Role of magnetic resonance cholangiopancreatography for choledocholithiasis: analysis of patients with negative MRCP

OBJECTIVE

To investigate the negative predictive value of magnetic resonance cholangiopancreatography (MRCP) for common bile duct (CBD) stones and the prognosis of patients suspected to have choledocholithiasis in whom the MRCP was negative for CBD stones.

METHODS

We enrolled the patients suspected to have choledocholithiasis in whom the MRCP was negative for the CBD stones between January 2008 and March 2011 and retrospectively analyzed the outcomes of 115 patients.

RESULTS

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 27 patients (23%, group 1), and none had CBD stones. The negative predictive value of MRCP was 100%. During a median follow-up of 18.3 months, acute cholangitis with newly developed CBD stones occurred in two patients. Eighty-eight patients (77%, group 2) did not undergo ERCP and all recovered from acute cholangitis without CBD surgery. During a median follow-up of 18.7 months, acute cholangitis, acute cholecystitis, gallstone pancreatitis, and pancreatico-biliary cancers occurred in four (4.6%), three (3.5%), one (1.2%), and three (3.5%) patients, respectively. New CBD stones were found in only two patients among four patients with recurrent acute cholangitis. No patient had recurrent cholangitis caused by MRCP-missed CBD stones. The rates of recurrent cholangitis and cholangitis-free survival did not differ between groups 1 and 2.

CONCLUSION

The negative predictive value of MRCP was very high. ERCP can be reserved for patients who are MRCP negative for choledocholithiasis, but close follow-up is needed because of recurrent cholangitis or pancreatico-biliary cancer.

Mechanism of E1A-induced transforming growth factor-beta (TGF-beta) resistance in mouse keratinocytes involves repression of TGF-beta type II receptor transcription

Cellular transformation driven by the E1A oncogene is associated with the development of cellular resistance to the growth inhibitory effects of transforming growth factor-beta (TGF-beta). We demonstrate that development of resistance occurs simultaneously with decreased expression of TGF-beta type II receptor (TGF-beta RII) mRNA and protein. To determine whether changes in transcriptional regulation are responsible for the decreased receptor expression in E1A-transformed cells, a series of mobility shift assays was performed utilizing nuclear extracts from E1A-transformed and untransformed murine keratinocytes using radiolabeled positive regulatory elements (PRE1 and PRE2) of the TGF-beta RII promoter. The results from these assays suggest that E1A-transformed cells express markedly lower levels of nuclear proteins that bind specifically to PRE1 and PRE2. Transfection of both E1A-transformed and untransformed cell lines with a series of mutant promoter constructs confirmed that both PREs contribute significantly to basal expression of TGF-beta RII and that inactivation of either element leads to markedly reduced promoter activity. We conclude that development of TGF-beta resistance in E1A-transformed cells is achieved in part through transcriptional down-regulation of the TGF-beta RII gene and that this down-regulation is the result of decreased expression of unidentified transcription factor complexes that interact with PRE1 and PRE2.

Diagnostic issues in tuberculosis of the ribs with a review of 12 surgically proven cases

The ribs and surrounding chest wall are uncommon sites of tuberculosis (TB). Tuberculosis of the rib bone is often delayed in diagnosis or is recurrent with medical treatment. Rib TB is often negative or shows nodular shadows which is mimicking a metastatic tumour. We reviewed 12 cases of rib TB, which were confirmed by surgical rib resection. The most common reason given for attending the hospital was palpation of the chest wall mass, the onset of chest pain or draining sinus on the chest wall. The correct diagnosis was often delayed due to misdiagnosis of the other conditions. The misdiagnosis was produced from vague symptoms and various radiological features of rib TB. Occasionally, previous TB history could provide an indication of rib TB. Occasionally, their pre-operative diagnostic processes were inadequate and were not consistent depending on the physician. From these reviews, we attempted to reconstruct the best diagnostic and therapeutic modalities. Our recommendation for detecting rib TB is an accurate medical history and physical examination, and early differential diagnosis with bone scintigram, computed tomogram, and percutaneous needle biopsy. Surgery can be a final diagnostic option for differential diagnosis or in a therapeutic role for recalcitrant or complicated cases.

Phosphorylation of the p190 RhoGAP N-terminal domain by c-Src results in a loss of GTP binding activity

p190 RhoGAP is a multi-domain protein that is thought to regulate actin cytoskeleton dynamics. It can be phosphorylated both in vitro and in vivo at multiple sites by the Src tyrosine kinase and one or more of these sites is postulated to modulate p190 function. One of the regions which is multiply phosphorylated by Src in vitro is the N-terminal GTP binding domain. Using a partially purified, bacterially expressed recombinant protein that includes the GTP binding domain (residues 1-389), we show that GTP binds to this fragment in a specific and saturable manner that is both time- and dose-dependent and that tyrosine phosphorylation of this fragment by c-Src results in a loss of GTP binding activity. These findings suggest that tyrosine phosphorylation of the p190 N-terminal domain can alter its ability to bind GTP.

Experience with esophageal stenting for caustic burns in children

Seven children with deep circumferential esophageal burns were treated with antibiotics, steroids, and intraluminal silastic stents. Strictures did not develop if the esophagus was healed at the time the stent was removed. However, strictures developed if healing was incomplete. Esophageal stenting needs to be continued until healing has been demonstrated endoscopically.

Results of treatment of gastroesophageal reflux with bethanechol

Thirty-seven infants and children with gastroesophageal reflux were studied with prolonged esophageal pH monitoring before and during treatment with bethanechol. Total reflux scores improved by 69% (P = 6.47 X 10(-7) during bethanechol therapy. This improvement resulted primarily from decreases in the frequency and the duration of reflux episodes occurring more than two hours after feeding. Our findings indicate that infants and children with gastroesophageal reflux may safely be treated with bethanechol; thus the need for surgery is avoided.

Microvascular decompression in trigeminal neuralgia: a correlation of three-dimensional time-of-flight magnetic resonance angiography and surgical findings

We analyzed 104 patients with trigeminal neuralgia who underwent microvascular decompression and who were followed up for more than 12 months during the period from January 1992 to June 1998. In this recent series, we utilized three-dimensional time-of-flight magnetic resonance angiography (3D-TOF MRA) for all patients with trigeminal neuralgia. A 3D-TOF MRA was beneficial in treatment planning and in predicting surgical outcome by demonstrating cranial nerve compression as well excluding other etiologies such as tumor or vascular lesions. The patients were followed up for 1-7 years (mean 5.7 +/- 1.2 years). Initial pain relief was complete in 89 patients (85.6%) and partial in 12 patients (11.5%). There were three primary failures (2.9%). The acceptable pain relief rate (complete relief: 79.8%, partial relief: 11.5%) was determined in the long-term follow-up of surgical results. Pain recurred in 6 patients (5.8%). The mean time to recurrence was 48 months (36-93 months). There were no serious or annoying complications such as anesthesia dolorosa.

Long-term results of implantation of posterior chamber intraocular lens by suture fixation

We reviewed the long-term results of implantation of posterior chamber intraocular lens (PC IOL) by suture fixation in 23 patients without zonular or capsular support. In terms of preoperative state, 15 were aphakic, 5 had cataracts and 3 were aphakic with concurrent corneal opacity. The latter had penetrating keratoplasty as well at the time of surgery. They were followed up for more than 1 year, and the best corrected vision remained the same or improved in all cases after surgery. The transscleral suture fixation-related complications included vitreous hemorrhage, hyphema and retinal detachment.

The effective use of intrapleural bupivacaine for analgesia after thoracic and subcostal incisions in children

Twenty-four patients having undergone thoracotomies and subcostal incisions were treated for 24 hours with intrapleural bupivacaine with epinephrine. Vital signs, pain scores, and serum bupivacaine levels were recorded. No patient required narcotic medications and all patients obtained adequate analgesia. There were no complications of the technique or toxicity of the drug. Further studies need to be performed to extend the duration of use, to determine pharmacokinetics, and to compare with other techniques.

Baculovirus expression vectors that incorporate the foreign protein into viral occlusion bodies

Current baculovirus expression systems typically produce soluble proteins that accumulate within the infected insect cell or are secreted into the growth medium. A system has now been developed for the incorporation of foreign proteins, along with the matrix protein, polyhedrin, into baculovirus occlusion bodies. Initial studies showed that a recombinant virus expressing a translational fusion between polyhedrin and GFP did not form occlusion bodies. However, a baculovirus coexpressing native polyhedrin and the polyhedrin-GFP fusion protein formed occlusion bodies that fluoresced under UV light, demonstrating that they included the polyhedrin-GFP fusion protein. This was confirmed by immunoblot analysis. Thus, incorporation of a foreign protein into occlusion bodies depends on an interaction between native polyhedrin and the polyhedrin fusion protein. Electron microscopy demonstrated that the occlusion bodies containing GFP also incorporated virions as expected. These ColorPol occlusion bodies were as infectious to insect larvae as occlusion bodies produced by wild-type virus. This new system expands the capabilities for foreign gene expression by baculoviruses, which has implications for biopesticide design, novel vaccine delivery systems, and fusion protein purification applications.

Acquired aganglionosis

A documented case of acquired aganglionosis is presented in which transrectal biopsies taken 4 mo apart first showed the presence then subsequently the absence of ganglion cells. Colostomy followed by a Soave procedure was curative.

The two-stage mutation model in retinal hemangioblastoma

BACKGROUND

The two-stage mutation model involving successive inactivation of both alleles of a tumor suppressor gene was originally proposed by Knudson, who analyzed the age incidence curves for unilateral and bilateral retinoblastoma, and suggested that hereditary tumors arise by a single somatic event superimposed on a defective genetic background and sporadic tumors by a two-stage somatic process. In this study, the age-incidence curve of patients with retinal hemangioblastoma with and without associated von Hippel-Lindau disease were analyzed.

METHODS

We reviewed the literature between 1964 and 1998 to find all reported cases of retinal hemangioblastoma and classified patients in a type A group (n = 223) when associated with von Hippel-Lindau disease and a type B group (n = 30) when not associated with von Hippel-Lindau disease. We analyzed and compared the age incidence of these two groups.

RESULTS

There was a statistically significant difference between the mean age at diagnosis of retinal hemangioblastoma in the two groups, i.e., 48.4 +/- 16.6 years for type B patients and 24.9 +/- 12.0 years for type A patients (p < 0.0001). The age incidence curve for type A retinal hemangioblastoma fit a first-order equation (log S = 0.411-0.034t) with r = 0.97, indicating a single somatic mutation, whereas the age incidence curve for type B retinal hemangioblastoma fit a second-order equation (log S = 0.184-2.25 x 10(-4)t2) with r = 0.97, indicating two somatic mutations.

CONCLUSIONS

Type B (sporadic) retinal hemangioblastoma may arise from two separate somatic mutations inactivating both alleles at the von Hippel-Lindau locus, whereas patients with von Hippel-Lindau disease (type A) inherit a defective allele and require only one additional somatic mutation.

[Change of Clostridium difficile colitis during recent 10 years in Korea]

BACKGROUND/AIMS

Our clinical experience and recent published literatures suggest that Clostridium difficile colitis (CDC) has become more common and potentially more pathogenic in recent years. The aim of study was to evaluate changes in the epidemiological features of CDC in hospitalized patients in Korea.

METHODS

We retrospectively reviewed all patients of CDC diagnosed at Kangnam St. Mary Hospital from 1998 to 2007. CDC was defined as having a positive C. difficile cytotoxicity assay, or endoscopic or pathologic evidence of CDC.

RESULTS

A total of 189 cases (male 73, female 116, mean age 63.3 years) of CDC were diagnosed during the study period. The prevalence of CDC increased from 1.9/10,000 patient admissions in 1998-1999 to 8.82/10,000 patient admissions in 2006-2007. One hundred sixty three indication for cases (86.2%) of patients identified a prior use of antibiotics in the 2 months preceding diagnosis. The most common antibiotic use was prophylactic use during perioperational period (33.3%) followed by pneumonia (23.3%). The overall response rate to initial antibiotics was 82.7%. One hundred seventy two (91%) patients were initially treated with metronidazole. The response rate was 84.3%. All patients with initial failure to metronidazole were successfully treated by vancomycin. The response rate of vancomycin as first treatment was 80%. Three deaths were associated with CDC despite the use of combination of metronidazole and vancomycin.

CONCLUSIONS

The prevalence of CDC in hospitalized patients in Korea significantly increased from 1998 to 2007.

Gastroprotective Effects of Grape Seed Proanthocyanidin Extracts against Nonsteroid Anti-Inflammatory Drug-Induced Gastric Injury in Rats

Background/Aims

To investigate the gastroprotective effects of grape seed proanthocyanidin extracts (GSPEs) against nonsteroid anti-inflammatory drug (NSAID)-induced gastric mucosal injury in rats.

Methods

Sprague-Dawley rats were randomly allocated to the normal control, indomethacin, low-dose GSPE, high-dose GSPE and misoprostol groups. All groups except the normal control group received pretreatment drugs for 6 consecutive days. On the 5th and 6th day, indomethacin was administered orally to all groups except for normal control group. The microscopic features of injury were analyzed. The levels of gastric mucosal glutathione, gastric mucosal prostaglandin E₂ (PGE₂), and proinflammatory cytokines were investigated.

Results

The total areas of ulceration in the GSPE and misoprostol groups were significantly decreased compared with the indomethacin group (p<0.05). However, a difference in ulcer formation among the drug treatment groups was not observed. Meanwhile, the glutathione levels in the high-dose GSPE group were higher than those of both the indomethacin and misoprostol groups (p<0.05) and were similar to those of the normal control group. Additionally, there was no difference among the groups in the levels of gastric mucosal PGE₂ and proinflammatory cytokines.

Conclusions

High-dose GSPE has a strong protective effect against NSAID-induced gastric mucosal injury, which may be associated with the antioxidant effects of GSPE.

Subsets associated with developing acute pancreatitis in patients with severe hypertriglyceridemia and the severity of pancreatitis

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia (HTG) is a rare but well-recognized cause for acute pancreatitis (AP). This study aimed to determine subsets related to development of AP in patients with severe HTG and the severity of HTG-induced AP (HTG-AP).

METHODS

Patients who had severe HTG (serum triglyceride level >1,000 mg/dL) more than once between Jan. 2010 and Dec. 2017 in a single institute were evaluated retrospectively. Patients were divided into two groups, with AP or without AP, and were compared. HTG-APs in patients with severe HTG were compared to APs due to other causes during the same period.

RESULTS

Sixty-three patients (19.3%) presented with AP of a total 326 patients with severe HTG. The AP group displayed younger age, more alcohol consumption and diabetes mellitus, and higher initial/maximum serum levels of triglyceride, glucose, HbA1c, total cholesterol, and calculated non-high-density lipoprotein cholesterol (p < 0.05). HTG-APs were clinically more severe compared with 277 APs due to other causes in terms of CRP (p < 0.001), CT severity index (p = 0.002), revised Atlanta classification (p < 0.001), and hospital stay (p = 0.011). In logistic regression analysis, maximum serum triglyceride level (OR 2.706, p = 0.015), alcohol consumption amount (OR 5.292, p < 0.001), and age (OR 0.358, p = 0.017) were independently associated with development of AP in patients with severe HTG.

CONCLUSIONS

Development of AP in patient with severe HTG was independently associated with younger age, higher serum TG level, and more alcohol consumption. HTG-APs are clinically more severe than APs due to other causes.

Hypobaric hypoxia-induced intrauterine growth retardation

2-week-pregnant New Zealand White rabbits were placed into a hypobaric chamber and maintained at 3,657 m (12,000 ft). Upon delivery (31 +/- 1 days) or at cesarean section (on day 30), all newborns were sacrificed and organ weights were compared to those of control pups maintained at 128 m (420 ft). Significant findings in the hypobaric animals included a diminished birth weight, placental weight, and liver weight per body weight. Placental weight per body weight was similar in both groups. The brain weight per body weight, brain to liver ratio, and right ventricle to left ventricle plus intraventricular septal weight ratio were significantly increased in the hypobaric pups.

Right-sided congenital diaphragmatic herniae presenting as pleural effusions in the newborn: dangers and pitfalls

Congenital diaphragmatic hernia presented with right-sided pleural effusion in two newborn infants.

Prophylactic gastrostomy tubes for patients receiving radical radiotherapy for head and neck cancers: a retrospective review

Patients undergoing radical radiotherapy for head and neck cancers often experience significant complications. We sought to evaluate the impact of prophylactic gastrostomy tubes (PGTs) among these patients on four easily evaluable adverse outcomes, namely, absolute weight loss, percentage weight loss, admissions for nutritional reasons and treatment interruptions. A retrospective review was carried out on patients undergoing radical radiotherapy for primary head and neck cancers from September 1999 to October 2005 at the Wellington Blood and Cancer Centre (n = 71). PGTs were placed in 7 (10%) patients. Patients with PGTs were compared with the patients without PGTs (the control group) by univariate and multivariate analyses. By univariate analysis, there was no significant difference in absolute or percentage weight loss between those with PGTs and the control group. By multivariate analysis, those with PGTs lost 5.2% (P = 0.016) less weight than the control group. There were no significant differences between the two groups with regard to admissions for nutritional reasons or treatment interruptions. The use of PGTs can reduce weight loss in patients undergoing radical radiotherapy for head and neck cancers, and its use should be further evaluated in future studies.

The application of in vivo confocal microscopy and tear LDH measurement in assessing corneal response to contact lens and contact lens solutions

PURPOSE

To evaluate differences in corneal response to daily wear (DW) of soft contact lens (CL) wear with different CL solutions and to assess the ability of in vivo confocal microscopy (CM) and tear lactate dehydrogenase (LDH) measurement to detect such differences in NZW rabbits.

METHODS

Daily treatment of lenses consisted of a rub and rinse cleaning, then overnight soak in one of five solutions: Sauflon All in One (ALL), Compound A (CoA), OPTI-FREE((R) )Rinsing, Disinfecting, and Storage Solution (OPT), ReNu((R)) <?Pub Caret>Multipurpose Solution (REN), and UNISOL( (R)) Saline Solution (UNI). Rabbits (4/test group) wore 71% H( 2)O/type4 soft lenses approximately 7 hours daily. On days 0, 1, 3 and 7, slit lamp examination, tear LDH measurement, and in vivo CM were performed after removal of lenses. Using in vivo CM, epithelial thickness, epithelial cell area, and stromal thickness were measured, both centrally and peripherally.

RESULTS

Epithelial thickness in ALL, CoA, and UNI-treated eyes showed a significant decrease of 15.6%, 13. 3%, and 10.6% (p < 0.05 in all groups), centrally, while CoA, OPT, and UNI showed a significant decrease of 9.3%, 7.1%, and 4.4% (p < 0. 05 in all groups), peripherally. ALL showed a significant 9.5% (p < 0.05) decrease of central cell area, while CoA showed a significant 21.5% (p < 0.01) decrease peripherally. UNI demonstrated a significant 3.2% (p < 0.05) decrease in central stromal thickness. ALL, CoA, and UNI showed a significant increase in LDH level of 152. 1%, 192.1%, and 308.2% (p < 0.05 in all groups) at day 3, respectively, but values declined at day 7. Significant changes in basal epithelial morphology were also observed with CoA on day 7 on in vivo CM.

CONCLUSIONS

Overall, lens care solutions in combination with CL wear may interact to cause increased epithelial desquamation leading to decreased surface cell area and epithelial thickness. The clinical significance of these changes will require further investigation. In vivo CM combined with tear LDH assay is a quantitative, objective, non-invasive method of assessing CL wear and CL disinfecting solution effects on the cornea, and is able to detect differences in corneal response to different CL solutions.

Evidence for the ability of nucleophosmin/B23 to bind ATP

By taking advantage of its ability to be retained by ATP-agarose, we have demonstrated that nucleophosmin/B23 is capable of binding ATP. The specificity of the binding was confirmed by the absence of significant binding to AMP-agarose and by its loss when nucleophosmin/B23 in nuclear extracts was preincubated with ATP. Preincubation of the nuclear extracts with other ribonucleotide triphosphates (GTP, CTP, UTP) did not compete for the binding of nucleophosmin/B23 to ATP-agarose. The purified recombinant nucleophosmin/B23 was also able to be retained by ATP-agarose. The Kd for binding of ATP to the purified recombinant nucleophosmin/B23, on the basis of retention on a nitrocellulose membrane, was 86.5+/-8.3 microM; the number of binding sites was 0.68 per nucleophosmin/B23 protein molecule. To determine the possible ATP-binding site of nucleophosmin/B23, various deletion clones including the two mutants in which the putative ATP-binding sequence had been deleted were constructed. Deletion of the portions of the molecule (residues 83-152 and 185-240) had little effect on the ATP binding. The C-terminal deleted mutant (residue 242 to the C-terminus deleted) lost most of its ability to be retained by ATP-agarose and to bind [alpha-32P]ATP on a nitrocellulose membrane. The results indicate that the C-terminal portion (residues 242-294) contains the essential ATP-binding site of nucleophosmin/B23.

Organotypic slice cultures of pancreatic ductal adenocarcinoma preserve the tumor microenvironment and provide a platform for drug response

BACKGROUND

/Objective: The conventional models currently used to evaluate various anti-tumor therapeutic agents are not sufficient for representing human pancreatic ductal adenocarcinoma (PDA), which has a unique tumor microenvironment. We aimed to produce an organotypic slice culture model from human PDA that resembles the in vivo situation and to evaluate the responses of PDA slices to established cytotoxic drugs.

METHODS

PDA tissues were obtained from 10 patients who underwent pancreatic resection. The tissues were sliced by a vibratome, and the tumor slices were then cultured. The viability of tumor slices during slice culture was evaluated using H&E and immunohistochemical staining, and stromal cells were demonstrated. The effects of cytotoxic drugs on PDA cell lines and slices were analyzed.

RESULTS

Tumor slices maintained their surface areas and tissue viability for at least five days during culture. Preserved proliferation and apoptosis in tumor slices were observed by the expression of Ki-67 and cleaved caspase-3. Stromal cells including macrophages (CD68⁺ and CD163⁺), T cells (CD3⁺, CD8⁺, and FOXP3⁺), and myeloid cells (CD11b⁺) were present throughout the culture period. Staurosporine, gemcitabine, and cisplatin treatment of PDA cell lines and tumor slices exerted proportional cytotoxic effects in terms of MTT viability, tumor cell number, and Ki-67 and cleaved caspase-3 expression.

CONCLUSIONS

Organotypic human PDA slice cultures preserved their viability and tumor microenvironment for at least five days during slice culture. PDA slice culture appears to be a feasible preclinical test model to assess the response to anti-tumor agents.