Isolated Biliary Fistula After Donor Right Hepatectomy and Its Novel Interventional Treatment: Isolated Liver-Punctured Drainage

Isolated biliary leakage is difficult to manage, and afflicted patients often develop refractory fistula. The present case was a 43-year-old male donor whose wife developed acute fulminant liver failure. Computed tomography (CT) volumetry showed that the estimated remnant liver volume was only 394 mL (31%) if his right lobe would be harvested. Since remnant liver volume was marginal, our proposed cut line for the right hepatectomy was set in order to preserve branches of the middle hepatic vein draining segments 4b+8 and 5. Right hepatectomy was performed, but on postoperative day 14, the donor developed fever and right back pain, and enhanced CT showed a 6 cm intra-abdominal abscess at the site of cutting, and we diagnosed it as an isolated biliary fistula since the isolated segment 5/8 was receiving arterial blood supply and exhibiting regrowth. A transabdominal abscess drainage was performed, after which the patient lost 30 to 50 mL of bile juice per day in drainage until 2 months after the drainage procedure. Ethanol injection, acetic acid injection, and transarterial or portal embolization for the isolated liver were proposed, but these all were impossible to carry out because there were no accessible routes. Thus, re-abscess drainage with a 7-French drainage catheter was performed through the isolated liver on postoperative day 53, and the isolated functional liver was punctured to induce liver atrophy. After this drainage, the isolated liver started to shrink and bile output had been stopped. In conclusion, our punctured-liver drainage could be effective for the treatment of isolated biliary fistula, allowing physicians to avoid an invasive additional liver resection or other invasive percutaneous approach using chemical reagents.

Acquired undescended testis and possibly associated testicular torsion in children with cerebral palsy or neuromuscular disease

INTRODUCTION

Torsion of an undescended testis (UDT) associated with cerebral palsy (CP) and neuromuscular disease (NMD) is an uncommon condition that is not well recognized by primary care physicians or healthcare providers.

OBJECTIVE

The objective of this study was to highlight the clinical importance of torsion of a UDT in children with CP and NMD.

MATERIALS AND METHODS

Eleven children with testicular torsion of a UDT operated on at the study institute between 1991 and 2015 were identified. The records of seven children (63.6%) associated with CP or NMD were retrospectively reviewed. Clinical findings of testicular torsion were assessed along with the treatment outcome and testicular salvageability.

RESULTS

All seven children were not identified with a UDT by public health checkup for infant and young children. No children with CP or NMD had torsion of a descended testis during the present study period. Median age at surgery was 15 years (range, 1-20 years). The testis location was at the external inguinal ring in five patients, in the inguinal canal in one, and in the superficial inguinal pouch in one. Of the contralateral testes, four were a UDT, one was a retractile testis, and two were descended testes. Orchiectomy was performed in six patients (85.7%). In the remaining patients, the testis was preserved but became atrophic.

DISCUSSION

This study demonstrated that children with CP or NMD may be affected with torsion of a UDT with peak at around puberty with the poor salvage rate, even if the testes appear descended in infancy and young children. Shortcomings of this study were the retrospective design and a small series of children undergoing surgery for torsion of a UDT.

CONCLUSION

Pediatric urologists need to educate primary care physicians and healthcare providers in the recognition of acquired UDTs and possibly associated testicular torsion in children with CP and NMD. Genital examination should be continued regularly until adolescence in these children to detect acquired UDT. These children should be referred to pediatric urologists to promote surgery as soon as the diagnosis of acquired UDT is carried out. It is believed that it is perhaps the best approach to prevent loss of the testis in children with CP and NMD.

Probing ultrafast spin-relaxation and precession dynamics in a cuprate Mott insulator with seven-femtosecond optical pulses

A charge excitation in a two-dimensional Mott insulator is strongly coupled with the surrounding spins, which is observed as magnetic-polaron formations of doped carriers and a magnon sideband in the Mott-gap transition spectrum. However, the dynamics related to the spin sector are difficult to measure. Here, we show that pump-probe reflection spectroscopy with seven-femtosecond laser pulses can detect the optically induced spin dynamics in Nd2CuO4, a typical cuprate Mott insulator. The bleaching signal at the Mott-gap transition is enhanced at ~18 fs. This time constant is attributable to the spin-relaxation time during magnetic-polaron formation, which is characterized by the exchange interaction. More importantly, ultrafast coherent oscillations appear in the time evolution of the reflectivity changes, and their frequencies (1400-2700 cm-1) are equal to the probe energy measured from the Mott-gap transition peak. These oscillations can be interpreted as the interference between charge excitations with two magnons originating from charge-spin coupling.

Identification of specifically reduced Th2 cell subsets in allergic rhinitis patients after sublingual immunotherapy

BACKGROUND

Although Th2 cells are well known to play important roles in allergic diseases including allergic rhinitis (AR), the factors that induce and sustain the pathogenesis of AR remain unclear. The recent development of sublingual immunotherapy (SLIT) is expected to allow changes to the underlying pathogenesis of AR. However, which Th2 cell subsets are important in house dust mite-induced AR (HDM-AR), the influence of SLIT on the pathogenic Th2 cells, and the association of Th2 cell subsets with SLIT efficacy have not been clarified.

METHODS

The cytokine production and frequency of HDM-reactive T-cell subsets in peripheral blood mononuclear cells (PBMCs) were evaluated using flow cytometry in 89 HDM-AR patients (placebo [n = 43] and HDM 300 IR [n = 46]) who participated in a placebo-controlled study of SLIT with HDM tablets. All patients provided samples both before treatment as a baseline and at the end of the 52-week study. The PBMCs were stained with CellTrace™ Violet (CTV) before culture with HDM extract, and HDM-reactive T cells were detected as the proliferated cells with diminished CTV.

RESULTS

HDM-reactive IL-5⁺ IL-13⁺ CD27^- CD161⁺ CD4⁺ cells and ST2⁺ CD45RO⁺ CD4⁺ cells were observed in the peripheral blood from each patient with HDM-AR; these cells significantly decreased after SLIT in the group treated with active tablets. HDM-reactive ST2⁺ CD45RO⁺ CD4⁺ cells were significantly lower in active-responders.

CONCLUSION

Allergen-reactive ST2⁺ CD45RO⁺ CD4⁺ cells or those combined with IL-5⁺ IL-13⁺ CD27^- CD161⁺ CD4⁺ cells may be useful as markers indicating the successful treatment of SLIT. These cells may play a crucial role in the pathogenesis of AR as pathogenic memory Th2 cells.

Idiopathic benign paroxysmal positional vertigo with persistent vertigo/dizziness sensation is associated with latent canal paresis, endolymphatic hydrops, and osteoporosis

OBJECTIVE

The aim of the present study was to examine the association of neuro-otological examination, blood test, and scoring questionnaire data with treatment-resistant intractability in idiopathic benign paroxysmal positional vertigo (BPPV) patients.

METHODS

We experienced 1520 successive vertigo/dizziness patients at the Vertigo/Dizziness Center in Nara Medical University during May 2014 to April 2018. Six hundred and eleven patients were diagnosed as BPPV (611/1520; 40.2%) according to the diagnostic guideline of the International Classification of Vestibular Disorder in 2015. Among BPPV patients, there were 201 intractable patients (201/611; 32.9%), 66 of whom were idiopathic and enrolled to be hospitalized and receive neuro-otological examinations, including the caloric test (C-test), vestibular evoked cervical myogenic potentials (cVEMP), subjective visual vertical (SVV), glycerol test (G-test), electrocochleogram (ECoG), inner ear magnetic resonance imaging (ieMRI), blood tests including anti-diuretic hormone (ADH) and bone alkaline phosphatase (BAP), and self-rating questionnaires of depression score (SDS). Sixty-six patients were diagnosed as horizontal type cupula (hBPPVcu; n=30), horizontal type canal (hBPPVca; n=10), posterior type (n=20), and probable and/or atypical BPPV (n=6). Data are presented as ratios (+) of the number of idiopathic BPPV patients with examination and questionnaire data outside of the normal range.

RESULTS

The ratio (+) data were as follows: C-test=21.2% (14/66), cVEMP=24.2% (16/66), SVV=48.5% (32/66), G-test=18.2% (12/66), ECoG=18.2% (12/66), ieMRI=12.1% (8/66), ADH=9.1% (6/66), BAP=13.6% (9/66), and SDS=37.9% (25/66). Multivariate regression analysis revealed that the periods of persistent vertigo/dizziness were significantly longer in BPPV patients with hBPPVcu, C-test (+), endolymphatic hydrops (+), and BAP (+) compared with those with negative findings.

CONCLUSION

Although patients with idiopathic BPPV are usually treatable and curable within 1 month, the presence of hBPPVcu, canal paresis, endolymphatic hydrops, and elevated BAP may make the disease intractable, and thus require additional treatments.

Effectiveness of Preceding Solo Kidney Transplantation for Type 1 Diabetes With End-Stage Renal Failure

Preceding solo kidney transplantation for type 1 diabetes with end-stage renal failure is controversial because of less pancreatic graft survival in pancreas transplantation after kidney transplantation (PAK) than in simultaneous pancreas and kidney transplantation (SPK).

METHODS

To study the effectiveness of preceding solo kidney transplantation for type 1 diabetes with end-stage renal failure, comparative retrospective analysis was performed between SPK (n = 232) and PAK (n = 39) that were performed until December 2016.

RESULTS

At 1, 3, and 5 years, pancreatic graft survival in SPK was 87.5%, 86.4%, and 82.8%, respectively, and 87.1%, 65.0%, and 49.1%, respectively, in PAK, which showed lesser long-term graft survival than SPK. Because 10 cases out of 16 (62.5%) failed into pancreatic graft loss with rejection in PAK, which was about 3 times more than in SPK, control of rejection is very important; rejection episodes were decreased by rabbit antithymocyte globulin induction resulting in improved graft survival. Five-year patient survival was 88.0% in SPK and 96.6% in PAK.

CONCLUSION

Considering patient survival, preceding solo kidney transplantation for type 1 diabetes with end-stage renal failure should be performed if a donor is available.

Propensity score-matched comparison of non-anatomical resection and radiofrequency ablation for hepatocellular carcinoma in patients with up to three tumours, each measuring up to 3 cm in diameter

Background

Non‐anatomical liver resection (NAR) and radiofrequency ablation (RFA) are treatment options for early‐stage hepatocellular carcinoma (HCC). The aim was to compare the outcomes of NAR and RFA for HCC in patients with three or fewer tumour nodules, each measuring not more than 3 cm in maximum diameter.

Methods

Eligible patients undergoing NAR or RFA with curative intent between September 2002 and December 2014 were identified. A propensity score‐matching analysis was performed to reduce bias, and outcomes in these patients were analysed.

Results

From a total of 199 patients, 1:1 propensity score matching identified 70 matched pairs. Patients having NAR had a longer hospital stay (median 10 days versus 4 days for those who had RFA; P < 0·001) and a higher morbidity rate (24 versus 10 per cent respectively; P = 0·042). Patients who had NAR had slightly better recurrence‐free survival but this failed to reach statistical significance in univariable analysis (P = 0·064). There was no significant difference in overall survival between the two groups (P = 0·475). RFA was identified as an independent risk factor for recurrence‐free survival (hazard ratio (HR) 1·57; P = 0·041) in multivariable analysis. Local recurrence was significantly more common in patients receiving RFA (23 versus 1 per cent; P < 0·001).

Conclusion

RFA was an independent risk factor for shorter recurrence‐free survival, with a significantly higher local recurrence rate than NAR. Despite these differences, overall survival was not affected.

Lipoteichoic acids are embedded in cell walls during logarithmic phase, but exposed on membrane vesicles in Lactobacillus gasseri JCM 1131T

Lipoteichoic acid (LTA) is a cell surface molecule specific to Gram-positive bacteria. How LTA localises on the cell surface is a fundamental issue in view of recognition and immunomodulation in hosts. In the present study, we examined LTA localisation using strain JCM 1131T of Lactobacillus gasseri, which is a human intestinal lactic acid bacterium, during various growth phases by immunoelectron microscopy. We first evaluated the specificity of anti-LTA monoclonal antibody clone 55 used as a probe. The glycerophosphate backbone comprising almost intact size (20 to 30 repeating units) of LTA was required for binding. The antibody did not bind to other cellular components, including wall-teichoic acid. Immunoelectron microscopy indicated that LTA was embedded in the cell wall during the logarithmic phase, and was therefore not exposed on the cell surface. Similar results were observed for Lactobacillus fermentum ATCC 9338 and Lactobacillus rhamnosus ATCC 7469T. By contrast, membrane vesicles were observed in the logarithmic phase of L. gasseri with LTA exposed on their surface. In the stationary and death phases, LTA was exposed on cell wall-free cell membrane generated by autolysis. The dramatic alternation of localisation in different growth phases and exposure on the surface of membrane vesicles should relate with complicated interaction between bacteria and host.

Magnetic Field Control of Cycloidal Domains and Electric Polarization in Multiferroic BiFeO_{3}

The magnetic field induced rearrangement of the cycloidal spin structure in ferroelectric monodomain single crystals of the room-temperature multiferroic BiFeO_{3} is studied using small-angle neutron scattering. The cycloid propagation vectors are observed to rotate when magnetic fields applied perpendicular to the rhombohedral (polar) axis exceed a pinning threshold value of ∼5  T. In light of these experimental results, a phenomenological model is proposed that captures the rearrangement of the cycloidal domains, and we revisit the microscopic origin of the magnetoelectric effect. A new coupling between the magnetic anisotropy and the polarization is proposed that explains the recently discovered magnetoelectric polarization perpendicular to the rhombohedral axis.

Intravenous Administration of Tacrolimus Stabilizes Control of Blood Concentration Regardless of CYP3A5 Polymorphism in Living Donor Liver Transplantation: Comparison of Intravenous Infusion and Oral Administration in Early Postoperative Period

BACKGROUND

We compared achievement rate of sufficient tacrolimus blood concentration in the early postoperative period and incidence of acute cellular rejection within 1 month after living donor liver transplantation (LDLT) between tacrolimus intravenous (IV) and oral administration groups.

METHODS

From October 2005 to November 2016, 61 LDLT patients administered tacrolimus, who could be genotyped for CYP3A5*3 and *1, were chosen from the electronic record database. The patients were then divided into the 2 groups (an IV group [n = 38] and an oral group [n = 23]). We defined patients with 1*1 or *1*3 as expressors and those with *3*3 as nonexpressors. Sufficient trough level tacrolimus blood concentration on postoperative day (POD) 3 was defined as 10-20 ng/mL.

RESULTS

Comparable concentrations were seen between the 2 groups, with mean blood concentration 13.7 ± 8.5 ng/mL in the oral group and 15.2 ± 4.3 ng/mL in the IV group. Achievement rate of sufficient tacrolimus concentration on POD 3 was significantly higher in the IV group than in oral group: 97% (37 of 38) vs 65% (15 of 23), respectively (P = .001). When we focused on achievement rate in the oral group according to CYP3A5 polymorphism, the frequency of expressors (17%) was significantly lower than that of nonexpressors (82%) (P = .016). However, in the IV group this negative influence was totally eliminated, resulting in high achievement rates regardless of CYP3A5 polymorphism. In terms of incidence of acute cellular rejection, there was no significant difference between the 2 groups (IV 32% vs oral 17%, P = .250).

CONCLUSION

IV administration of tacrolimus allowed us to obtain more stable control of blood concentration regardless of CYP3A5 genotype.

Correction of CAPD Catheter Displacement Using Gastric Biopsy Forceps: The Push-Pull Method

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the “push-pull method”. A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5–10 minutes and there were no complications.

Abstract P3-01-05: A feasibility study of sentinel lymph node detection and analysis of safety to omit axillary lymph node dissection in clinically node-negative breast cancer patients after neoadjuvant chemotherapy

Background: Concerns still remain about lower sentinel node (SN) detection and higher false-negative rates (FNR) in breast cancer patients treated with neoadjuvant chemotherapy (NAC), especially those who are clinically node-positive before NAC. It is necessary to analyze the validity of sentinel node biopsy (SNB) after NAC and evaluate whether the SN identification rate and FNR for clinically N0 (cN0) patients after NAC would be acceptable or not in order to omit axillary lymph node dissection (ALND).

Objectives and methods: We identified SN by radioisotopic methods followed by completion of ALND in cN0 patients after NAC from 2013 to 2016 as part of a clinical research study (SNB group, N=68) to analyze the accuracy of SNB, and retrospectively investigated the prognosis of patients treated with NAC from 2006 to 2012 (control group, N=92) to evaluate whether the validity of SNB would be acceptable or not.

Results: Mean patient ages in the SNB group and control group were 51.0 years and 49.5 years, respectively (p=0.17), and the distribution of intrinsic subtypes was not significantly different between the two groups. The numbers of cN1≤ before NAC in the SNB group and control group were 85.5% (57/68) and 80.4% (74/92), respectively (p=0.58), and the pathological complete response rates were 25.0% (17/68) and 19.6% (18/92), respectively (p=0.41). Lymphoscintigraphy using 99mTc-phytate acid was performed in the SNB group, and hot spots were detected at the ipsilateral axilla in 62 of 68 (91.2%) patients, in all of whom SNs could be identified by using a gamma-probe. The FNR, which indicates no metastasis in SNs and metastasis in non-SN, was 5.9% (4/68). Among these four patients, three were of the luminal type while one was triple negative. The number of patients without metastasis in both SN and non-SN, which are candidates for omission of ALND, was 26 of 68 (38.2%). They included eight of nine HER2-enriched patients and six of 13 luminal-HER2 patients. Conversely, there were no false-negative cases in these subtypes. Moreover, all SNs were identified even if there were metastases in SNs. Regarding the prognosis of the control group, the 10-year disease free survival of post-NAC N0 (ypN0) (52/92, 56.5%) and ypN1≤ (40/92, 43.5%) were 80.7% and 61.2%, respectively (p=0.08); in addition, the 10-year overall survival of yN0 and ypN1≤ were 90.4% and 72.6% (p=0.26). Thus, the prognosis of ypN1≤ was not significantly inferior to that of ypN0. If omission of ALND were performed for false negative cases, then the risk of axillary relapse would be a concern. However, these data indicate the possibility that 5.9% of FNR as shown in the SNB group would not have much influence on prognosis.

Conclusion: The accuracy of SN detection by radioisotopic methods for cN0 breast cancer after NAC was not maintained like that for -early breast cancer although it was better than the results of previous studies. However, there were no false-negative cases in HER2-enriched and luminal-HER2 subtypes, which could be potential candidates for omission of ALND. In addition, omission of ALND for false-negative patients would have less influence on the prognosis.

Citation Format: Maeno K, Yamamoto K, Ono M, Oba T, Iesato A, Ono K, Ito T, Kanai T, Ito K-I. A feasibility study of sentinel lymph node detection and analysis of safety to omit axillary lymph node dissection in clinically node-negative breast cancer patients after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-05.

Evolution of spall-damage in iron caused by repeated plate impacts: Ultrasonic evaluation

This paper focuses on the developed of spall-damage that occurs in pure iron as a result of repeated impact. The employed low-frequency scanning acoustic microscopy (LF-SAM) observations combined with the measurements of ultrasonic wave velocity, attenuation, backscattering intensity and amplitude spectrum of the reflected wave, enabled us to provide a nondestructive evaluation. The spall-damage distribution was analyzed in the C-scan images, and we found the spall-damage increase with impact stress when the latter exceeds the characteristic spall-threshold stress. Moreover, we recorded the decreased sound velocity, amplitude ratio, and the increase of backscattering intensity, significant attenuation (the high frequency component of the reflected wave) for enhanced impact stress. It was also demonstrated that the tiny cracks generated in iron develop significantly during subsequent impacts either with lower or higher impact stress. Since the presented results concern for the first time the multiple-impact experiments, we contend that the applied ultrasonic investigations constitute the effective method of nondestructive spall-damage evaluation.

Mogamulizumab-induced photosensitivity in patients with mycosis fungoides and other T-cell neoplasms

BACKGROUND

Mogamulizumab (Mog) is a defucosylated, therapeutic monoclonal antibody, targeting CCR4 and was first approved in Japan for the treatment of adult T-cell leukaemia/lymphoma (ATLL), followed by cutaneous T-cell lymphoma and peripheral T-cell lymphoma.

OBJECTIVE

To retrospectively investigate development of photosensitivity in patients with mycosis fungoides and other T-cell neoplasms after treatment with Mog.

METHODS

We treated seven cutaneous lymphoma patients with Mog. Upon combination treatment with narrow-band UVB, we noticed that four patients developed photosensitivity dermatitis following Mog therapy, including two cases of mycosis fungoides, one case of adult T-cell leukaemia/lymphoma and one case of EB virus-associated T-cell lymphoproliferative disorder. Phototest was performed with UVA and UVB, and immunohistochemical staining for CD4, CD8 and Foxp3 was conducted in both photosensitivity and lymphoma lesions.

RESULTS

Phototest revealed that the action spectrum of the photosensitivity was UVB in three cases and both UVB and UVA in one case. Histopathologically, the photosensitive lesions were characterized by a lichenoid tissue reaction with a CD8⁺ T cell-dominant infiltrate, sharing the feature with chronic actinic dermatitis, an autoreactive photodermatosis with a cytotoxic T-cell response. Foxp3⁺ regulatory T cells (Tregs) were decreased in the photosensitivity lesions compared with the lymphoma lesions.

CONCLUSION

Increased incidence of photosensitivity reaction was observed during Mog treatment. Decreased number of Tregs in the lesional skin suggests that this reaction is possibly induced by autoreactive cytotoxic T cells.

Species-specific control of hepatocyte growth factor expression and production in adipocytes in a differentiation-dependent manner

Hepatocyte growth factor (HGF) is a mesenchymal cell-derived factor that regulates cell growth, cell motility, and morphogenesis. Since there are conflicting reports on HGF-producing cells, we herein examined HGF activity in conditioned medium (CM) of bovine and mouse preadipocytes before and after adipogenic differentiation. CM of bovine adipocytes and mouse preadipocytes induced the morphogenesis of mammary epithelial cells that was inhibited by an NK4 HGF antagonist, whereas CM of bovine preadipocytes and mouse adipocytes did not. HGF mRNA expression was increased by a treatment with dexamethasone and isobutylmethylxanthine in bovine as well as human cells, whereas it was decreased in rodent cells. It was unfortunate that HGF gene promoter activity failed to reflect HGF mRNA expression in these cells. After actinomycin D treatment, expression of HGF mRNA remained stable in pre- and differentiated bovine adipocytes and mouse preadipocytes, whereas rapidly decreased in mouse-differentiated adipocytes. These results indicate that expression and production of HGF are regulated in a species-specific adipogenic differentiation-dependent manner and suggest that the decrease in HGF mRNA in mouse differentiated adipocytes is, at least in part, mediated by differentiation-dependent loss of its stability.

Test of the Brink-Axel Hypothesis for the Pygmy Dipole Resonance

The gamma strength function and level density of 1^{-} states in ^{96}Mo have been extracted from a high-resolution study of the (p[over →], p[over →]^{'}) reaction at 295 MeV and extreme forward angles. By comparison with compound nucleus γ decay experiments, this allows a test of the generalized Brink-Axel hypothesis in the energy region of the pygmy dipole resonance. The Brink-Axel hypothesis is commonly assumed in astrophysical reaction network calculations and states that the gamma strength function in nuclei is independent of the structure of the initial and final state. The present results validate the Brink-Axel hypothesis for ^{96}Mo and provide independent confirmation of the methods used to separate gamma strength function and level density in γ decay experiments.