An arterial pulse examination is not sufficient for diagnosis of peripheral arterial disease in lumbar spinal canal stenosis: a prospective multicenter study.

STUDY DESIGN: Prospective, multicenter study. OBJECTIVE: To conduct peripheral arterial disease (PAD) screening on intermittent claudication (IC) in patients with lumbar spinal canal stenosis (LSCS) to examine the relationships among combined LSCS and PAD, symptoms, and physical findings. SUMMARY OF BACKGROUND DATA: IC occurs due to two underlying diseases, LSCS and PAD, and has an increasing prevalence with the aging of society. Reliable diagnosis of PAD is critical for appropriate conservative management of IC patients with LSCS in an Orthopedic Surgery Outpatient Department (OSOPD). METHODS: PAD tests were prospectively conducted in 201 patients with IC and LSCS who initially visited an OSOPD at a hospital affiliated with the Nogoya Spine Group. Occurrence of PAD as a complication was assessed using ankle brachial pressure index (ABI) and toe brachial pressure index (TBI) tests. PAD was diagnosed in patients with ABI ≤ 0.9 or TBI ≤ 0.6, and the relationship of the occurrence of PAD with symptoms and physical findings such as abnormal arterial pulses was investigated. RESULTS: Combined LSCS and PAD was found in 52 patients (26%), with 45 cases (22%) diagnosed on the basis of TBI test in patients with a normal ABI. Of the patients with PAD, many suffered from risk factors for PAD, with a significantly higher frequency of PAD in patients with hyperlipidemia (P < 0.05). PAD also occurred significantly more frequently in patients with abnormal pulses in the popliteal (P < 0.05), posterior tibial (P < 0.0001), and dorsal pedis (P < 0.0001) arteries; however, the sensitivity of these tests for PAD diagnosis was relatively low, at 34%, 60% and 68%, respectively. CONCLUSION: The results of the prospective study define the rate of occurrence of combined LSCS and PAD using ABI and TBI tests for the first time, and the findings suggest that screening for PAD should be conducted in LSCS patients. ABI and TBI tests are necessary for PAD screening in outpatients, whereas observation of the arterial pulse in the lower extremities is necessary but not sufficient for PAD diagnosis.

[Immunohistochemical and clinical features of patients with benign middle ear tumors].

The middle ear is a rare site for benign tumors. We report six patients with benign middle ear tumors surgicaly removed: three with carcinoid, one with adenoma, and two with paraganglioma. These tumors showed similar histological features in trabecular and glandular architecture, so further immunohistochemical study was needed to make a definitive histopathological diagnosis. When we analyzed clinical features of patients diagnosed immunohistochemically, the differentiation of two patients with paraganglioma from the remaining four with adenomatous tumors such as adenoma and carcinoid was relatively easy from otomicroscopic findings and enhancement in temporal bone MRI. It was however difficult to differentiate patients with adenomatous tumors from each other because they induced similar clinical symptoms and showed similar findings in images. For a definitive diagnosis, it is necessary to conduct exploratory tympanotomy or removal of the tumors to obtain enough specimen for histological and immunohistochemical studies. Tumors induced no bone destruction or complications. We recommend staged operations for total removal of tumors and for good postoperative hearing.

Small nonfunctioning islet cell tumor in the body of the pancreas: report of a case.

Islet cell tumors of the pancreas are uncommon, and nonfunctioning tumors are even rarer than functioning ones. We report the case of a 67-year-old woman with a small nonfunctioning islet cell tumor, 6 x 5 mm in diameter, which was detected incidentally by ultrasonography, and subsequently confirmed by double-helical computed tomography. Diagnosis was established by histopathological examination after 80% distal pancreatectomy with splenectomy, and by various laboratory tests. Histologically, the islet cell tumor showed highly cellular spindle or epithelioid cells, which were positive for Grimelius stain. Immunohistochemical examination revealed that the tumor cells were positive for chromogranin A, but negative for somatostatin, insulin, glucagon, and gastrin. Its small size, location, and benignity make this a very rare type of nonfunctioning islet cell tumor.

Performance monitoring by the anterior cingulate cortex during saccade countermanding.

Consensus is emerging that the medial frontal lobe of the brain is involved in monitoring performance, but precisely what is monitored remains unclear. A saccade-countermanding task affords an experimental dissociation of neural signals of error, reinforcement, and conflict. Single-unit activity was monitored in the anterior cingulate cortex of monkeys performing this task. Neurons that signaled errors were found, half of which responded to the omission of earned reinforcement. A further diversity of neurons signaled earned or unexpected reinforcement. No neurons signaled the form of conflict engendered by interruption of saccade preparation produced in this task. These results are consistent with the hypothesis that the anterior cingulate cortex monitors the consequences of actions.

Anorectal melanoma: successful treatment by surgical excision and combination chemoimmunotherapy.

Anorectal melanoma is an extremely rare malignancy, and has a poor prognosis mainly due to delays in diagnosis and lack of effective systemic therapy. We report the case of a 63-year-old female patient with anorectal melanoma. Diagnosis was established after surgery by histology and immunohistochemistry. Surgical management consisted of abdominoperineal resection of the rectum. Postoperatively, the patient received combination therapy of dacarbazine, nimustine hydrochloride, vincristine sulfate, and interferon-beta for 3 cycles. Ten months later, a solitary brain metastatic tumor was noted in the left occipital region, which was resected surgically followed by the above combination therapy for 2 cycles. The last metastatic work-up was normal, and no evidence of recurrence was observed at 2-year follow-up. In our case, abdominoperineal resection of the rectum appears to have some effect in preventing regional and lymph node recurrence. Furthermore, our case suggests that prolongation of survival may depend on extensive block resection and combination therapy of DAV and interferon-beta.