up at 25.8 months (range: 6–76 months).

Conclusion: Nerve‐sparing procedures for RPLND are appropriate for patients with metastatic testicular cancer, even after chemotherapy. The procedure preserves ejaculatory function in the majority of the patients without increasing the risk of local recurrence. Nerve‐sparing RPLND improves the quality of life in patients who require postchemotherapy RPLND to treat residual tumor.
Usefulness of diagnostic imaging in primary hyperparathyroidism
Authors: SEKIYAMA KAZUYA , AKAKURA KOICHIRO , MIKAMI KAZUO , MIZOGUCHI KEN‐ICHI , TOBE TOYOFUSA , NAKANO KOICHI , NUMATA TSUTOMU , KONNO AKIYOSHI , ITO HARUO
Published: March 2003

Background : In patients with primary hyperparathyroidism, prevention of urinary stone recurrence can be achieved by surgical removal of the enlarged parathyroid gland. To ensure the efficacy of surgery for primary hyperparathyroidism, preoperative localization of the enlarged gland is important. In the present study, usefulness of diagnostic imaging for localization of the enlarged gland was investigated in primary hyperparathyroidism.

Methods : We retrospectively examined the findings of imaging studies and clinical records in 79 patients (97 glands) who underwent surgical treatment for primary hyperparathyroidism at Chiba University Hospital between 1976 and 2000. The detection rates of accurate localization were investigated for imaging techniques, such as ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), thallium‐201 and technetium‐99m pertechnetate (Tl‐Tc) subtraction scintigraphy and 99mTc‐methoxyisobutylisonitrile (MIBI) scintigraphy, and analysed in relation to the size and weight of the gland and pathological diagnosis.

Results : The detection rates by US, CT, MRI, Tl‐Tc subtraction scintigraphy and MIBI scintigraphy were 70%, 67%, 73%, 38% and 78%, respectively. The overall detection rate changed from 50% to 88% before and after 1987. The detection rate of MIBI scintigraphy was superior to Tl‐Tc subtraction scintigraphy.

Conclusion : In primary hyperparathyroidism, improvement of accurate localization of an enlarged parathyroid gland was demonstrated along with recent advances in imaging techniques including MIBI scintigraphy.
Patent foramen ovale and cryptogenic cerebral infarction
Authors: McGaw D. , Harper R.
Published: March 2003

The patent foramen ovale (PFO) has been increasingly implicated in the aetiology of stroke, particularly in young patients with no other identifiable cause (cryptogenic stroke). The mechanism is by the passage of venous clots through the patent foramen into the arterial circulation, enabling cerebral embolism. Such patients with cryptogenic stroke and PFO are often treated with life‐long anticoagulants or antiplatelet agents in an attempt to decrease the risk of a recurrence. Less commonly, surgical closure of the PFO has been undertaken in these patients. However, the recent evolution of closure devices that are delivered percutaneously by standard cardiac catheter techniques now offer an alternative non‐surgical option. These alternative therapies are yet to be compared adequately. Two issues remain to be resolved. First, in determining appropriate therapy, patients with cryptogenic stroke may be divided into three groups: those with no PFO but an alternative unrecognized aetiology, those with an ‘innocent’ PFO and an alternative unrecognized aetiology and those with a causative PFO. The distinction between these groups clearly has important treatment implications. Second, the risk versus benefit of each available treatment modality must be determined for these different patient subgroups. These two issues require resolution before rational evidence‐based treatment can be prescribed for patients with PFO and cryptogenic stroke. (Intern Med J 2001; 31: 42–47)
Outcomes in the management of atrial fibrillation: clinical trial results can apply in practice
Authors: Jackson S. L. , Peterson G. M. , Vial J. H. , Daud R. , Ang S. Y.
Published: March 2003

Background: The benefits of antithrombotic therapy in chronic atrial fibrillation (AF) have been established in clinical trials, but there is a paucity of data on outcomes in practice.

Aims: The objective was to establish a large ongoing database of patients with non‐valvular AF, to enable the accurate determination of clinical outcomes.

Methods: A retrospective review of the medical records for consecutive patients who had AF documented on electrocardiogram at the major teaching hospital in Tasmania between 1 January 1997 and 30 June 1999 was performed. An extensive range of demographic and clinical variables was recorded for all patients with chronic or paroxysmal non‐valvular AF.

Results: The 505 patients (60% males) included in the database had a median age of 76 years. According to risk stratification criteria, 79% of the patients with previously diagnosed chronic or paroxysmal AF had a high risk of developing stroke at the time of admission to hospital care. However, only one‐third (34%) of these patients were receiving warfarin (or warfarin plus aspirin), with almost one‐quarter (24%) receiving no antithrombotic agent. The annual incidence of ischaemic strokes was 3.4% (1.5–6.4%; 95% CI) when taking warfarin, compared to 7.0% (5.2–9.4%) for patients not taking warfarin and 7.8% (5.4–11.1%) for patients taking aspirin. The annual incidence of bleeding complications in patients taking warfarin was 14.2% (10.0–19.5%) overall and 3.4% (1.5–6.4%) for major bleeds. In patients not taking warfarin, the overall annual incidence of bleeds was 8.4% (6.3–10.9%) and 3.9% (2.5–5.7%) for major bleeds.

Conclusions: Warfarin is underused in patients with AF. In clinical practice, warfarin confers a similar stroke risk reduction to that observed in trials, with an increase in incidence of only minor bleeding complications. Aspirin did not appear to reduce the risk of stroke. (Intern Med J 2001; 31: 329–336)
Effects of improved glycaemic control on endothelial function in patients with type 2 diabetes
Authors: Bagg W. , Whalley G. A. , Gamble G. , Drury P. L. , Sharpe N. , Braatvedt G. D.
Published: March 2003

Background: Patients with type 2 diabetes have abnormal endothelial function but it is not certain whether improvements in glycaemic control will improve endothelial function.

Aims: To examine the effects of short‐term improved glycaemic control on endothelial function in patients with inadequately regulated type 2 diabetes mellitus.

Methods: Forty‐three patients with type 2 diabetes and glycosylated haemoglobin (HbA1c) > 8.9% were randomized to either improved glycaemic control (IC) n = 21 or usual glycaemic control (UC) n = 22 for 20 weeks. Using high‐resolution B‐mode ultrasound, brachial artery flow‐mediated dilatation (FMD) and glyceryl trinitrate‐mediated dilatation (GTN‐D) were measured at baseline and 20 weeks later.

Results: After 20 weeks, HbA1c was significantly lower in IC versus UC (IC 8.02 ± 0.25% versus UC 10.23 ± 0.23%, P < 0.0001) but changes in FMD and GTN‐D were not different between the groups (FMD at baseline and week 20 IC 5.1 ± 0.56% versus 4.9 ± 0.56% and UC 4.2 ± 0.51% versus 3.1 ± 0.51%; P = 0.23: GTN‐D IC 12.8 ± 1.34% versus 10.4 ± 1.32% and UC 13.7 ± 1.2% versus 12.7 ± 1.23%; P = 0.39). In the IC group weight increased by 3.2 ± 0.8 kg after 20 weeks compared to 0.02 ± 0.70 kg in UC (P = 0.003). Blood pressure and serum lipid concentrations did not change in either group.

Conclusions: Short‐term reduction of HbA1c levels did not appear to affect endothelial function in patients with type 2 diabetes and previously poorly regulated glycaemic control. (Intern Med J 2001; 31: 322–328)
Cerebral venous sinus thrombosis: a diagnostic challenge
Authors: Fink J. N. , McAuley D. L.
Published: March 2003

Abstract Background: Cerebral venous sinus thrombosis (CVT) is a potentially serious but treatable disorder that has been underdiagnosed in the past. Delay in diagnosis and treatment of this disorder has resulted in the death of one of our patients.

Aim: To review the local experience with CVT in order to identify factors that may allow diagnosis and appropriate treatment decisions to be made more readily in the future.

Methods: A retrospective review of all cases of CVT diagnosed or treated at Auckland Hospital between 1990 and 1999.

Results: Twenty‐five cases of CVT were identified. The number of cases diagnosed increased from less than one per year in 1990–94 to eight in 1999. Clinical signs at presentation included headache (96%), focal neurological deficits (60%), seizures (40%) and papilloedema (43%). Delayed diagnosis after admission to hospital occurred in two young women presenting with neurological symptoms during pregnancy or puerperium, in two cases in whom focal symptoms were not explained by negative computed tomography and in five cases presenting with intracerebral haemorrhage. Twenty patients received anticoagulant therapy and their condition remained stable or improved after treatment.

Conclusions: The diagnosis of CVT should be considered in women with any neurological symptoms during pregnancy or puerperium and in all cases of unexplained intracerebral haemorrhage. CVT should also be considered in cases of recent onset and progressive headache, particularly when associated with focal neurological symptoms or signs, seizures or papilloedema. Magnetic resonance imaging with magnetic resonance venography is the investigation of choice. Anticoagulation with heparin remains the mainstay of treatment, even in the presence of intracerebral haemorrhage. (Intern Med J 2001; 31: 384–390)
Role of the observed long case in postgraduate medical training
Authors: Pavlakis N. , Laurent R.
Published: March 2003

Abstract

Background: The teaching of long case examination technique emphasizes case presentation, problem identification and discussion of management. It assumes that history taking and ability to perform a complete physical examination in a limited time are adequate. These can only be assessed by directly observing the long case examination.

Aims: To explore the usefulness of observing long case performance.

Methods: We used a structured assessment form to observe and evaluate the overall long case performance of 19 doctors in our physicians’ training programme. Nine, group A, had received 6 months training, whereas the 10 in group B had only just commenced clinical examination training.

Results: Ten (53%) passed their long case, seven from group A and three from group B. Thirteen (68%) passed the history and examination section. Three failed the history component and five failed the examination component. The groups had similar scores for observed history taking. Common problems included poor time management, excessive time required to take the history and lack of organization of questions. Physical examination was usually poorly organized, requiring the use of short cuts, particularly in the respiratory, musculoskeletal and neurological systems. Group A were better at presentation and discussion, with eight (89%) passing compared with four (40%) passing in group B.

Conclusion: These results reflect the emphasis in our training programme on long case discussion and management, rather than examination technique. The observed case allowed for detection of defects in history‐taking skills and time management. Therefore, it is valuable in preparing candidates for their Fellowship examinations. (Intern Med J 2001; 31: 523–528)
Obesity: the science behind the management
Authors: Steinbeck K.
Published: March 2003

The prevalence of obesity is increasing in Western and Westernizing countries. The changing environment plays a major role in this increase, particularly the reduction in physical activity. There is also a strong genetic contribution to the development of obesity, although single‐gene defect obesity is rare. Neither the environment nor genes is simple to modify. Obesity is an energy‐balance disorder, and the human body has evolved to resist any loss of body fat. This biological drive to maintain weight is coordinated through central pathways, with the involvement of many neuropeptides. Thus, dietary restriction will induce changes designed to counter weight loss, including a fall in resting metabolic rate. The management of obesity demands reasonable goals, which focus on metabolic, rather than cosmetic, improvement. As obesity is a complex condition, multiple therapeutic strategies are required. Dietary modification, an increase in physical activity, a reduction in sedentary activity and behaviour modification all form the basis of obesity therapy. Drug therapy options at present are limited and may have a stronger role in weight maintenance. Currently, surgical management of obesity has the best long‐term outcomes. Long‐term maintenance of weight loss is achieved by few individuals. Those individuals who are successful are able to maintain long‐term restrictive eating habits and high levels of physical activity. (Intern Med J 2002; 32: 237−241)
HMG CoA reductase‐inhibitor‐related myopathy and the influence of drug interactions
Authors: Huynh T. , Cordato D. , Yang F. , Choy T. , Johnstone K. , Bagnall F. , Hitchens N. , Dunn R.
Published: March 2003

We report four cases of rhabdomyolysis and severe, disabling myopathy associated with HMG CoA reductase‐inhibitor therapy. Patient 1 developed symptoms following the addition of roxithromycin to combination lipid‐lowering therapy with simvastatin and gemfibrozil. Patients 2 and 3 became symptomatic after developing acute on chronic renal impairment while taking simvastatin. The muscle biopsy of patient 3 revealed a necrotizing myopathy and the presence of inclusion bodies. Patient 4 developed symptoms within 4 weeks of starting cerivastatin monotherapy. The four cases illustrate the importance of considering the potential for drug interactions and making appropriate dosage adjustments for renal insufficiency in patients receiving HMG CoA reductase therapy. (Intern Med J 2002; 32: 486−490)