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Renal hypoperfusion from renal artery stenosis (RAS) activates the renin-angiotensin system, which in turn causes volume overload and hypertension. Atherosclerosis and fibromuscular dysplasia are the most common causes of renal artery stenosis. Recurrent flash pulmonary edema, also known as Pickering syndrome, is commonly associated with bilateral renal artery stenosis. There should be a high index of clinical suspicion for renal artery stenosis in the setting of recurrent flash pulmonary edema and severe hypertension in patients with atherosclerotic disease. Duplex ultrasonography is commonly recommended as the best initial test for the detection of renal artery stenosis. Computed tomography (CT) angiography (CTA) or magnetic resonance (MR) angiography (MRA) are useful diagnostic imaging studies for the detection of renal artery stenosis in patients where duplex ultrasonography is difficult. If duplex ultrasound, CTA, and MRA are indeterminate or pose a risk of significant renal impairment, renal angiography is useful for a definitive diagnosis of RAS. The focus of medical management for RAS relies on controlling renovascular hypertension and aggressive lifestyle modification with control of atherosclerotic disease risk factors. The restoration of renal artery patency by revascularization in the setting of RAS due to atherosclerosis may help in the management of hypertension and minimize renal dysfunction.

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13515号 / 論医博第2265号 / 新制||医||1061(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 湊谷 謙司, 教授 石見 拓, 教授 江木 盛時 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Hyperspectral imaging (HSI) in abdominal surgery is a new non-invasive tool for the assessment of the perfusion and oxygenation of various tissues and organs. Its benefit in pancreatic surgery is still unknown. The aim of this study was to evaluate the key impact of using HSI during pancreatoduodenectomy (PD). In total, 20 consecutive patients were included. HSI was recorded during surgery as part of a pilot study approved by the local Ethics Committee. Data were collected prospectively with the TIVITA® Tissue System. Intraoperative HS images were recorded before and after gastroduodenal artery (GDA) clamping. We detected four patients with celiac artery stenosis (CAS) caused by a median arcuate ligament (MAL). In two of these patients, a reduction in liver oxygenation (StO2) was discovered 15 and 30 min after GDA clamping. The MAL was divided in these patients. HSI showed an improvement of liver StO2 after MAL division (from 61% to 73%) in one of these two patients. There was no obvious decrease in liver StO2 in the other two patients with CAS. HSI, as a non-invasive procedure, could be helpful in evaluating liver and gastric perfusion during PD, which might assist surgeons in choosing the best surgical approach and in improving patients’ outcomes.

Infantile hypertrophic pyloric stenosis (IHPS) is a disorder characterized by hypertrophy of the pylorus causing obstruction of the gastric outlet. IHPS occurs in 1 to 3.5 per 1000 live births and normally develops between weeks 3 to 5 of age. Patients commonly present forceful, projectile, nonbilious vomiting. The diagnosis is confirmed with ultrasound in which pyloric muscle thickness (PMT) and pyloric canal length (PCL) are measured as less than or equal to 3.0 mm and 14.5 mm, respectively. Definitive treatment is surgicalpyloromyotomy. Similarly, duodenal atresia can cause projectile, nonbilious vomiting. However, it typically presents within the first 24 to 38 hours of birth. If not diagnosed antenatally, then the classic “double bubble sign” on abdominal x-ray or upper GI series is pathognomonic. In this case study, we discuss a case in which diagnostic imaging leads to the misdiagnosis of a patient presenting with projectile vomiting. Initial presentation, differential diagnosis, and hospital workup will be discussed. We present this case study to raise awareness of the possible misdiagnosis of a common childhood illness due to aberrant radiographic presentation.

Subglottic stenosis (SGS) is an abnormal narrowing of the airway at the level of the cricoid cartilage, above the first tracheal ring and immediately beneath the vocal folds. Individuals with SGS experience a reduction in their ability to breathe as well as adverse effects on voice function. SGS can result from a variety of causes with the type of treatment depending on stenosis severity. Surgical techniques such as laryngotracheal and cricotracheal reconstruction are beneficial for airway maintenance; however, these procedures have resulted in negative effects on voice production. On the other hand, there are patients with SGS who do not require surgery and still experience voice problems. The purpose of this study was to quantify the effects of SGS on vocal fold vibration using an excised larynx benchtop mechanical model. Using a within-subjects repeated measures design, nine porcine larynges underwent experimental conditions including 0% (i.e., normal airway), 50% and 75% stenosed. The primary outcome measure was phonation threshold flow (PTF), which is the rate of flow observed at the onset of phonation. For all larynges, the normal and stenosed conditions were sampled three times each and averaged. Analysis of the results revealed no statistically significant differences in PTF; however, descriptive data showed decreases in PTF and increased variability in PTF values as percent stenosis increased. These findings lay important groundwork for future research in SGS, specifically those that employ ex vivo methodologies. PTF has emerged as a promising means of quantifying voice function in addition to the traditional onset pressure measures. Future studies should examine a broader range of stenosis conditions with a larger sample size to promote generalization to clinical populations including individuals with SGS.

Subglottic stenosis (SGS) is a narrowing of the airway below the vocal folds and above the trachea. This narrowing may be idiopathic or caused by scarring in the airway due to prolonged endotracheal intubation, radiation therapy, trauma, or gastroesophageal reflux disease. People who present with SGS often experience respiratory difficulty both at rest and during exertion. Breathing difficulty increases with stenosis severity. SGS is also associated with voice problems. Research has identified relationships among stenosis severity, voice function and certain types of surgical management; however, many aspects of these relationships are not fully understood due to the complexities of studying human phonation in this population. The purpose of the present study was to examine the effects of SGS on aerodynamic features of voice function using an excised larynx benchtop mechanical model. Specifically, this research involved the comparison of excised porcine vocal fold vibration at baseline and under experimental conditions of 50% and 75% stenosed. The dependent variable was phonation threshold pressure (PTP), the minimum pressure needed to initiate and maintain vocal fold vibration. PTP was analyzed for nine excised porcine larynges, sampled three times each, at baseline and the two stenosis conditions. The results of this study revealed no differences in PTP based on within-subjects comparisons. Because airflow changes with airway narrowing, this finding might indicate that other factors are responsible for the voice problems associated with SGS that were not accounted for in the current mechanical model. Vocal fold tone is not easily simulated in a benchtop setup and might be an important consideration for future studies. The quantification and manipulation of vocal fold adduction, as well as the study of high-speed imaging, could be useful in future work involving excised larynx mechanical models for the study of SGS. The results from this pilot work represent an important step toward optimizing the experimental setup for studying aerodynamic features of SGS.

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No description available.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23767号 / 医博第4813号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 大鶴 繁, 教授 小西 靖彦, 教授 森田 智視 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM