Identification of patients at high risk for recurrence in carcinoma of the ampulla of Vater: Analysis in 460 patients.

Aim: Carcinoma of the ampulla of Vater (CAV) shows a favorable prognosis compared to that with the other periampullary tumors, while some cases have a poor prognosis. The aims of the present study are to clarify the clinicopathological factors associated with poor recurrence-free survival (RFS) in patients with CAV after curative resection and to validate the usefulness of adjuvant chemotherapy (AC). Patients: The study design is a multicenter retrospective cohort study. Patients with CAV who underwent pancreaticoduodenectomy between January 2008 and December 2020 at 26 hospitals were analyzed. The 30 clinicopathological factors were evaluated. A propensity score matching (PSM) was used to compare between patients with and without AC. Results: Finally, 460 patients were analyzed. Median duration of follow-up was 47.2 months. Twenty-one prognostic factors associated with poor RFS were identified by univariate analysis. In multivariate analysis, aged ≥71, tumor diameter ≥12 mm, pT2 or higher stage (pT≥2), portal vein invasion (PV+), venous invasion(V+), and node positive disease (pN+) were independent prognostic factors for poor RFS. Out of 80 patients who received AC, 63 patients were assigned to analysis for PSM. The results showed no beneficial effect of AC on RFS. The preoperative factors potentially predicting pT≥2, V+, and/or N+ were at least one of following; (1) CA19-9 > 37 IU/mL, (2) ulcerative or mixed type appearance, (3) except for well-differentiated tumor, or (4) except for intestinal subtype of histology. Conclusions: Aged ≥71, tumor diameter ≥12 mm, pT≥2, PV+, V+, and pN+ were independent prognostic factors for poor RFS in patients with CAV. An additional therapeutic strategy may be desirable in CAV patients at high risk for recurrence.

The comprehensive role of general physicians is very important in the chronic phase of a disaster area: Beyond and after the Great East Japan Earthquake.

The Great East Japan Earthquake was a major earthquake, one of the largest (Magnitude 9.0) in Japan since 1900. 18 997 human lives were lost in the subsequent tsunami around the Sanriku coast of eastern Japan. Ishinomaki City, which was close to the epicenter, is one of the greatest locations that experienced of the greatest loss of human life: 3819 people. The Ishinomaki Red Cross Hospital (IRCH), which is the main trunk hospital of the Ishinomaki medical sphere, moved to a hill away from the Pacific Ocean in order to avoid future tsunami 5 years prior to the Great East Japan Earthquake. IRCH was therefore nearly intact and its functions were maintained after the Great East Japan Earthquake. Other neighboring medical facilities were in a catastrophic state; for emergency, patients were all concentrated at the IRCH, and the medical staff of IRCH became exhausted. In response, the Japanese Red Cross Society collected and transported physicians, nurses, pharmacists, medical engineers, and medical clerks, to IRCH from Red Cross hospitals across the country during the period of April to August 2011. The dispatched medical personnel operated a makeshift clinic on a rotating basis autonomously in the hospital to support the IRCH. In this temporary clinic, the primary and secondary emergency staff conducted the center's general practice.

Assessment and significance of abdominal aortic calcification in chronic kidney disease.

BACKGROUND: Abdominal aortic calcification is a common complication and a predictor of cardiovascular mortality in dialysis patients. However, abdominal aortic calcification in pre-dialysis chronic kidney disease (CKD) is poorly understood. METHODS: A cohort study of 101 adult Japanese patients (mean age 66.6 +/- 11.3 years old) with pre-dialysis CKD (18, 29 and 54 in stages 3, 4 and 5, respectively) was performed. At entry, a non-contrast computed tomography scan was used to determine the abdominal aortic calcification index (ACI). Clinical characteristics and laboratory variables were also assessed. The patients were followed for a mean period of 48 +/- 12 months. RESULTS: Among the subjects, 82% had abdominal aortic calcification (50, 83 and 91% for CKD stages 3, 4 and 5, respectively), and the median ACI was 16.7% (8.5, 20.0 and 21.4%, respectively). Multivariate logistic regression analyses identified older age, presence of diabetes and decreased estimated glomerular filtration rate (e-GFR) as independent predictors of the presence (ACI > 0%) and extent (ACI >or= 20%) of aortic calcification. Multivariate Cox proportional hazards analysis identified ACI >or= 20% and diabetes as independent predictors for de novo cardiovascular events in CKD stages 4 and 5. CONCLUSION: Decreased GFR may be associated with the presence and extent of abdominal aortic calcification, and a high level of calcification may be associated with de novo cardiovascular events in pre-dialysis CKD, suggesting that elucidation of the mechanism through which CKD contributes to vascular calcification may lead to an improved prognosis in patients with pre-dialysis CKD.

[Case of Henoch-Schönlein purpura nephritis successfully treated with tonsillectomy and steroid pulse therapy].

A 30-year-old Japanese man was admitted to our hospital because of fever, sore throat, abdominal pain, purpura skin lesion of the lower legs, and macrohematuria. On admission, his urine was positive (++) for protein; the sediment contained 100 red blood cells per high-power field, and the daily proteinuria level was 1.7 g. Renal biopsy was performed, and we diagnosed Henoch-Schönlein purpura nephritis (HSPN). Six months after the renal biopsy, the patient underwent a tonsillectomy. The pathological diagnosis of the resected tonsils was chronic tonsillitis. After tonsillectomy, the daily proteinuria had decreased to 0.1 g and the sediment contained only 10-19 red blood cells per high-power field. High-dose methylprednisolone therapy (500 mg/day for 3 days for three courses) was started two weeks after the tonsillectomy, followed by oral prednisolone at the initial dose of 30 mg on alternate days. The oral prednisolone was tapered gradually over 1 year. Antiplatelet drug (dipyridamole, 300 mg/day) and angiotensin II receptor antagonist (olmesartan, 10 mg/day) were also administered. This combination therapy resulted in a significant decrease in proteinuria and disappearance of microhematuria. The patient finally achieved clinical remission. Recent reports have shown that in patients with IgA nephropathy, combined tonsillectomy and methylprednisolone pulse therapy have an effect on clinical remission. In addition, it has been suggested that HSPN and IgA nephropathy represent a spectrum of clinical presentations of similar disorders. The result of this case indicated that this combination therapy had a favorable effect on clinical remission in adult patients with HSPN.

The influence of dialysate calcium on the therapeutic effects of sevelamer hydrochloride in hemodialysis patients with secondary hyperparathyroidism under treatment of intravenous vitamin d metabolites.

The management of hyperphosphatemia is essential to treat secondary hyperparathyroidism and to prevent ectopic calcification. Sevelamer hydrochloride (sevelamer), a new phosphate binder that contains neither aluminum nor calcium, which could be theoretically beneficial for the management of hyperphosphatemia in dialysis patients with secondary hyperparathyroidism who are receiving intravenous vitamin D metabolites (maxacalcitol or calcitriol). To reduce calcium loads, a dialysate calcium concentration of 2.5 mEq/L is recommended by Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines. In Japan, a dialysate calcium concentration of 3.0 mEq/L prevails. We investigated the influence of dialysate calcium on the therapeutic effect of sevelamer in 40 hemodialysis patients who are under treatment of intravenous vitamin D metabolites for secondary hyperparathyroidism (VD(+)) and compared the results with those of 41 patients who had not received vitamin D metabolites (VD(-)). Serum phosphorus and calcium-phosphorus products showed no significant change by sevelamer in either the VD(+) subgroup of patients receiving hemodialysis with dialysate calcium of 2.5 mEq/L (DCa2.5) or those receiving hemodialysis with dialysate calcium of 3.0 mEq/L (DCa3.0), while serum phosphorus and calcium-phosphorus products decreased in both the VD(-) subgroups. Serum calcium decreased in the DCa2.5 subgroup and did not change in the DCa3.0 subgroup in both the VD(+) and the VD(-) subjects. Parathyroid hormone and alkaline phosphatase increased in the DCa2.5 subgroup and did not change in the Ca 3.0 subgroup in the VD(+) subjects. Serum calcium decreased in both subgroups in the VD(-) subjects. Parathyroid hormone obtained after sevelamer administration in the VD(-) group was within the target range of the K/DOQI guidelines. In conclusion, the concomitant use of sevelamer as a phosphate binder and the dialysate of calcium concentration of 2.5 mEq/L have possibilities for worsening secondary hyperparathyroidism in patients receiving intravenous vitamin D.

Antiproteinuric effect of niceritrol, a nicotinic acid derivative, in chronic renal disease with hyperlipidemia: a randomized trial.

PURPOSE: Lipoprotein (a) [Lp(a)] levels increase in patients with renal disease. We administered niceritrol, a nicotinic acid derivative, to patients with chronic renal disease and a high serum Lp(a) level, and studied its effects on lipid metabolism, proteinuria, and renal function. METHODS: Thirty-three patients with chronic renal disease whose serum Lp(a) levels were > or = 15 mg/dL were randomly (but not blindly) assigned to treatment with niceritrol (n = 16) or to an untreated control group (n = 17). Parameters of lipid metabolism, excretion of urinary protein, and renal function were examined for 12 months. RESULTS: Changes in urinary protein excretion, as well as Lp(a) levels, differed significantly between the two groups. The mean (+/- SD) change from baseline in excretion of urinary protein was 0.77 +/- 1.23 g/d in the control group compared with -1.41 +/- 2.26 g/d in the niceritrol group at 12 months (P =0.003). Mean Lp(a) levels increased by 3 +/- 10 mg/dL in the control group compared with a decrease of 10 +/- 13 mg/dL in the niceritrol group at 12 months (P =0.004). The mean creatinine clearance declined by 10 +/- 12 mL/min in the control group, compared with 1 +/- 13 mL/min in the niceritrol group at 12 months (P =0.06). CONCLUSION: Lipid levels improved with niceritrol treatment, whereas the excretion of urinary protein decreased, perhaps slowing the rate of loss of renal function in chronic renal disease.

Time-course of iodine elimination by hemodialysis in patients with renal failure after angiography.

The study was designed to examine the time-course of iodine elimination by hemodialysis to determine a desirable duration for dialysis after angiography to prevent contrast media nephropathy (CMN) in patients with renal failure. Reduction rates of iodine by hemodialysis (DRR) of 1 to 3 h and the renal elimination of iodine (RER) for 20 h after hemodialysis were prospectively examined in 8 chronic renal failure (CRF) patients. The mean DRR was 46.6% at 1 h, 65.2% at 2 h, and 75.1% at 3 h, and the mean RER was 49.4% in the CRF patients. Renal function significantly deteriorated in 2 CRF patients after angiography. Plasma iodine was eliminated by more than 80% after 2 h of hemodialysis following angiography, and the subsequent renal elimination in patients with mild-to-moderate renal failure was also examined. There is no need of prophylactic hemodialysis to prevent CMN for these patients when they have no additional risk factors such as a high dose of contrast medium, diabetes mellitus, or severe heart failure. However, 2 h of hemodialysis is desirable immediately after angiography for patients with moderate renal failure and one additional risk factor, and three hours or more of hemodialysis is also desirable for patients with severe renal failure, and for those with moderate renal failure having two or more additional risk factors.

Effect of long-term administration of prostaglandin I(2) in incipient diabetic nephropathy.

BACKGROUND/AIMS: Diabetic nephropathy is one of the primary diseases of refractory renal failure and heads the list of patients undergoing dialysis. Therefore, it is very important to get treatment in incipient nephropathy. METHODS: Twenty-seven patients in incipient diabetic nephropathy of type 2 diabetes mellitus who showed signs of microalbuminuria were randomly, but not blindly, assigned to two groups, either the beraprost sodium (PGI(2)) group or the control group, and effects of the preparation on urinary albumin excretion or other parameters were examined for 24 months. RESULTS: Urinary albumin excretion was significantly decreased after 18 months in beraprost sodium group; however, there was no change in the control group. Difference was observed between the two groups after month 12; however, it was not significant (p = 0.0673 at month 24). Three factors that affect urinary albumin excretion, e.g. blood pressure, blood sugar and protein intake, were almost constant during the study period. The level of creatinine clearance was significantly decreased in beraprost sodium group after 24 months as compared with the control group. CONCLUSION: In this study, we found that the long-term 24-month administration of PGI(2) preparation, beraprost sodium, decreased albuminuria in patients of incipient diabetic nephropathy. The possible mechanisms are that the PGI(2) may have alleviated constriction effect of angiotensin II on efferent glomerular arteriole and attenuated glomerular hyperfiltration, and inhibited growth of mesangial cells by platelet-derived growth factor as well.