Standard steroid treatment for autoimmune pancreatitis

OBJECTIVE

To establish an appropriate steroid treatment regimen for autoimmune pancreatitis (AIP).

METHODS

A retrospective survey of AIP treatment was conducted in 17 centres in Japan. The main outcome measures were rate of remission and relapse.

RESULTS

Of 563 patients with AIP, 459 (82%) received steroid treatment. The remission rate of steroid-treated AIP was 98%, which was significantly higher than that of patients without steroid treatment (74%, 77/104; p<0.001). Steroid treatment was given for obstructive jaundice (60%), abdominal pain (11%), associated extrapancreatic lesions except the biliary duct (11%), and diffuse enlargement of the pancreas (10%). There was no relationship between the period necessary to achieve remission and the initial dose (30 mg/day vs 40 mg/day) of prednisolone. Maintenance steroid treatment was given in 377 (82%) of 459 steroid-treated patients, and steroid treatment was stopped in 104 patients. The relapse rate of patients with AIP on maintenance treatment was 23% (63/273), which was significantly lower than that of patients who stopped maintenance treatment (34%, 35/104; p = 0.048). From the start of steroid treatment, 56% (55/99) relapsed within 1 year and 92% (91/99) relapsed within 3 years. Of the 89 relapsed patients, 83 (93%) received steroid re-treatment, and steroid re-treatment was effective in 97% of them.

CONCLUSIONS

The major indication for steroid treatment in AIP is the presence of symptoms. An initial prednisolone dose of 0.6 mg/kg/day, is recommend, which is then reduced to a maintenance dose over a period of 3-6 months. Maintenance treatment with low-dose steroid reduces but dose not eliminate relapses.

Physical fitness and indices of lifestyle-related diseases before and after interval walking training in middle-aged and older males and females

HYPOTHESIS

Whether increasing peak aerobic capacity for walking (VO(2peak)) by interval walking training (IWT) is closely linked with decreasing the indices of lifestyle-related diseases (LSDs) in middle-aged and older people were examined.

METHODS

For 4 months from April to September 2005 or 2006, 246 males and 580 females (∼65 years) performed IWT consisting of ≥5 sets of fast walking at ≥70% VO(2peak) for 3 min followed by slow walking at ≤40% VO(2peak) for 3 min ≥4 days/week. Before and after IWT, we measured VO(2peak), body mass index (BMI), %body fat, arterial blood pressure, thigh muscle strength and blood parameters. We analysed 198 males and 468 females who had undergone all the measurements both before and after IWT. To examine the hypothesis, we divided the subjects equally into three groups according to their pretraining VO(2peak): low, middle and high groups for each sex.

RESULTS

Before training, it was found that thigh muscle strength and blood high-density lipoprotein cholesterol concentration were lower, whereas body weight, BMI, %body fat, arterial blood pressure and blood glucose were higher in the low group than the high group (all, p<0.05). After training, although VO(2peak) and thigh muscle strength increased and body weight, BMI, %body fat, blood pressure and blood glucose concentration decreased in all groups (all, p<0.05), the changes were greatest in the low group for both sexes.

CONCLUSION

VO(2peak) at baseline and changes in response to training were closely linked with indices of LSDs.

Techniques to facilitate ERCP with a conventional endoscope in patients with previous pancreatoduodenectomy

There is little guidance on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous pancreatoduodenectomy. We reviewed techniques for ERCP with a conventional endoscope and assessed its value in 10 patients with previous pancreatoduodenectomy (15 ERCPs). After exploration of the surgical reconstruction, we used a front-viewing endoscope, and we used a small firm pillow under the abdomen and hand compression for preventing loop formation. Successful insertion to the ductal anastomoses and biliary cannulation were achieved in 13 / 15 procedures (87 %). In 6 procedures where we attempted pancreatic cannulation, we could not identify the pancreatojejunostomy, but after spraying contrast around the suspected location of the ductal anastomosis we obtained a pancreatogram in 4 / 6 procedures (67 %). Endoscopic biliary interventions were successful in 6 / 7 procedures (86 %). No complications were encountered. Use of appropriate techniques makes ERCP with a conventional endoscope feasible, effective, and safe in patients with previous pancreatoduodenectomy. Endoscopic therapy can be performed successfully in the bile duct, but has limited value regarding the pancreatic duct.

Effective "short" double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series

BACKGROUND AND STUDY AIMS

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal anatomy, a double-balloon enteroscope (DBE) permits examinations of a much longer segment of the small bowel than does a standard endoscope, and may be used to perform ERCP in such patients. Since only limited accessories are available for a conventional DBE, we performed ERCP with a "short" DBE, which has a 2.8-mm working channel and a 152-cm working length and for which conventional accessories are available, in patients with altered gastrointestinal anatomy, and evaluated this alternative technique.

PATIENTS AND METHODS

In 68 patients with a Roux-en-Y total gastrectomy (n = 36), Billroth II gastrectomy (n = 17), or pancreatoduodenectomy (n = 15), ERCP (103 procedures) was performed with a "short" DBE.

RESULTS

Deep insertion was successful in 100/103 procedures (97 %). Cholangiogram was successfully obtained in 98/100 procedures (98 %). Treatment was accomplished in all 98 procedures in which a cholangiogram was obtained (100 %). Therapeutic interventions including stone extraction (n = 47), nasobiliary drainage (n = 38), stent placement (n = 36), sphincterotomy (n = 31), choledochojejunostomy dilation (n = 29), tumor biopsy (n = 10), and naso-pancreatic duct drainage (n = 1) were performed successfully. Complications occurred in 5/103 procedures (5 %), all in patients with Roux-en-Y reconstruction.

CONCLUSIONS

Despite the relatively high rate of complications seen in patients with Roux-en-Y reconstruction, ERCP with a "short" DBE is effective in patients who have undergone bowel reconstruction.

Serological evidence of infection with hepatitis E virus among wild Yezo-deer, Cervus nippon yesoensis, in Hokkaido, Japan

In this study, 520 serum samples from Yezo-deer in the Hidaka district, Hokkaido, Japan were examined by enzyme-linked immunosorbent assay to investigate whether the animals were infected with hepatitis E virus (HEV). The distribution of optical density values showed a bimodal pattern and 181 samples (34.8%) were deemed to be antibody-positive against HEV. At least five (2.8%) of the positive sera gave specific bands by Western blot analysis. An age-dependent increase in prevalence of the antibodies was found among the animals. These findings indicate that Yezo-deer are a possible host for HEV infection. To avoid the risk of becoming HEV infected, the consumption of raw Yezo-deer meat must be prohibited.

Phase II trial report of the new neoadjuvant chemotherapy with S-1 and docetaxel for advanced breast cancer

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Background: Primary chemotherapy with anthracycline and taxanes is a gold standard regimen which realize pathologically complete response in 20% of patients with advanced breast cancer. However, sequential administration of anthracycline and taxanes induces serious side effects. This regimen is therefore difficult to use for higj-risk patients. S-1 is a new oral anti-tumor drug, which is composed of 5-fluoro-1-(tetrahydro -2- furanyl)-2, 4(1H, 3H)-pyrimidinedione (Tegafur, FT), 5-chloro-2, 4- dihydroxypyridine (Gimeracil, CDHP) and potassium 1, 2, 3, 4-tetrahydro-2, 4-dioxo-1, 3, 5-triazine-6-carboxylate (potassium Oteracil, Oxo). Combined treatment with docetaxel and S-1 yielded significant response in patients with gastric cancer with minimal side effects due to biochemical modulation of both CDHP and Oxo. The purpose of this study was to evaluate the efficacy and toxicity of docetaxel in combination with S-1 for advanced breast cancer. Methods: Patients with advanced breast cancer (Stage IIA to IV) were treated with i.v. docetaxel (40mg/m2) on day 1 and oral S-1(80mg as FT/m2/day) on days 1 to 14 every 3 weeks for 8 courses. The clinical response was evaluated every 3 months with MMG, MRI, ultrasonography and CT scan based on RECIST criteria. The patients underwent surgery after completion of chemotherapy. Pathologic examination was performed with thin-sliced specimens. The specimens were also reserved for genetic analysis. Written informed consent was obtained from all patients or family members after the Ethics Committee of Tokushima University Hospital approved the study protocol. Results: Twenty-two patients completed the therapy and underwent surgery. Four cases (18.2%) of pathologic complete response (pCR) were recognized on pathologic examination. The response rate was 90.9% and 95.5% of the patients could preserved their breast. Bone marrow suppression was substantial, and low-grade anorexia, nausea, and peripheral neuropathy were observed. Conclusions: The new regimen of S-1 combined with docetaxel is expected to exhibit satisfactory efficacy in treating advanced breast cancer as primary chemotherapy. Genetic analysis will be performed to examine and to find biomarkers for measurement of the efficacy of this therapy.

No significant financial relationships to disclose.

The evaluation of post-operative alignment in total knee replacement using a CT-based navigation system

We compared the alignment of 39 total knee replacements implanted using the conventional alignment guide system with 37 implanted using a CT-based navigation system, performed by a single surgeon. The knees were evaluated using full-length weight-bearing anteroposterior radiographs, lateral radiographs and CT scans. The mean hip-knee-ankle angle, coronal femoral component angle and coronal tibial component angle were 181.8 degrees (174.2 degrees to 188.3 degrees), 88.5 degrees (84.0 degrees to 91.8 degrees) and 89.7 degrees (86.3 degrees to 95.1 degrees), respectively for the conventional group and 180.8 degrees (178.2 degrees to 185.1 degrees), 89.3 degrees (85.8 degrees to 92.0 degrees) and 89.9 degrees (88.0 degrees to 93.0 degrees), respectively for the navigated group. The mean sagittal femoral component angle was 85.5 degrees (80.6 degrees to 92.8 degrees) for the conventional group and 89.6 degrees (85.5 degrees to 94.0 degrees) for the navigated group. The mean rotational femoral and tibial component angles were -0.7 degrees (-8.8 degrees to 9.8 degrees) and -3.3 degrees (-16.8 degrees to 5.8 degrees) for the conventional group and -0.6 degrees (-3.5 degrees to 3.0 degrees) and 0.3 degrees (-5.3 degrees to 7.7 degrees) for the navigated group. The ideal angles of all alignments in the navigated group were obtained at significantly higher rates than in the conventional group. Our results demonstrated significant improvements in component positioning with a CT-based navigation system, especially with respect to rotational alignment.

The Wistar Bonn Kobori rat, a unique animal model for autoimmune pancreatitis with extrapancreatic exocrinopathy

The male Wistar Bonn/Kobori (WBN/Kob) rat is known to be a unique animal model for chronic pancreatitis with widely distributed fibrosis and degeneration of parenchyma because of the infiltration of lymphocytes. In this report, we show that female (but not male) rats develop dacryoadenitis at 3 months of age, and that both male and female WBN/Kob rats develop sialoadenitis, thyroiditis, sclerotic cholangitis and tubulointerstitial nephritis over 18 months of age. The infiltration of CD8+ cells and the deposits of tissue-specific IgG2b were observed in the injured pancreas and lachrymal glands. Furthermore, the number of regulatory T cells (defined as CD4+ Forkhead box P3+ cells) decreased in the periphery of both male and female WBN/Kob rats, suggesting that the onset of these diseases is attributable, at least, to the failure in the maintenance of peripheral immune tolerance. These features show clearly that WBN/Kob rats are a useful animal model for autoimmune pancreatitis and Sjøgren-like syndrome or multi-focal fibrosclerosis in humans. We also show that these autoimmune diseases can be prevented by a newly devised strategy of bone marrow transplantation (BMT) in which bone marrow cells are injected directly into the bone marrow cavity: intrabone marrow-BMT.

Carboxyl terminus of the 34 kDa protein of Mycobacterium paratuberculosis shares homologous B-cell epitopes with Mycobacterium avium and Mycobacterium intracellulare

Monoclonal antibodies (mAbs) against a recombinant carboxyl terminus of the 34 kDa protein of Mycobacterium paratuberculosis were produced in mice. Two of the mAbs cross-reacted with Mycobacterium avium and Mycobacterium intracellulare in both an elisa and immunoblot. The recombinant protein also reacted with polyclonal sera produced in rabbits against all three mycobacteria, indicating the presence of cross-reactive epitopes in the protein. To determine the reactivity of cattle sera against epitopes recognised by the mAbs, competition assays between bovine sera and the mAbs were carried out. Two mAbs were significantly inhibited by sera from cattle that were naturally infected with M paratuberculosis. The results indicate that epitopes on the carboxyl terminus of the 34 kDa protein common to M paratuberculosis, M avium and M intracellulare readily induce antibody production in naturally infected cattle. These epitopes reduce the diagnostic specificity of the carboxyl terminus of the 34 kDa protein, which was originally thought to contain only M paratuberculosis-specific epitopes.

Th1 but not Th17 cells predominate in the joints of patients with rheumatoid arthritis

OBJECTIVES

Recent animal studies have revealed critical roles of interleukin (IL)17, which is produced by a newly identified subset of helper T cells, Th17 cells, in the development of autoimmune diseases including arthritis. However, in human rheumatoid arthritis (RA), detailed characteristics and the prevalence of Th17 cells are unclear.

METHODS

Peripheral blood mononuclear cells (PBMC) were obtained from 123 patients with RA and 28 healthy controls. Mononuclear cells were also prepared from synovial membrane or synovial fluid of 12 patients with RA. IL17 (IL17A) positive T cells were identified by a flow cytometer after ex vivo stimulation with phorbol myristate acetate and ionomycin. Disease activity was assessed with the 28-joint Disease Activity Score (DAS28).

RESULTS

IL17 positive cells were detected in CD45RO+ CD4 T cells. Most IL17 positive T cells produced neither interferon (IFN)gamma nor IL4, but tumour necrosis factor (TNF)alpha similar to murine Th17 cells. The frequency of Th17 cells was neither increased in RA nor correlated with DAS28. Unexpectedly, the frequency of Th17 cells was significantly decreased in the joints compared with PBMC of the same patients with RA, whereas Th1 cells were more abundant in the joints than in PBMC.

CONCLUSIONS

We could not obtain evidence that positively supports predominance of Th17 cells in RA. Further careful investigation is necessary before clinical application of IL17-targeting therapy.

Role of the appendix in the pathogenesis of ulcerative colitis

Although human appendix has been considered as a vestigial remnant, recent observations have focused attention on the role of the appendix in the pathogenesis of ulcerative colitis (UC). Many case-control studies suggest that previous appendectomy is rare in UC patients. This inverse relation is limited to patients who undergo appendectomy before the age of 20 years. Moreover, several investigators reported the improvement of UC after appendectomy, especially in young patients. In the appendix of UC patients, the CD4/CD8 ratio is significantly increased, and the proportion of CD4+CD69+ (early activation antigen) T cells, but not of CD4+HLA-DR+ (mature activation antigen) T cells, is also significantly increased. These findings suggest that the appendix may be a priming site in the development of UC. Further studies including analysis of CD4+ and CD8+ T cells are necessary to clarify the role of the appendix in the pathogenesis of UC.