[A case of delayed peripheral neuropathy caused by diquat poisoning]

Diquat is a kind of conductive contact-killing herbicides. The damage of central nervous system is relatively common, but the peripheral neuropathy caused by diquat has not been reported yet. In September 2021, we treated a patient with diquat poisoning. During the hospitalization, the patient was diagnosed with peripheral neuropathy. Therapy for peripheral nerve injury was given on the basis of conventional treatment of poisoning. The patient was discharged after his condition was stable. The follow-up showed that the peripheral neuropathy of patient was better than before. According to the condition of this patient, it is suggested that we should not only protect the function of gastrointestinal tract, liver, kidney, and central nervous system early, but should also pay attention to the damage of peripheral nervous system in clinical work. We should intervene earlier to improve the prognosis of patients.

[Outcomes of the second pregnancy after Triple-P procedure in women complicated with placenta accreta spectrum disorders]

Objective: To investigate the safety of the Triple-P procedure in women complicated with severe placenta accreta spectrum disorders (PAS) and its influence on second pregnancy. Methods: From January 2015 to December 2017, the outcomes of the second pregnancy after the Triple-P procedure in 11 pregnant women complicated with PAS in the Third Affiliated Hospital of Guangzhou Medical University and the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed. Results: By December 2021, a total of 11 pregnant women who underwent the Triple-P procedure for PAS had a second pregnancy, with a median interval of 3 years (2-3 years). Of the 11 pregnant women, 7 delivered after 36 weeks of gestation. The median gestational age was 38 weeks, and 4 terminated within the first trimester. PAS recurred in 1 of 7 pregnant women (1/7) and was associated with placenta previa. All of the 7 pregnant women were delivered by cesarean section, with a median postpartum blood loss of 300 ml (200-450 ml), and only one pregnant woman required blood transfusion. None of the pregnant women were transferred to the intensive care unit, and there were no uterine rupture, bladder injury, puerperal infection, and neonatal adverse outcomes. Conclusion: Pregnant women who underwent the Triple-P procedure for severe PAS could be considered for second pregnancy with strictly management by an experienced multidisciplinary team, which may result in a good outcome.

AD-9308 ameliorates the impacts of 4-HNE on the progress of pulmonary arterial hypertension in aldehyde dehydrogenase 2*1*2 knock-in mice

 

Endothelial dysfunctions play a critical role on the development of pulmonary arterial hypertension (PAH). It has been reported that the one-year mortality rate is still up to 15% even with PAH-targeted therapy, implying that there may be untargeted pathways. 4-hydroxynenonal (4-HNE), an unsaturated aldehyde, is highly induced in the lungs of PAH animals and its serum levels were also reported to be higher in PAH patients. 4-HNE is metabolized by mitochondrial aldehyde dehydrogenase (ALDH2), which is dysfunctional in near 40% of East Asian people. Currently, the impacts of 4-HNE on endothelial dysfunctions in the development of PAH are unclear. In terms of translational medicine, we proposed that modulation of 4-HNE level may alleviate the progress of PAH patients with ALDH2 deficiency.

We found that 4-HNE alone was not sufficient to induce pulmonary artery endothelial cell (PAEC) functional changes, including proliferation, migration and tube formation, whereas their effects emerge from the depletion of ALDH2. We further mimicked human ALDH2 functional deficiency by using daidzin (DZN), an inhibitor which is able to block the substrate binding site of ALDH2. ALDH2 functional inhibition alone did not induce any PAEC functional change, while an add-on of 4-HNE impaired PAEC functions. In addition, 4-HNE significantly reduced eNOS activity with combined DZN treatment. Consistent with the mechanism of ALDH2 activity-mediated angiogensis, ALDH2 enhancers Alda-1 and AD-5591 completely reverse the anti-angiogenic effects of 4-HNE in the presence of DZN. To further confirm whether ALDH2 functional deficiency impact on PAH development in mammals, heterozygous ALDH2*1/*2 transgenic and wild-type mice were subjected to chronic hypoxia to induce PAH. ALDH2*1/*2 transgenic mice had similar right ventricular systolic pressure (RVSP) as wild-type mice. However, after exposure to chronic hypoxia, ALDH2*1/*2 transgenic mice indeed developed a significantly higher RVSP than that in wild-type mice. Furthermore, we demonstrated that 4-HNE expression was profoundly enhanced in ALDH2*1/*2 transgenic mice by chronic hypoxia-induced PAH with pulmonary artery smooth muscle cell hyperplasia. More importantly, we found that AD-9308, an enhancer of ALDH2 significantly decreased hypoxia-induced RVSP elevation in heterozygous ALDH2*1/*2 transgenic mice.

Taken together, our data demonstrate that 4-HNE and ALDH2 functional deficiency potentially contribute to PAH development and worsening, and that ALDH2 enhancers may be promising as a PAH adjunct therapy, particularly for patients with ALDH2 nonfunctional alleles.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Taiwan

[Analysis of the efficacy and related influencing factors of pelvic packing in the treatment of intractable postpartum hemorrhage after emergency perinatal hysterectomy]

Objective: To investigate the effect of pelvic packing on the control of intractable postpartum hemorrhage after emergency perinatal hysterectomy (EPH). Methods: Eleven cases with complete clinical data of pelvic packing due to failure of hemostasis after EPH were collected to evaluate the outcome, complications, hospital stay of pregnant women, and to analyze the factors affecting the effect of pelvic packing. The cases included patients who were admitted to the Third Affiliated Hospital of Guangzhou Medical University after pelvic packing treatment in the other hospital due to continuous bleeding after EPH or who were referred to our hospital for pelvic packing treatment due to continuous bleeding after EPH from January 2014 to August 2021. Results: The median gestational week of 11 pregnant women was 38.3 weeks(38.0-39.9 weeks) , and the methods of termination of pregnancy were cesarean section in 7 cases (7/11) and vaginal delivery in 4 cases (4/11). The median time between postpartum hemorrhage and pelvic tamponade was 10 hours (5-57 hours), the median amount of bleeding was 8 500 ml(4 800-15 600 ml) , the median number of pelvic tamponade was 3 pieces (2-7 pieces), and the median retention time of gauze pad was 6.0 days (3.0-6.0 days). The median frequency of laparotomy in this pregnancy was 3 times (2-3 times), with a maximum of 4 among the 11 cases, the first pelvic packing was successful in hemostasis in 9 cases, and the final successful treatment in all of the 11 cases. All parturients had hemorrhagic shock (11/11) and disseminated intravascular coagulation (11/11) before pelvic packing. Other common complications were multiple organ dysfunction syndrome (9/11), cardiac arrest (4/11), deep vein thrombosis (3/11), septic shock (3/11), and intestinal obstruction (1/11). All parturients took out the gauze after the coagulation function returned to normal and there was no active bleeding. The recovery time of coagulation function in 11 cases was 3 days (3-5 days), the retention time of gauze pad was 6 days (3-6 days), the median length of stay in intensive care unit was 14 days (11-26 days), and the median total length of stay was 22 days (16-49 days). Conclusions: Pelvic packing could be used as a temporary strategy for intractable postpartum hemorrhage after EPH, which provides a key time for injury control resuscitation for patients with unstable vital signs. This technology provides an opportunity for referral to superior medical institutions and further treatment.

CHA2DS2-VASc score as independent outcome predictor in patients with acute ischemic stroke with and without atrial fibrillation

Introduction

Atrial fibrillation (AF) was a significant independent risk factor for 1-year mortality of first acute ischemic stroke. The CHA2DS2-VASc scores were initially developed to assess the risk of stroke or systemic embolism in patients with AF. Recently, this scoring system have been demonstrated to have clinical value for predicting the severity of infarction and long-term clinical outcomes in acute ischemic stroke but the evidence is not strong enough due to limited numbers and single center data.

Purpose

This large-scale prospective cohort study aimed to investigate the independent predictive value of CHA2DS2-VASc scores and AF in such patients.

Materials and methods

We included patients from Taiwan Stroke Registry (TSR) with ischemic stroke within 2006 to 2016 as the present study population. Patients were mainly divided in atrial fibrillation (AF) group and non-AF group. We future classified patient by CHA2DS2-VASc (congestive heart failure, hypertension, age≥75 years, diabetes, previous stroke, vascular disease, age 65–74 years, sex category) score 0–1 and ≥2. The primary outcome was major adverse cardiovascular events (MACE), which include re-stroke, myocardial infarction and cardiovascular death, occurred within 1 year after the onset of stroke. The secondary outcome was the all-cause mortality.

Results

We defined 2972 patients with MACE and 61,937 patients without MACE. With adjusting with the confounding of CHA2DS2-VASc scores, The AF group was associated with increased MACE (OR=1.15; 95% CI=1.00, 1.33), myocardial infarction (adjusted OR=3.89; 95% CI=1.81, 8.34), CV death (OR=5.73; 95% CI=3.77, 8.69) and all-cause mortality (OR=1.50; 95% CI=1.37, 1.65) but not in re-stroke (adjusted OR=1.02; 95% CI=0.88, 1.18). After controlling for AF, patients with CHA2DS2-VASc scores ≥2 had significantly higher odds of MACE (OR=1.28; 95% CI=1.16, 1.41), re-stroke (OR=1.27; 95% CI=1.16, 1.40) and all-cause mortality (OR=2.26; 95% CI=2.06, 2.48) than that of patients with CHA2DS2-VASc scores 0–1. The survival curve revealed both AF and CHA2DS2-VASc scores are independent risk factors of 1 year MACE and mortality. By investigating the individual risk factor of CHA2DS2-VASc score, diabetes, hypertension and age over 65 years old increase the risk of MACE significantly.

Conclusions

CHA2DS2-VASc scores appear to have potent independent value as AF for predicting 1 year MACE and all-cause mortality in patients of acute ischemic stroke.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

[Association of hyperuricemia-induced renal damage with sirtuin 1 and endothelial nitric oxide synthase in rats]

Objective: To investigate the association of hyperuricemia-induced renal damage with sirtuin 1 (SIRT1) and endothelial nitric oxide synthase (eNOS) in rats. Methods: Using the random number table method, 32 Sprague-Dawley rats were randomly divided into 4 groups: control group, model A group (the model was generated using oxonic acid potassium salt alone), model B group (hyperuricemia model was generated using oxonic acid potassium salt combined with uric acid) and resveratrol group, with 8 rats in each group. The experiment lasted 12 weeks. Serum uric acid and cystatin C levels were monitored regularly. In week 12, serum creatinine and urea nitrogen levels were measured, and the kidneys were extracted. The expression of SIRT1 and eNOS in renal tissues was measured and determined by immunohistochemistry, quantitative reverse-transcription polymerase chain reaction (RT-qPCR) and western blotting. Immunohistochemistry of alpha-smooth muscle actin combined with Masson staining was employed to evaluate the degree of renal fibrosis, and pathological changes were observed based on hematoxylin and eosin staining. Results: In week 12, the uric acid levels in both the model A and model B groups were higher than those in the control group [(316±43) μmol/L, (297±40) μmol/L vs (118±44) μmol/L, both P<0.05]. The levels of cystatin C in the model A, model B, and resveratrol groups were all higher than those in the control group [(156±20) ng/ml, (143±29) ng/ml, (128±26) ng/ml vs (62±18) ng/ml, all P<0.05]. Creatinine levels were higher in the model A and model B groups than those in the control group [(68.5±10.3) μmol/L, (64.5±13.9) μmol/L vs (43.2±10.6) μmol/L, both P<0.05]. The levels of uric acid, cystatin C and creatinine in the resveratrol group were lower than those in the model A group (all P<0.05). Immunohistochemistry, RT-qPCR, and Western blotting for renal SIRT1 and eNOS showed that the expression in the model A and model B groups was inhibited, while the expression in the resveratrol group was not significantly inhibited, compared with that in the control group. Microscopically, obvious abnormalities were not found in the renal tissue of the control group. Renal inflammatory cell aggregation and edema occurred, and interstitial fibrosis was obvious in both the model A and model B groups, while these lesions in the resveratrol group were significantly improved. Conclusions: Hyperuricemia may cause renal injury by inhibiting the expression of SIRT1 and eNOS.

[One case successfully rescued acute poisoning caused by misadministration of large amount of glufosinate]

Objective: To report a case of acute glufosinate-ammonium poisoning cause respiratory cardiac arrest and grass amine poisoning cases of successful rescue. Methods: The clinical data of a case of acute glufosinate-ammonium poisoning admitted to a third-class a hospital in April 2018 were analyzed and summarized. Results: The patient was poisoned by oral administration of a large amount of glufosinate-ammonium. Respiratory and cardiac arrest occurred during treatment and resuscitation was successful Later, the nervous system showed impaired function, The patients were treated with complete gastrointestinal cleansing, hemoperfusion, and the protection of important organs. Conclusion: For a large number of patients with oral glufosinate-ammonium poisoning, we should pay close attention to the damage of nervous system while taking active and conventional detoxification treatment.

Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy

BACKGROUND

Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD.

METHODS

Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line.

RESULTS

After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation.

CONCLUSION

Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.

Comparison between the therapeutic effects of differentiated and undifferentiated Wharton's jelly mesenchymal stem cells in rats with streptozotocin-induced diabetes

BACKGROUND

Despite the availability of current therapies, including oral antidiabetic drugs and insulin, for controlling the symptoms caused by high blood glucose, it is difficult to cure diabetes mellitus, especially type 1 diabetes mellitus.

AIM

Cell therapies using mesenchymal stem cells (MSCs) may be a promising option. However, the therapeutic mechanisms by which MSCs exert their effects, such as whether they can differentiate into insulin-producing cells (IPCs) before transplantation, are uncertain.

METHODS

In this study, we used three types of differentiation media over 10 d to generate IPCs from human Wharton’s jelly MSCs (hWJ-MSCs). We further transplanted the undifferentiated hWJ-MSCs and differentiated IPCs derived from them into the portal vein of rats with streptozotocin-induced diabetes, and recorded the physiological and pathological changes.

RESULTS

Using fluorescent staining and C-peptide enzyme-linked immunoassay, we were able to successfully induce the differentiation of hWJ-MSCs into IPCs. Transplantation of both IPCs derived from hWJ-MSCs and undifferentiated hWJ-MSCs had the therapeutic effect of ameliorating blood glucose levels and improving intraperitoneal glucose tolerance tests. The transplanted IPCs homed to the pancreas and functionally survived for at least 8 wk after transplantation, whereas the undifferentiated hWJ-MSCs were able to improve the insulitis and ameliorate the serum inflammatory cytokine in streptozotocin-induced diabetic rats.

CONCLUSION

Differentiated IPCs can significantly improve blood glucose levels in diabetic rats due to the continuous secretion of insulin by transplanted cells that survive in the islets of diabetic rats. Transplantation of undifferentiated hWJ-MSCs can significantly improve insulitis and re-balance the inflammatory condition in diabetic rats with only a slight improvement in blood glucose levels.

P5294Metabolically healthy obese is associated with better left atrial function and lower risk of adverse cardiovascular events including atrial fibrillation

Purpose

Metabolic syndrome (MetS) and obesity are both crucial risk factors for heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF). However, the prognostic value of utilizing left atrial (LA) deformation imaging in metabolically healthy obese (MHO) or metabolically unhealthy normal weight (MUNW) subjects remains largely unexplored.

Methods

Speckle-tracking echocardiography was used to evaluate LA strain and strain rate among 3,915 subjects free from clinical heart failure (mean age: 50.0±10.6 years, 66.2% male) undergoing annual cardiovascular health survey. Metabolically unhealthy was defined by the presence of at least one MetS component or history of cardiovascular disease. Participants were categorized as: metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy overweight/obese (MHO), metabolically unhealthy overweight/obese (MUO).

Results

Markedly decreased LA strain, early-diastolic LA strain rate and increased LA stiffness were observed with metabolic disorders (all trend p: <0.05). During a median follow-up period of 3.68 years, significantly higher risk of primary endpoints (death, heart failure, major cardiovascular events) was observed in MUO vs. MHO (HR=1.87, p=0.005) and MUNW vs. MHNW (HR=2.82, p=0.004). Similar patterns with incident AF (MUO vs MHO: HR=3.05, p=0.001, MUNW vs MHNW: HR=4.04, p=0.002) were also observed. After multivariate adjustment, risk of AF remained associated with low LA strain (β=−0.07, p<0.001), systolic LA strain rate (β:−0.05, p=0.007) and high LA stiffness (β=0.18, p<0.001).

Comparison between metabolic groups MHNW (N=1107) MUNW (N=255) p (MUNW vs MHNW) MHO (N=1859) MUO (N=694) p (MUO vs MHO) Age 48±10.57 54.29±11.52 <0.001 49±10.02 54.21±10.49 <0.001 LA GLS (%) 40.6±7.68 37.16±7.5 <0.001 36.77±7.66* 33.58±8.01‡ <0.001 LA SRs 1.79±0.41 1.76±0.48 NS 1.63±0.39* 1.55±0.41‡ <0.001 LA SRe 2.11±0.62 1.8±0.63 <0.001 1.68±0.55* 1.48±0.52‡ <0.001 LA stiffness 0.17±0.08 0.22±0.12 <0.001 0.21±0.11* 0.25±0.13‡ <0.001 *p<0.001 for MHO vs MHNW, ‡p<0.001 for MUO vs MUNW. LA GLS = left atrial global longitudinal strain, LA SRs = left atrial systolic strain rate, LA SRe = left atrial early-diastolic strain rate, NS = non-significant.

Kaplan-Meier curves of adverse events

Conclusion

Metabolic abnormality may contribute to certain aspects of mechanistic LA dysfunction tightly linked to clinical events, even with normal lean body mass. Our observations may be insightful for targeted interventions in higher-risk patients with subclinical atrial dysfunction.

[Ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes based on Robson classifications]

Objective: To investigate the ratio of transfer cesarean section after trial of labor and maternal-fetal outcomes based on Robson classifications. Methods: The delivery data by cesarean section in Third Affiliated Hospital of Guangzhou Medical University from January 1st, 2009 to December 31st, 2015 (gestational age ≥28 weeks and newborn birth weight >1 000 g) were retrospectively collected. The ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes were analyzed by weighted adverse outcome score in different Robson classifications. Results: (1) The highest ratio of transfer cesarean section after trial of labor was classification 9 (all abnormal lies, including previous cesarean section and breech were excluded) reached 47.31% (431/911) , followed by classification 2 (nulliparous women with a single cephalic pregnancy, ≥37 weeks gestation who had labour induced) accounted for 44.90%(409/911). (2)The tops of weighted adverse outcome score of transfer cesarean section after trial of labor were classification 10 (single cephalic pregnancy at <37 weeks gestation, including women with previous cesarean delivery) 24.55, classification 5 (single cephalic pregnancy multiparous women, with at least one previous cesarean delivery, ≥37weeks gestation) 3.64. Conclusion: Carefully evaluating the delivery mode and emphasizing the intrapartum management in nulliparous women with a single cephalic pregnancy, at ≥37 weeks gestation who had labour induced and trial of labor after cesarean section is essential to reduce the risk of adverse outcomes in transfer cesarean section after trial of labor.

Syncope caused by complete heart block and ventricular arrhythmia as early manifestation of systemic lupus erythematosus in a pregnant patient: a case report

Systemic lupus erythematosus (SLE) can affect all heart structures including the conduction system, with either reversible or permanent derangement. However, only a few cases of adult SLE and complete atrioventricular (AV) block have been reported. We describe a young pregnant woman who initially presented with complete AV block on electrocardiography before the diagnosis of SLE. Syncope subsequently developed during the postpartum period due to frequent nonsustained polymorphic ventricular tachycardia, suggesting lupus myocarditis. The ventricular arrhythmia was successfully treated by intravenous corticosteroids, lidocaine and implantation of a permanent pacemaker. This may represent the first report of complete AV block with polymorphic ventricular tachycardia, which was identified before the other clinical features of SLE fully manifested. SLE should be considered if a patient presents with complete AV block without other clinical features. It may warn for early diagnosis and appropriate treatment of SLE including lupus-related heart disease.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

[Analysis of 2 204 stillbirths in 11 hospitals of Guangdong province]

Objective: To analyze the incidence and causes of stillbirth in 11 hospitals of Guangdong province, and to explore the appropriate interventions. Methods: Clinical data of stillbirth in 11 hospitals of Guangdong province were collected from January 2014 to December 2016. The gestational weeks, causes, maternal conditions and other factors were analyzed. Results: (1) From 2014 to 2016, 103 472 newborns were delivered in the 11 hospitals, and the number of stillbirth was 2 204, with the incidence of 2.13%. Among them, 0.71%(738/103 472) was therapeutic induction, 1.42%(1 066/103 472) was natural stillbirth. At different gestational age (<28 weeks, 28-<37 weeks and ≥37 weeks), the incidence of stillbirth was 55.63% (1 226/2 204), 28.45% (627/2 204) and 15.92% (351/2 204), respectively, with statistically significant difference (P<0.01). (2) For stillbirth<28 weeks, the first reason was therapeutic induction, accounting for 53.34% (654/1 226). For stillbirth during 28-37 weeks, pre-eclampsia was the major cause, accounting for 40.67% (255/627). And for full-term stillbirth, the causes were umbilical cord factors (19.37%, 68/351), abnormal labor (17.09%, 60/351). (3) In all the stillbirth cases, the incidence of fetal growth restriction (FGR) <28 weeks was significantly higher than that during 28-37 weeks [23.49% (288/1 226) vs 18.02% (113/627) , P<0.01]. (4) The stillbirth rate during labor was significantly higher in women ≥35 years old than in younger women [63.88% (191/299) vs 36.12% (108/299) ; χ(2)=9.346, P=0.000]. For the causes of stillbirth during labor, the incidence of severe maternal obstetrical complications [61.11% (33/54) vs 38.89% (21/54) ; χ(2)=3.323, P=0.002], abnormal labor [65.82% (52/79) vs 34.18% (27/79) ; χ(2)=4.067, P=0.001] and abnormal fetal position [66.63% (26/39) vs 33.37% (13/39) ; χ(2)=3.002, P=0.013] were higher in women ≥35 years old than in younger women. (5) Cesarean section during labor accounted for 33.77% (101/299) of stillbirth, including 76 cases of emergency cesarean section or converted to cesarean section during labor. Conclusions: (1) The incidence of stillbirth in the 11 hospitals is high, and the causes are different at different gestational ages, therefore, different interventions are needed to reduce the incidence in different gestational weeks. Supervision of therapeutic induction should be strengthened <28 gestational weeks; standard management of pregnancy might decrease the occurrence of natural death ≥28 weeks. (2) Attention should be paid to fetal body weight during pregnancy, especially FGR. (3) The stillbirth rate is high in elderly pregnant women, so it is important to strengthen the management of the elderly pregnant women.

[Late reoperations after repaired Stanford type A aortic dissection]

Objective: To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection. Methods: From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun's procedure in 1 patient, Wheat combined with Sun's procedure in 1 patient, Bentall combined with Sun's procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun's procedure. Results: Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up. Conclusions: Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun's procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

[Risk factors analysis of reversible posterior leukoencephalopathy syndrome in pre-eclampsia or eclampsia gravida]

Objective: To investigate the risk factors of reversible posterior leukoencephalopathy syndrome (RPLS) in pre-eclampsia or eclampsia gravida. Methods: This study was conducted in the Third Affiliated Hospital of Guangzhou Medical University between January 2013 and March 2016. A total of 100 patients who had no severe neurological diseases and were diagnosed pre-eclampsia or eclampsia, and underwent brain MRI were collected retrospectively. They were divided into 2 groups according to the MRI results, the RPLS group (n=49) and the non-RPLS group (n=51). The medical history, clinical symptoms and the results of laboratory examination were analyzed by the logistic regression, in order to explore the risk factors. Results: In single factor analysis, HELLP syndrome, pregnancy associated with other diseases, poor prenatal care, grade 3 hypertension, elevated systolic blood pressure or diastolic blood pressure, elevated WBC, aspartate transaminase (AST), alanine aminotransferase (ALT), uric acid (UA) and lactate dehydrogenase (LDH), decreased platelet (PLT), headache, visual changes, seizures and conscious disturbance were more frequent in the RPLS group than those in the non-RPLS group (all P<0.05). According to the multivariate logistic regression analysis, the elevated WBC (OR=1.291, 95% CI: 1.058-1.575, P=0.012), UA (OR=1.008, 95% CI: 1.001-1.016, P=0.032) and headache (OR=18.260, 95% CI: 3.562-93.607, P=0.000) were the independent risk factors. Conclusions: Maternal history, clinical symptoms and some laboratory examinations might help in the early diagnosis of RPLS in pre-eclampsia or eclampsia gravida. Headache, the elevation of WBC and UA were the most significant factors.

[Multi-centric clinical study of trial of labor after cesarean section]

OBJECTIVE

To study the feasibility and safety of trial of labor after cesarean section (TOLAC).

METHODS

Retrospective analysis of five medical center of Guangdong province from January 2011 to December 2015 hospitalized delivery information, compare the same scar TOLAC (research group) with the scar pregnancy (control group) pregnancy outcomes, to study the feasibility and safety of TOLAC.

RESULTS

(1) During 2011-2015, total delivery 95 600 cases in five medical center, 13 824 cases of thme with uterine scar pregnancy, including 12 027 cases elective repeat cesarean section and 1 797 cases (13.00%, 1 797/13 824) with scar uterus vaginal trial of labor. Among 1 308 cases of vaginal delivery, the success for trial of labor rate was 72.79% (1 308/1 797). From 2011 to 2015, there were increased rate of pregnancy after cesarean section, which were respectively 10.71%, 13.28%, 14.45%, 15.54% and 16.98%. The will of vaginal birth were rising and the rate were respectively 11.85%, 12.25%, 13.49%, 13.82% and 12.93%. (2) There were 489 (27.21%, 489/1 797) cases of scar uterus maternal emergency cesarean section in the trial of labor, reason for "social factors" require for cesarean delivery have 68 cases, the percentage was 13.91% (68/489), compared with control group (7.18%, 206/2 869), the difference was statistically significant difference (χ(2)=27.356, P=0.000). Doctors diagnosed as "aura uterine rupture" in the labor was 11.86% (58/489), compared with that in control group (1.43%, 41/2 869), the differences were statistically significant difference (χ(2)=1 578.223, P=0.000). (3) The incidence of uterine rupture of the research group (0.74%, 9/1 211) was significantly higher than that of control group (0.01%,2/31 200; χ(2)> 2 000, P=0.000). The incidence of postpartum hemorrhage in research group was 6.94% (84/1 211), compared with that in the control group (3.05%, 951/31 200), there was statistically significant difference (χ(2)=16.328, P=0.000). While, there were no statistical significancefor the labor time limit, birth rate of severe asphyxia and neonatal birth weight average differences between two groups (P>0.05).

CONCLUSIONS

The rate of pregnancy after cesarean section is increasing year by year, and the will of vaginal birth is increasing, while it still are generally low. TOLAC is safe and feasible, but also significantly higher risk, strictly labor monitoring and can proceed fast cesarean delivery in delivery room is an important guarantee of safe delivery.

Endoscopic Holmium:YAG laser-assisted lithotripsy: A Preliminary Report

PROBLEM/OBJECTIVE

Laser-assisted lithotripsy under sialendoscopy has the potential to overcome the limitations of traditional sialendoscopic lithotripsy when facing salivary stones. In this preliminary study, we report our experience with Holmium:YAG laser-assisted lithotripsy.

METHODS

Data from 11 Asian patients receiving sialendoscopies for laser-assisted lithotripsy performed in our department from August 2013 to June 2014 were recorded and reviewed.

RESULTS

A total of 18 procedures were performed in 11 Taiwanese patients with symptoms of obstructive sialoadenitis who were diagnosed with sialolithiasis. The sizes of the stones ranged between 3 mm and 13 mm. The endoscopic lithotomy procedures were performed in all 11 patients, and stone fragmentation with the Holmium:YAG laser was done successfully in all patients. All patients were followed for a minimum of 3 months, and there was no evidence of complications or recurrences over the follow up period.

CONCLUSION

The Holmium:YAG laser allowed successful fragmentation of stones in all 11 patients. Our experience with this procedure supports the use of Holmium:YAG laser-assisted lithotripsy through sialendoscopy in Asian patients.

Undifferentiated Wharton's Jelly Mesenchymal Stem Cell Transplantation Induces Insulin-Producing Cell Differentiation and Suppression of T-Cell-Mediated Autoimmunity in Nonobese Diabetic Mice

Type 1 diabetes mellitus is caused by T-cell-mediated autoimmune destruction of pancreatic β-cells. Systemic administration of mesenchymal stem cells (MSCs) brings about their incorporation into a variety of tissues with immunosuppressive effects, resulting in regeneration of pancreatic islets. We previously showed that human MSCs isolated from Wharton's jelly (WJ-MSCs) represent a potential cell source to treat diabetes. However, the underlying mechanisms are unclear. The purpose of this study was to discern whether undifferentiated WJ-MSCs can differentiate into pancreatic insulin-producing cells (IPCs) and modify immunological responses in nonobese diabetic (NOD) mice. Undifferentiated WJ-MSCs underwent lentiviral transduction to express green fluorescent protein (GFP) and then were injected into the retro-orbital venous sinus of NOD mice. Seven days after transplantation, fluorescent islet-like cell clusters in the pancreas were apparent. WJ-MSC-GFP-treated NOD mice had significantly lower blood glucose and higher survival rates than saline-treated mice. Systemic and local levels of autoaggressive T-cells, including T helper 1 cells and IL-17-producing T-cells, were reduced, and regulatory T-cell levels were increased. Furthermore, anti-inflammatory cytokine levels were increased, and dendritic cells were decreased. At 23 days, higher human C-peptide and serum insulin levels and improved glucose tolerance were found. Additionally, WJ-MSCs-GFP differentiated into IPCs as shown by colocalization of human C-peptide and GFP in the pancreas. Significantly more intact islets and less severe insulitis were observed. In conclusion, undifferentiated WJ-MSCs can differentiate into IPCs in vivo with immunomodulatory effects and repair the destroyed islets in NOD mice.

Effect of age and biological subtype on the risk and timing of brain metastasis in breast cancer patients

BACKGROUND

Brain metastasis is a major complication of breast cancer. This study aimed to analyze the effect of age and biological subtype on the risk and timing of brain metastasis in breast cancer patients.

PATIENTS AND METHODS

We identified subtypes of invasive ductal carcinoma of the breast by determining estrogen receptor, progesterone receptor and HER2 status. Time to brain metastasis according to age and cancer subtype was analyzed by Cox proportional hazard analysis.

RESULTS

Of the 2248 eligible patients, 164 (7.3%) developed brain metastasis over a median follow-up of 54.2 months. Age 35 or younger, HER2-enriched subtype, and triple-negative breast cancer were significant risk factors of brain metastasis. Among patients aged 35 or younger, the risk of brain metastasis was independent of biological subtype (P = 0.507). Among patients aged 36-59 or >60 years, those with triple-negative or HER2-enriched subtypes had consistently increased risk of brain metastasis, as compared with those with luminal A tumors. Patients with luminal B tumors had higher risk of brain metastasis than luminal A only in patients >60 years.

CONCLUSIONS

Breast cancer subtypes are associated with differing risks of brain metastasis among different age groups. Patients age 35 or younger are particularly at risk of brain metastasis independent of biological subtype.

Effects of CYP3A5 and CYP2D6 genetic polymorphism on the pharmacokinetics of diltiazem and its metabolites in Chinese subjects

PURPOSE

To assess the possibility of using CYP2D6 10 +/- CYP3A5*3 as biomarkers to predict the pharmacokinetics of diltiazem and its two metabolites among healthy Chinese subjects. METHODS 41 healthy Chinese were genotyped for CYP3A5 3 and CYP2D6 10, and then received a single oral dose of diltiazem hydrochloride capsules (300 mg). Multiple blood samples were collected over 48 h, and the plasma concentrations of diltiazem, N-desmethyl diltiazem and desacetyl diltiazem were determined by HPLC-MS/MS. The relationships between the genotypes and pharmacokinetics were investigated.

RESULTS

The pharmacokinetics of diltiazem, N-desmethyl diltiazem were not significantly affected by both CYP3A5 3 and CYP2D6*10 alleles. However, the systemic exposure of the pharmacologyically active metabolites, desacetyl diltiazem, was 2-fold higher in CYP2D6 10/10 genotype carriers than in 1/10 or 1/1 ones (AUC(o-inf) of CYP2D6 1/1, 1/10 and 10/10 are 398.2 +/- 162.9, 371,0 69.2 and 726.2 +/- 468.1 respectively, p <0.05).

CONCLUSIONS

Two of the most frequent alleles, CYP3A5 3 and CYP2D6 10, among Chinese do not have major impacts on the disposition of diltiazem and N-desmethyl diltiazem. However, the desacetyl diltiazem showed 2-fold accumulation in individuals with CYP2D6 10/10 genotype. Despite this, the effect of genotype of CYP2D6 on clinical outcome of diltiazem treatment is expected to be limited.

Reappraisal of pancreatic adenocarcinoma undergoing pancreaticoduodenectomy

BACKGROUND/AIMS

This study is to reappraise the clinical presentations, surgical and survival outcomes of pancreatic head adenocarcinoma.

METHODOLOGY

Data of pancreatic head adenocarcinomas undergoing pancreaticoduodenectomy were reappraised and compared between period 1 (1984-1996) and period 2 (1997-2009).

RESULTS

Surgical mortality was 3.6% in period 2 and 5.0% in period 2. The surgical morbidity was 35.7% in period 1, 35.3% in period 2. Pancreatic leakage was significantly lower (3.4%) in pancreaticogastrostomy group, as compared to 11.7% in pancreaticojejunostomy. There was 57.5% positive lymph node involvement and 77.4% perineural invasion. More patients underwent adjuvant or palliative chemotherapy in period 2 (42.2%) than in period 1 (14.8%). The 5-year survival for resected pancreatic head adenocarcinoma was 3.7% in period 1 and 11.1% in period 2. The 5-year survival after curative resection in period 1 was significantly lower than that in period 2 (4.2% vs. 14.7%).

CONCLUSIONS

Although surgical mortality has significantly decreased recently, pancreaticoduodenectomy continues to be a complex and technically-demanding procedure with high and unchanged surgical morbidity. The poor survival outcome of pancreatic head adenocarcinoma might be a combined reflection of difficulty in early detection, aggressive biological behavior of tumor itself and complex surgical anatomy for resection.

Diagnostic and therapeutic dilemmas in periampullary lesions

BACKGROUND/AIMS

Periampullary lesions often present diagnostic and therapeutic dilemmas. This study is to clarify the justification of pancreaticoduodenectomy for the resectable periampullary lesion without histological confirmation of malignancy.

METHODOLOGY

Clinical data for periampullary lesions with presumed malignancy were retrieved from our prospectively-collected computer database. The surgical risks and test performance characteristics in diagnosis were determined.

RESULTS

There were 636 patients undergoing pancreaticoduodenectomy, including 572 with malignancy and 64 (10.1% false positive rate) with benign lesions. No resection was attempted for 32 patients, but 8 (25% false negative rate) eventually turned out to be malignant. Our data showed a sensitivity of 98.6% (572/580), a specificity of 27% (24/88) and an accuracy of 89.2% (596/668) in detecting periampullary malignancy. The surgical risks after pancreaticoduodenectomy were significantly lower in the benign group, with 28.1% morbidity (vs. 43.7% in the malignant group), no pancreatic leakage (vs. 11.5% in malignant group) and no surgical mortality (vs. 7.3% in the malignant group).

CONCLUSIONS

Pancreaticoduodenectomy is justified for a periampullary lesion without histological confirmation whenever malignancy is suspected. Moreover, a nihilistic approach could be associated with a significant false negative rate (25%) if left unresected and might preclude a patient with periampullary malignancy from cure.

Solitary neurofibroma of the pancreas body not associated with type 1 neurofibromatosis

Neurofibromas arise from peripheral nerve cells. They are rarely found within the pancreas, especially not associated with type I neurofibromatosis. Here, we report a case of a neurofibroma in a 44-year-old woman who initially presented with epigastralgia. Imaging revealed one large cystic mass of 5.7 × 8 × 5.8 cm in the pancreatic body, which was resected with distal pancreatectomy. The postoperative course of treatment was without complication, and no signs of recurrence were observed after 1 year and 6 months' follow-up.

Remodeling of rabbit abdominal aorta and Cx43 gap junctions after stent placement: effect of balloon injury plus cholesterol-enriched diet

AIM

To examine the effect of stenting and cholesterol-enriched diet (CED) on vascular remodeling, including the expression of connexin43 (Cx43) gap junctions in smooth muscle cells (SMC).

METHODS

Rabbits abdominal aortae were either implanted stent made of 316 stainless steel (group 1) or denuded followed by stent placement 28 days later (groups 2 and 3). Animals were given normal chow except those of group 3, which were fed CED after the denudation. Eight weeks later, the development of neointima and the expression of connexin43 (Cx43) were examined. In parallel, human aortic SMC were grown on 316 stainless steel or treated with C-reactive protein (CRP) followed by analysis of Cx43.

RESULTS

The results showed that, serum CRP levels became transiently elevated after denudation and stent implantation. For the stented aortic segments, the dimensions of neointima were group 3 > group 2 > group 1 (P<0.05). In groups 1 and 2, Cx43 gap junctions are less in amount in neointima of the stented segment, compared to the unstented upstream neointima or medial layer (all P<0.01). In culture experiments, Cx43 in SMC grown on stent material was up-regulated in growth medium but down-regulated in differentiation medium, and CRP did not affect Cx43 expression.

CONCLUSION

Vascular remodeling post stent implantation varied according to the presence of balloon injury, CED, or both. Cx43 expression in SMC is altered after exposure to stent and the regulation depended on the milieu.

Photoconduction mechanism of oxygen sensitization in InN nanowires

The photoconduction (PC) mechanism in indium nitride (InN) nanowires (NWs) has been investigated via environment-, temperature-, and power-dependent measurements. The adsorbed oxygen-induced modulation of the surface state is proposed to be the leading factor in the long lifetime or high gain transport and in sensitizing photocurrent generation in the InN NWs. The electron trapping effect by adsorbed oxygen can be verified by the increased activation energy from 33 ± 4 (in vacuum) to 58 ± 2 meV (in oxygen). The observed supralinear power dependence of photocurrent also suggests the presence of acceptor states that influence the carrier recombination behavior and compensate the thermal carriers in the InN NWs. The potential influence of native oxide on the molecule-sensitive PC in this nitride nanomaterial is also inferred.

Surgical anatomy of the external branch of the superior laryngeal nerve in Chinese adults and its clinical applications

BACKGROUND

The purpose of this study was to determine the anatomic features of the external branch of the superior laryngeal nerve (EBSLN) in Chinese adults.

METHODS

We analyzed the anatomic distribution of the 86 EBSLNs in 43 cadavers.

RESULTS

The incidences of the EBSLN in the thyroid area were 94.2% and 91.3% on the right and left sides, respectively. In accord with the Cernea classification, type 1 was 16.2%, type2a was 39.5%, and type 2 was 38.3%. There were no significant differences between the right and the left side. The high-risk position of the EBSLN was 77.8%.

CONCLUSIONS

The inferior cornu of the thyroid cartilage was a reliable landmark in identifying the external branch of superior laryngeal nerve. Racial variations between the white and the Chinese should be taken into consideration for an explanation of the differences.

Systemic amyloidosis manifesting as a rare cause of hepatic failure

In 1854, the term "amyloid" was first used in the description of a liver specimen at autopsy by Virchow. The kidneys and heart are the most commonly involved organs in amyloidosis; liver and gastrointestinal tract involvement is less common, and the symptoms are usually mild. Here, we report the case of a 57-year-old male patient who presented with oral hemorrhagic bullae, thrombocytopenia and jaundice. Disseminated intravascular coagulation profile was positive. Abdominal sonography showed ascites, and abdominal computed tomography disclosed heterogeneous enhancement of the liver, with focal low attenuation regions and splenomegaly with poor contrast enhancement. Liver decompensation was highly suspected. Diagnostic laparoscopy with liver biopsy and colonoscopic biopsy from the rectum were subsequently performed. Typical apple-green birefringence was demonstrated on polarized light microscopy by Congo red staining. Systemic amyloidosis was diagnosed and colchicine prescribed. However, liver function deteriorated and intermittent gastrointestinal bleeding was found during the patient's hospitalization. The patient died due to uncorrectable coagulopathy and massive gastrointestinal bleeding. The final diagnosis was idiopathic amyloidosis with hepatic failure. Although amyloidosis rarely presents with hepatic failure, it should be considered in patients with signs of liver decompensation. Clinicians should be aware of this rare but potentially lethal presentation and arrange appropriate treatment promptly.

Pseudoaneurysm of the iliac artery secondary to Aspergillus infection after kidney transplantation

Infectious complications are the top causes of morbidity and mortality in patients who undergo renal transplantation. We report a patient who received a cadaveric renal transplant in Mainland China. One year post-transplantation, the patient had right buttock pain with radiation to the leg. Swelling and tenderness over the right groin was also found. Magnetic resonance imaging revealed a multilobulated cystic lesion, about 8 x 7 cm, at the right iliac fossa and presacral region extending to the posterior aspect of the graft kidney and up to the right psoas muscle. Drainage of the intra-abdominal abscess was performed. The abscess culture showed presence of Aspergillus spp. The patient had received steroids, tacrolimus and mycophenolate mofetil, which could be a risk factor for fungal infection. The cause of Aspergillus infection in our patient remains unclear. It may have been due to immune system insufficiency of the patient rendering the patient prone to infection. Pseudoaneurysm formation of the internal iliac artery following Aspergillus infection after kidney transplantation is rarely reported. Although it is a dilemma, once a severe situation such as pseudoaneurysm with aspergillosis presents, graft removal is suggested.

Risk factors for post-pancreaticoduodenectomy bleeding and finding an innovative approach to treatment

BACKGROUND

This study is to determine the risk factors and outcome for post-pancreaticoduodenectomy bleeding, and to assess the roles of surgery and intravascular intervention in its management.

METHODS

Post-pancreaticoduodenectomy data of 628 patients were analyzed with regards to post-pancreaticoduodenectomy bleeding.

RESULTS

Post-pancreaticoduodenectomy bleeding occurred in 58 patients (9.2%) and led to death in 23 patients. Pancreatic leakage and intra-abdominal abscess were independent risk factors for both extraluminal and intraluminal post-pancreaticoduodenectomy bleeding. The most common source of bleeding was the gastroduodenal artery (n = 9, 24.3%), and 8 of these patients (88.9%) experienced gastroduodenal artery bleeding in late post-pancreaticoduodenectomy bleeding. Hemostasis for post-pancreaticoduodenectomy bleeding was achieved by surgery in 22 patients (78.6%) and intravascular intervention in 7 patients (58.3%). Transarterial embolization for gastroduodenal artery bleeding did not deteriorate liver function in most patients except for 1 who died of hepatic failure.

CONCLUSIONS

The placement of metallic clips on the gastroduodenal artery stump during a pancreaticoduodenectomy is helpful in identifying overlooked intermittent sentinel bleeding during angiography. Transarterial embolization for gastroduodenal artery bleeding could not guarantee against hepatic failure. The intravascular placement of a covered stent is the preferred procedure to avoid the complete interruption of arterial blood supply to the liver.

Transforming growth factor-beta induces CD44 cleavage that promotes migration of MDA-MB-435s cells through the up-regulation of membrane type 1-matrix metalloproteinase

CD44, a transmembrane receptor for hyaluronic acid, is implicated in various adhesion-dependent cellular processes, including cell migration, tumor cell metastasis and invasion. Recent studies demonstrated that CD44 expressed in cancer cells can be proteolytically cleaved at the ectodomain by membrane type 1-matrix metalloproteinase (MT1-MMP) to form soluble CD44 and that CD44 cleavage plays a critical role in cancer cell migration. Here, we show that transforming growth factor-beta (TGF-beta), a multifunctional cytokine involved in cell proliferation, differentiation, migration and pathological processes, induces MT1-MMP expression in MDA-MB-435s cells. TGF-beta-induced MT1-MMP expression was blocked by the specific extracellular regulated kinase-1/2 (ERK1/2) inhibitor PD98059 and the specific phosphoinositide 3-OH kinase (PI3K) inhibitor LY294002. In addition, treatment with SP600125, an inhibitor for c-Jun NH(2)-terminal kinase (JNK), resulted in a significant inhibition of MT1-MMP production. These data suggest that ERK1/2, PI3K, and JNK likely play a role in TGF-beta-induced MT1-MMP expression. Interestingly, treatment of MDA-MB-435s cells with TGF-beta resulted in a colocalization of MT1-MMP and CD44 in the cell membrane and in an increased level of soluble CD44. Using an electric cell-substrate impedance sensing cell-electrode system, we demonstrated that TGF-beta treatment promotes MDA-MB-435s cell migration, involving MT1-MMP-mediated CD44 cleavage. MT1-MMP siRNA transfection-inhibited TGF-beta-induced cancer cell transendothelial migration. Thus, this study contributes to our understanding of molecular mechanisms that play a critical role in tumor cell invasion and metastasis.

Ordered YBCO sub-micron array structures induced by pulsed femtosecond laser irradiation

We report on the formation of organized sub-micron YBa(2)Cu(3)O(7) (YBCO) dots induced by irradiating femtosecond laser pulses on YBCO films prepared by pulse laser deposition with fluence in the range of 0.21 approximately 0.53 J/cm(2). The morphology of the YBCO film surface depends strongly on the laser fluences irradiated. At lower laser fluence (approximately 0.21 J/cm(2)) the morphology was pattern of periodic ripples with sub-micrometer spacing. Slightly increasing the laser fluence to 0.26 J/cm(2) changes the pattern into organized sub-micron dots with diameters ranging from 100 nm to 800 nm and height of 150 nm. Further increase of the laser fluence to over 0.32 J/cm(2), however, appeared to result in massive melting and led to irregular morphology. The mechanism and the implications of the current findings will be discussed. Arrays of YBCO sub-micron dots with T(c) = 89.7 K were obtained.

Glycine N-methyltransferase is a favorable prognostic marker for human cholangiocarcinoma

BACKGROUND AND AIM

Glycine N-methyltransferase (GNMT) is a susceptibility gene for human hepatocellular carcinoma (HCC). We previously reported that GNMT expression is diminished in HCC. Here we report our examination of GNMT expression patterns in cholangiocarcinoma and the relationship between its expression and prognosis.

METHODS

We analyzed GNMT expression in tumor tissues from 33 cholangiocarcinoma patients (19 male) using immunohistochemistry (IHC) procedures with a GNMT monoclonal antibody (mAb 4-17). GNMT expression intensity and percentages were scored on a scale of 0 to 6. The association between GNMT expression and survival was analyzed using the Kaplan-Meier method, and prognostic factors were evaluated with a multivariate Cox proportional hazards regression model.

RESULTS

High GNMT expression was found in epithelial cells of normal bile ducts. Six of 33 (18.2%) cholangiocarcinoma tissues had no GNMT expression. A statistically significant difference was noted in GNMT expression between male and female patients (68.4% vs 100%, P < 0.05). Compared to patients with GNMT expression scores > 3, the death hazard ratio for patients with GNMT scores <or= 3 was 3.68 (95% confidence interval = 1.17-11.59, P < 0.05).

CONCLUSIONS

GNMT expression is a favorable prognosis predictor for cholangiocarcinoma.

Comparison between pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy

BACKGROUND/PURPOSE

Pancreatic leakage is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) has been reported to be associated with a lower pancreatic leakage rate and morbidity rate than pancreaticojejunostomy (PJ). This study compared the preoperative characteristics, surgical risk factors, intraoperative parameters, and postoperative outcome between PJ and PG.

METHODS

From March 1992 to March 2005, a comparative study between PJ and PG for patients with periampullary lesions undergoing PD was conducted. A total of 377 consecutive patients underwent PD. Among them, 188 patients underwent PJ and 189 underwent PG.

RESULTS

The overall mortality, morbidity and pancreatic leakage following PD were 5%, 45.1% and 10.6%, respectively. The mortality, morbidity and pancreatic leakage were 8.9%, 56.4% and 17.6% in the PJ group, and 2.1%, 33.9% and 3.7% in the PG group (p < 0.001). Mean operative time was 9.3 hours versus 6.7 hours (p < 0.001), mean blood loss was 1032 mL versus 891 mL (p = 0.064) and mean hospital stay was 34.8 days versus 26.1 days (p < 0.001) in the PJ and PG groups, respectively. PJ, soft pancreas, pancreatic duct stenting, low surgical volume (< 20) and age (> 65 years) were identified as risk factors for pancreatic leakage, while PJ, soft pancreas, pancreatic duct stenting and low surgical volume (< 20) were four significant risk factors for surgical morbidity. Further, PJ, pancreatic leakage, low surgical volume (< 20) and age (> 65 years) were identified to be surgical risk factors for mortality.

CONCLUSION

PG is a safer method than PJ following PD as a significantly lower rate of pancreatic leakage, surgical morbidity and mortality, shorter operation time, and shorter postoperative hospital stay are reported.

Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy

BACKGROUND

To provide optimal selection of patients for preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiography, we evaluated simple, noninvasive biochemical parameters as screening tests to predict the absence of common bile duct stones prior to laparoscopic cholecystectomy.

METHODS

A total of 1002 patients underwent laparoscopic cholecystectomy. Five biochemical parameters were measured preoperatively: gamma glutamyl transferase (GGT), alkaline phosphatase, total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Conventional diagnostic tests, including ultrasound imaging, computed tomography, magnetic resonance imaging, common bile duct diameter, endoscopic retrograde cholangiopancreatography, and serum amylase were performed. Along with the five biochemical tests above, these diagnostic tests were scrutinized and compared as potential predictors for common bile duct stones.

RESULTS

Eighty-eight (8.8%) patients with gallstone disease who underwent laparoscopic cholecystectomy had concurrent common bile duct stones. Among all diagnostic tests, endoscopic retrograde cholangiopancreatography had the highest sensitivity (96.0%), specificity (99.1%), probability ratio (107.3), accuracy (98.0%), and positive predictive value (98.8%) in detecting common bile duct stones. At least one abnormal elevation among the five biochemical parameters had the highest sensitivity (87.5%). Total bilirubin had the highest specificity (87.5%), highest probability ratio (3.9), highest accuracy (84.1%), and highest positive predictive value (27.4%). All five biochemical predictors had high negative predictive values; gamma glutamyl transferase was highest (97.9%), while the lowest was total bilirubin (94.7%). Multivariate analysis showed only gamma glutamyl transferase, alkaline phosphatase, and total bilirubin to be independent predictors; gamma glutamyl transferase appeared to be the most powerful predictor (odds ratio 3.20).

CONCLUSION

Biochemical tests, especially gamma glutamyl transferase with 97.9% negative predictive value, are ideal noninvasive predictors for the absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. We suggest that unnecessary, costly, or risky procedures such as endoscopic retrograde cholangiopancreatography can be omitted prior to laparoscopic cholecystectomy in patients without abnormal elevation of these biochemical values.

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy

OBJECTIVES

Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups.

METHODS

We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate.

RESULTS

The mean follow-up time for PG and PJ were 37 +/- 23 and 103 +/- 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056).

CONCLUSIONS

There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Amyand's Hernia - Case Report and Review of the Literature

Amyand's hernia is an extremely rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis is much less common in this situation and few reports are found in the literature. We report a case of acute appendicitis with the tip of the appendix incarcerated outside the external ring of the right groin. A mobilized cecum and ascending colon were noticed during surgery. We conducted a review of the literature, emphasizing possible causes and suggesting a predisposing factor for the condition.

Gastric body partition for giant perforated peptic ulcer in critically ill elderly patients

BACKGROUND

To prevent or minimize leakage after simple closure of giant perforated peptic ulcers in critically ill elderly patients, we conducted a clinical study using gastric body partition to prevent upstream gastric juice and food from passing through the sutured ulcer.

METHODS

Ten critically ill elderly patients with giant (> 2.5 m) perforated peptic ulcer were included in the study of gastric body partition.

RESULTS

The patients' mean age was 78.2 years and mean delay in treatment was 95.6 hours. None of the 10 patients had major complications after operation, although minor leakage of the sutured ulcer occurred in 4 patients. Only one patient presented with recurrent anastomotic ulcer and one patient died 28 days after surgery.

CONCLUSIONS

Gastric body partition and gastrojejunostomy, in addition to simple closure of a giant perforated peptic ulcer, could be a quick, easy, and potentially effective alternative to avoid or at least to minimize leakage of the sutured ulcer. Moreover, gastric body partition, unlike antral partition, might not necessarily increase risks of hypergastrinemia and marginal ulcer.

Long-term follow-up study of surgical treatment for pancreatic stones

BACKGROUND/AIMS

With rare incidence and lack of extensive study for pancreatic stones, some issues in this area remain to be clarified. Surgical experience for pancreatic stones was presented, particularly focusing on the surgical risk and long-term outcome. We also evaluated the role of the pancreatic stone in pancreatitis and pancreatic cancer.

METHODOLOGY

Data of patients with pancreatic stones are analyzed between 1984 and 2002, with a median follow-up period of 67 months. Clinical features and characteristics of pancreas and pancreatic stone are evaluated. Diagnostic image studies are compared. Outcome measures are surgical risks including surgical morbidity and mortality, and degree of long-term symptom control.

RESULTS

There were 18 patients with pancreatic stones. The etiology was idiopathic in 50% of cases, and alcoholism in 33.3%. Abdominal pain was the most common (100%) clinical presentation. Pancreatic cancer was found in 4 (22.2%) patients. Most (61.1%) of the pancreatic stones were located in the pancreatic head. Only 1 patient had a single pancreatic stone, and 12 (66.7%) patients had more than 3 pancreatic stones. All the patients except one (94.4%) presented pictures of chronic pancreatitis. Surgical complication occurred in 2 (11.8%) patients, and surgical mortality in 1 (5.9%) resulting from pneumonia. Improvement of clinical symptoms after surgery was achieved in nearly all (93.8%) patients, including 56.3% free of symptoms, 25.0% much improvement and 12.5% mild improvement.

CONCLUSIONS

Removal of pancreatic stones combined with surgical drainage of pancreatic duct or resection of pancreas might have symptomatic benefits. Surgical intervention is recommended for all patients with pancreatic stones, in terms of symptom relief, cancer risk and low surgical risk.

Retroperitoneal bronchogenic cyst mimicking pancreatic cystic lesion

Retroperitoneal bronchogenic cyst is detected extremely rarely and often masquerades as other diseases. Here, we report 2 cases of retroperitoneal bronchogenic cyst mimicking pancreatic mucinous tumor. Histologically, both cysts were composed of ciliated respiratory-like epithelium with abundant mucin content, smooth muscle bundles and mature cartilage, compatible with the diagnosis of retroperitoneal bronchogenic cyst. In addition to these 2 cases, another 42 retroperitoneal bronchogenic cysts reported in the English literature were collected for review and analysis. Twelve (28%) were located over the peripancreatic area. Just over half (51%) of them were asymptomatic. No accurate preoperative diagnosis could be made for any of the lesions. About a third (33.3%) of the peripancreatic retroperitoneal bronchogenic cysts masqueraded as pancreatic cystic lesions.

Effect of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy

BACKGROUND/AIMS

Preoperative biliary drainage (PBD) in jaundiced patients undergoing pancreaticoduodenectomy remains controversial.

METHODOLOGY

Retrospective analysis of 313 patients undergoing pancreaticoduodenectomy between 1991 and 2004 was performed. Patients were stratified into PBD and no preoperative biliary drainage (NPBD) groups. Perioperative morbidity and mortality were evaluated and surgical risks compared. Nine retrospective studies were also evaluated.

RESULTS

PBD was performed in 210; 103 had NPBD. Common indications for PBD were jaundice and cholangitis. Postoperative complications occurred in 153; 20 died postoperatively. PBD patients were older and predominantly male. Cholangitis, low albumin, and higher preoperative bilirubin were increased in PBD. Pancreatic leakage and postoperative hospital days were increased in NPBD. Wound infection occurred more frequently in PBD, but this was not significant. Perioperative mortality rate was 6.7% in PBD compared to 5.8% in NPBD. Postoperative complication rate was 45.7% for PBD and 55.3% for NPBD. Twelve PBD patients had procedure-related complications. Of 2391 patients pooled from the nine reviews and our study (1516 PBD and 875 NPBD), no significant difference was observed in postoperative mortality and overall complications. Wound infection was significantly increased in PBD (p<0.001).

CONCLUSIONS

Preoperative biliary drainage did not increase postoperative morbidity and mortality rate in pancreaticoduodenectomy patients, but should be used judiciously.

Portal vein entrance of splenic erythrocytic progenitor cells and local hypoxia of liver, two events cause intrahepatic splenosis

Intrahepatic splenosis is a rare disorder of ectopic erythropoiesis in the liver. Although traumatic splenic rupture is the common factor in public cases, the mechanism of long latency is still unknown. The correlation between aging and hepatitis virus infection with the diagnosed occurrence was reported in a limited number of cases; nevertheless, it suggested that ectopic erythropoiesis in the liver could be induced by the hepatic disorder. Based on the susceptibility of the splenic erythropoiesis response to hypoxia and the inevitability of hypoxia caused by aging or pathological changes, we hypothesized that the two events caused the occurrence of the intrahepatic splenosis, the migration of the erythrocytic progenitor cells via the portal vein following traumatic splenic rupture, and the local induction of erythropoiesis by hypoxia.

Gastric body partition to avoid ulcerogenic risk and hypergastrinemia

BACKGROUND

For treatment of giant perforated peptic ulcers, we hypothesized that partitioning of the gastric body instead of the antrum would prevent hypergastrinemia and minimize ulcerogenic risk. By maintaining part of the acid-secreting gastric body in continuity with the excluded distal stomach, gastrin-secreting cells in the antrum would still be inhibited by gastric acid secretion from the gastric body.

METHODS

We studied (1) gastric body partition with gastrojejunostomy in 8 critically ill patients with giant perforated peptic ulcers and (2) the influence of gastric partition on serum gastrin in 18 dogs with gastric antral partition + gastrojejunostomy, or gastric body partition + gastrojejunostomy, or gastrotomy.

RESULTS

No patient developed major postoperative complications. Serum gastrin levels were normal in 6 patients but showed an abnormal increase in 2 patients 1 month after gastric body partition. Serum gastrin levels had returned to the normal range at postoperative follow-up after 2 years. In the animal study, serum gastrin levels and the number of G-cells in the excluded antrum and acid-secreting parietal cells in the gastric body were increased when evaluated on day 60 postoperatively or after antral partition, compared with preoperative data in the same group. These changes did not occur in the group undergoing partition of the gastric body and the group undergoing gastrostomy. Postoperative serum gastrin levels, and the number of G-cells and parietal cells also was significantly greater in the antral partition group than in the other 2 groups. No ulcer was found in any dog in the gastric body partition and gastrostomy groups, but ulcers occurred in 4 dogs in the antral partition group, all of whom died of ulcer perforation.

CONCLUSIONS

Gastric body partition + gastrojejunostomy is a simple, dependable procedure for patients with perforated giant peptic ulcers. This procedure does not require extreme expertise and can be performed in a very short time, even by a trainee general surgeon in emergency.