Isolated gallbladder rupture following blunt abdominal injury

Isolated traumatic gallbladder rupture subsequent to blunt abdominal injury is rare. Most literatures on the subjects consist of case reports. We reported a rare case of isolated gallbladder rupture and discussed the possible predisposing factors to gallbladder rupture.

Glycemic index, glycemic load, dietary carbohydrate, and dietary fiber intake and risk of liver and biliary tract cancers in Western Europeans

BACKGROUND

The type and quantity of dietary carbohydrate as quantified by glycemic index (GI) and glycemic load (GL), and dietary fiber may influence the risk of liver and biliary tract cancers, but convincing evidence is lacking.

PATIENTS AND METHODS

The association between dietary GI/GL and carbohydrate intake with hepatocellular carcinoma (HCC; N = 191), intrahepatic bile duct (IBD; N = 66), and biliary tract (N = 236) cancer risk was investigated in 477 206 participants of the European Prospective Investigation into Cancer and Nutrition cohort. Dietary intake was assessed by country-specific, validated dietary questionnaires. Hazard ratios and 95% confidence intervals were estimated from proportional hazard models. HBV/HCV status was measured in a nested case-control subset.

RESULTS

Higher dietary GI, GL, or increased intake of total carbohydrate was not associated with liver or biliary tract cancer risk. For HCC, divergent risk estimates were observed for total sugar = 1.43 (1.17-1.74) per 50 g/day, total starch = 0.70 (0.55-0.90) per 50 g/day, and total dietary fiber = 0.70 (0.52-0.93) per 10 g/day. The findings for dietary fiber were confirmed among HBV/HCV-free participants [0.48 (0.23-1.01)]. Similar associations were observed for IBD [dietary fiber = 0.59 (0.37-0.99) per 10 g/day], but not biliary tract cancer.

CONCLUSIONS

Findings suggest that higher consumption of dietary fiber and lower consumption of total sugars are associated with lower HCC risk. In addition, high dietary fiber intake could be associated with lower IBD cancer risk.

Prospective analysis of KRAS wild-type patients with metastatic colorectal cancer using cetuximab plus FOLFIRI or FOLFOX4 treatment regimens

Cetuximab, a monoclonal antibody targeting epidermal growth factor receptor, has proven to be efficient in the treatment of metastatic colorectal cancer. We made a prospective study of the efficacy and toxicities of cetuximab-combination first-line (FOLFOX4) versus second/third-line (FOLFIRI) chemotherapy in 98 KRAS wild-type patients who had metastatic colorectal cancer. Wild-type KRAS had been identified by direct sequencing. Associations between clinical response/progression-free survival/overall survival/toxicities and cetuximab-combination chemotherapy timing were evaluated. The overall response rate was significantly higher for first-line treatment than for second/third-line treatment (relative risk = 1.707, 95% confidence interval = 1.121-2.598). Both progression-free survival and overall survival indicated significantly longer survival of first-line treatment than second/third-line treatment patients. This study is a validation of a molecular analysis of KRAS wild-type status for the prediction of response to cetuximab-combination chemotherapy for metastatic colorectal cancer patients; its predictive role was less prominent in the second/third-line than in the first-line treatment patients.

The impact of body mass index on laparoscopic cholecystectomy in Taiwan: an oriental experience

BACKGROUND/PURPOSE

The outcome analysis of obese patients undergoing laparoscopic cholecystectomy (LC) in Asia-Pacific countries is rarely reported. This study examined associations between body mass index (BMI) and clinical outcomes of elective LC in Taiwan.

METHODS

A total of 627 patients with gallbladder disease due to gallstones undergoing LC were divided into three groups based on BMI: <25.0 kg/m2 (normal, NO; n = 310), 25.0-29.9 kg/m2 (overweight, OW; n = 252), and >30 kg/m2 (obese, OB; n = 65).

RESULTS

Both overweight and obesity were not associated with conversion and complication rates. The conversion rates of the three groups were 5.5 (NO), 6.0 (OW), and 4.6% (OB), and the complication rates were 3.2 (NO), 2.4% (OW), and 4.6% (OB), respectively. However, overweight and obesity were related to a trend toward longer operating time (NO 67.4 +/- 31.8; OW 77.8 +/- 35.6; OB 79.0 +/- 37.9 min) (P trend <0.001). One death (BMI 40.6 kg/m2) was due to septic complications. In the multivariable logistic analysis, only acute cholecystitis, but not BMI, was a predictor for conversion and complications.

CONCLUSIONS

Based on these results, it appears that BMI was not associated with clinical outcomes and that LC is a safe procedure in obese patients with uncomplicated gallstone disease in Taiwan.

Bacteriology and antimicrobial susceptibility in biliary tract disease: an audit of 10-year's experience

Cholelithiasis, choledocholithiasis and hepatolithiasis are common biliary tract diseases. These diseases may cause severe infection and/or sepsis. In addition to surgical treatments, prompt administration of appropriate antibiotic is important to control the biliary tract infection. The purpose of this study is to illustrate the bacteriology in biliary tract disease and provide information for antibiotic choices. From Jan 1991 to Aug 2000, 1394 patients including gallbladder (GB) stones, common bile duct (CBD) stones, intrahepatic duct (IHD) stones, GB polyps and biliary malignancy were subjects for this retrospective study. The overall positive rate of bile culture is 36% in this study while it was 25%, 66%, 67% and 9% for GB stones, CBD stones, IHD stones and biliary malignancy, respectively. A significantly higher (p = 0.001) positive culture rate was found for GB stones with acute cholecystits (47%) compared with that without inflammation (17%). Similarly, the culture rate for hepatolithiasis with acute cholangitis was higher than that without cholangitis (75% vs 51%, p = 0.011). Long-term external biliary drainage in biliary malignancy increased the risk of bacterial culture rate. For gallstone diseases, the most common organisms cultured were Gram negative bacteria (74%), in which Escherichia coli (36%) and Klebsiella (15%) were most commonly found, followed by Gram positive (15%) bacteria such as Enterococcus (6%), Staphylcoccus (3%), Streptococcus (2%). Bacteroides (5%) and Clostridium (3%) were occasionally found anaerobes (9%). Polymicrobial infection was encountered in 19%, 31% and 29% for patients with GB stones, CBD stones and IHD stones, respectively; frequency of mixed aerobic and anaerobic infection was 7%, 12% and 9%. In the current study, ampicillin in combination with sulbactam and aminoglycoside is still a suggestive empirical therapy. Antibiotic treatment should be adjusted based on later bacteriological cultures and clinical condition.

Group I metabotropic glutamate receptors elicit epileptiform discharges in the hippocampus through PLCbeta1 signaling

Activation of metabotropic glutamate receptors (mGluRs) produces multiple effects in cortical neurons, resulting in the emergence of network activities including epileptiform discharges. The cellular mechanisms underlying such network responses are largely unknown. We examined the properties of group I mGluR-mediated cellular responses in CA3 neurons and attempted to determine their role in the generation of the network activities. Group I mGluR stimulation causes depolarization of hippocampal neurons. This depolarization is primarily mediated by two sets of conductance change: the opening of a voltage-dependent cationic conductance (mediating I(mGluR(V))) and the closing of a voltage-independent (background) K(+) conductance. I(mGluR(V)) was no longer elicited by group I mGluR agonists in the presence of U73122, a phospholipase C (PLC) blocker. Also, the current could not be activated in hippocampal CA3 neurons from PLCbeta1 knock-out mice. In contrast, suppression of PLC signaling did not affect the group I mGluR-mediated suppression of background K(+) conductance. Thus, the suppression of the background K(+) conductance occurred upstream to PLC activation, whereas the generation of I(mGluR(V)) occurred downstream to PLC activation. Group I mGluR agonists normally elicited rhythmic single cell and population burst responses in the CA3 neurons. In the absence of an I(mGluR(V)) response, CA3 neurons in slices prepared from PLCbeta1-/- mutant mice could no longer generate these responses. The results suggest that I(mGluR(V)) expression in CA3 hippocampal neuron is PLCbeta1-dependent and that I(mGluR(V)) plays a necessary role in the generation of rhythmic single cell bursts and synchronized epileptiform discharges in the CA3 region of the hippocampus.

Group I mGluR activation turns on a voltage-gated inward current in hippocampal pyramidal cells

A unique property of the group I metabotropic glutamate receptor (mGluR)-induced depolarization in hippocampal cells is that the amplitude of the depolarization is larger when the response is elicited at more depolarized membrane potentials. Our understanding of the conductance mechanism underlying this voltage-dependent response is incomplete. Through the use of current-clamp and single-electrode voltage-clamp recordings in guinea pig hippocampal slices, we examined the group I mGluR-induced depolarization in CA3 pyramidal cells. The group I mGluR agonists (S)-3-hydroxyphenylglycine and (S)-3,5-dihydroxyphenylglycine turned on a voltage-gated inward current (I(mGluR(V))), which was pharmacologically distinct from the voltage-gated sodium and calcium currents intrinsic to the cells. I(mGluR(V)) was a slowly activating, noninactivating current with a threshold at about -75 mV. In addition to the activation of I(mGluR(V)), group I mGluR stimulation also produced a voltage-independent decrease in the K(+) conductance. Our results suggest that the depolarization induced by group I mGluR activation is generated by two ionic mechanisms-a heretofore unrecognized voltage-gated inward current (I(mGluR(V))) that is turned on by depolarization and a voltage-insensitive inward current that results from a turn-off of the K(+) conductance. The low-threshold and noninactivating properties of I(mGluR(V)) allow the current to play a significant role in setting the resting potential and firing pattern of CA3 pyramidal cells.

Cervical necrotizing fasciitis: a case report

Necrotizing fasciitis is a severe soft tissue infection characterized by cutaneous necrosis, suppurative fasciitis, vascular thrombosis and extreme systemic toxicity. Involvement of head and neck structures is rare, but occur most frequently in patients with diabetes and chronic alcoholism. Once initiated, the disease progresses rapidly and diffusely, involving adjacent fascial spaces. Necrotizing fasciitis may also extend to the cervical viscera, mediastinum and anterior chest wall. A 65-year-old chronic alcoholic man, with long-standing diabetes and liver cirrhosis under irregular treatment is described. The patient developed a deep neck infection from a buccal abscess after a local incision. The infection then extended to an orocutaneous fistula and deep neck superficial and middle layer fascias, with necrotizing fasciitis. Management requires early recognition, high doses of appropriate antimicrobial therapy, early surgical drainage and radical debridement of necrotic tissue. The disease carries a high rate of morbidity and mortality, especially in the elderly.

Diagnosis of mucopolysaccharidosis type IIIB

Mucopolysaccharidosis (MPS) includes a group of lysosomal storage diseases. Among them, type III (Sanfilippo) disease is rarely described in Taiwan because of their complexity. With accurate quantifying and precise separation of urinary glycosaminoglycans (GAGs), and specific enzyme measurements, two cases of MPS IIIB disease were able to be described. They both had mild-to-moderate degrees of mental retardation, facial dysmorphism and dysostosis multiplex which do not differ from other types of MPS. Total amounts of GAGs in the urine were only mildly elevated but, among them, heparan sulfate was the highest. Skin fibroblasts alpha-N-acetyl-glucosaminidase activities were low in both cases. Therefore, analysis of GAGs and enzyme assays are important for the diagnosis of patients suspected to have MPS, especially type III disease.

Arylsulfatase A pseudodeficiency in Chinese

Arylsulfatase A (ASA) pseudodeficiency was found to be much rarer in Taiwan than in most western countries (2.5% versus 7.3%-20% carrier rate). The linkage of two mutations (A2725G and A1788G) in the pseudodeficiency allele was preserved in Chinese, and A2725G did not occur alone. This unusual linkage of mutations has not been fully explained previously because the frequency of A2725G alone was not clear (as low as 4% in the only report). However, A1788G was found in 55 of 160 (34.4%) DNA samples tested in this study. These data suggest that the A2725G mutation occurred in DNA that already contained the A1788G change, at an ancient time in one of our common ancestors.

Anti-inflammatory and radical scavenge effects of Arctium lappa

The effects of Arctium lappa L. (root) on anti-inflammatory and free radical scavenger activity were investigated. Subcutaneous administration of A. lappa crude extract significantly decreased carrageenan-induced rat paw edema. When simultaneously treated with CCl4, it produced pronounced activities against CCl4-induced acute liver damage. The free radical scavenging activity of its crude extract was also examined by means of an electron spin resonance (ESR) spectrometer. The IC50 of A. lappa extract on superoxide and hydroxyl radical scavenger activity was 2.06 mg/ml and 11.8 mg/ml, respectively. These findings suggest that Arctium lappa possess free radical scavenging activity. The inhibitory effects on carrageenan-induced paw edema and CCl4-induced hepatotoxicity could be due to the scavenging effect of A. lappa.

Superoxide anion scavenging effect of coumarins

The superoxide scavenging effects of fifteen coumarins were tested on the xanthine-xanthine oxidase-cytochrome C system. The results showed that fraxetin(10) displayed the strongest activity, and its percent inhibition at 100, 10 and 1 muM were 100, 100 and 53.13% respectively. Esculetin(4) showed the second strongest activity resulting in percent inhibition at 100 and 10 muM were 87.16 and 52.38% respectively. Both fraxetin(10) and esculetin(4) have been isolated from the plant, Fraxinus bungeana DC (Oleaceae) which has been used in folk medicine as an analgesic and anti-inflammatory medicine. It seems that two phenolic hydroxy groups in the ortho position in the molecule of coumarins play an important role in scavenging activity.

Diagnosis of I-cell disease

I-cell disease (mucolipidosis II) is a rare lysosomal storage disease, with its primary defect the deficiency of an enzyme responsible for lysosomal enzyme processing, resulting in multiple lysosomal enzyme insufficiency. Diagnosis of I-cell disease usually can be made by the specific patterns of enzyme distribution: deficient intracellular, but excessive extracellular, enzymes. A six month old female infant was found to have bilateral congenital dislocation of hips, developmental delay, coarsening of facial appearance and dysostosis multiplex. In view of the very early onset of disease, I-cell disease was suspected. Lysosomal enzyme tests (including alpha-mannosidase, alpha-fucosidase, beta-glucuronidase and beta-galactosidase) were performed on the leukocytes, skin fibroblasts, plasma and media from fibroblast cultures. All activities of the four enzymes were low in both leukocytes and fibroblasts, but were 10- to 70-fold higher than normal in plasma, and high in culture media. Both the clinical and laboratory findings here were consistent with a diagnosis of I-cell disease.