Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis

BACKGROUND

The best approach for cholecystocholedocholithiasis remains a matter of debate. The aim of this study was to evaluate the technical aspects, learning curve and outcome of laparoscopic transcystic common bile duct exploration (LTCBDE).

METHODS

Patients who underwent laparoscopic cholecystectomy with LTCBDE between January 2007 and December 2012 were identified from an institutional database. Data on preoperative investigations, intraoperative and postoperative findings were retrieved retrospectively from the patients' hospital notes.

RESULTS

There were 399 women (56·4 per cent) and 309 men (43·6 per cent), with a median age of 58 (range 18-87) years. Microincision (incision of the cystic duct at the confluence with the common bile duct (CBD) with extension of only 3-5 mm at the lateral margin of the CBD) and lithotripsy were used in the transcystic exploration in 119 patients, and increased the success rate of LTCBDE from 74·2 to 91·0 per cent. The median duration of operation was 85 (i.q.r. 65-120) min and the median postoperative hospital stay was 2 (1-3) days. Retained common bile duct stones were observed in 13 patients, and postoperative complications developed in 27 patients. The cumulative sum duration of operation learning curve comprised two phases; phase 1 included the first 250 patients and phase 2 the remaining 458 patients. Duration of operation and postoperative hospital stay decreased with increasing volume per surgeon. Recurrence of common bile duct stones was diagnosed in 26 patients during a median follow-up of 4 years.

CONCLUSION

LTCBDE with or without microincision and/or lithotripsy is a safe and effective approach.

Association of patellar bone marrow lesions with knee pain, patellar cartilage defect and patellar cartilage volume loss in older adults: a cohort study

AIM

To examine the cross-sectional and longitudinal associations of patellar bone marrow lesion (BMLs) with knee pain, cartilage defects and cartilage volume in older adults.

METHODS

A total of 904 randomly selected subjects (mean 62.4 years, 49.9% female) were studied. Fat suppressed T1-weighted spoiled gradient recall and T2-weighted fast spin echo magnetic resonance imaging (MRI) sequences were used to assess cartilage volume, cartilage defects and/or BMLs at baseline (n = 904) and 2.6 (range: 1.4-4.8) years' follow-up (n = 414). Knee pain was assessed by self-administered Western Ontario McMaster Osteoarthritis Index (WOMAC) questionnaire at baseline (n = 904) and follow-up (n = 790).

RESULTS

The prevalence of any patellar BMLs was 19% and was higher in those with tibiofemoral BMLs. In multivariable analyses, patellar BMLs were positively associated with any knee pain at baseline and an increase in knee pain when going up/down stairs (odds ratio (OR): 1.67, 95% confidence interval (CI): 1.08, 2.59) but not with other knee pain subscales. Patella BMLs were also associated with patellar cartilage defects both at baseline and change over time (OR: 1.76, 95% CI: 1.00, 3.70) but not tibiofemoral defects. Patellar BMLs were negatively associated with baseline and change in patella cartilage volume (β: -2.10%, 95% CI: -3.39%, -0.80%). These associations remained significant after further adjustment for tibiofemoral BMLs.

CONCLUSIONS

Patellar BMLs were consistently associated with increased knee pain especially going up/down stairs, increased patellar cartilage defects, and decreased patellar cartilage volume cross-sectionally and longitudinally, suggesting a predominantly compartment specific role for patellar BMLs.

Association between information provision and decisional conflict in cancer patients

BACKGROUND

In this study, we aimed to identify demographic and clinical variables that correlate with perceived information provision among cancer patients and determine the association of information provision with decisional conflict (DC).

PATIENTS AND METHODS

We enrolled a total of 625 patients with cancer from two Korean hospitals in 2012. We used the European Organization for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire (QLQ-INFO26) to assess patients' perception of the information received from their doctors and the Decisional Conflict Scale (DCS) to assess DC. To identify predictive sociodemographic and clinical variables for adequate information provision, backward selective logistic regression analyses were conducted. In addition, adjusted multivariate logistic regression analyses were carried out to identify clinically meaningful differences of perceived level of information subscales associated with high DC.

RESULTS

More than half of patients with cancer showed insufficient satisfaction with medical information about disease (56%), treatment (73%), other services (83%), and global score (80%). In multiple logistic regression analyses, lower income and education, female, unmarried status, type of cancer with good prognosis, and early stage of treatment process were associated with patients' perception of inadequate information provision. In addition, Information about the medical tests with high DCS values clarity [adjusted odds ratio (aOR), 0.54; 95% confidence interval (CI) 0.30-0.97] and support (aOR, 0.53; 95% CI 0.33-0.85) showed negative significance. For inadequate information perception about treatments and other services, all 5 DCS scales (uncertainty, informed, values clarity, support, and effective decision) were negatively related. Global score of inadequate information provision also showed negative association with high DCS effective decision (aOR, 0.43; 95% CI 0.26-0.71) and DCS uncertainty (aOR, 0.46; 95% CI 0.27-0.77).

CONCLUSION

This study found that inadequate levels of perceived information correlated with several demographic and clinical characteristics. In addition, sufficient perceived information levels may be related to low levels of DC.

Association between the CYP11B2 gene -344T>C polymorphism and coronary artery disease: a meta-analysis

Numerous studies have evaluated the association between the CYP11B2 gene -344T>C polymorphism and coronary artery disease (CAD) risk. However, the specific association is still controversial. To address this issue, PubMed, EMBASE, and China National Knowledge Infrastructure databases were searched for eligible articles that reported on the relationship between the CYP11B2 gene -344T>C polymorphism and CAD, and were published before April 2014. Data from five separate studies with 3687 subjects were analyzed by meta-analysis. No significant variation in CAD risk was detected by any of the genetic models in the overall study population. Taking into account the effect of ethnicity, further stratified analyses demonstrated significant association in both Caucasian (TT vs TC: OR = 0.80, 95%CI = 0.64-1.00) and Asian populations (TT vs TC: OR = 1.25, 95%CI = 1.01-1.54; dominant model: OR = 0.80, 95%CI = 0.66-0.98). The pooled ORs were not substantially altered after the exclusion of one study in the control group that deviated from Hardy-Weinberg equilibrium, highlighting the reliability of our meta-analysis results. In conclusion, this meta-analysis suggested that the -344T>C polymorphism in the CYP11B2 gene might be associated with susceptibility to CAD in Caucasians and Asians.

Markers of Autolysis in Acute ST Elevation Myocardial Infarction

INTRODUCTION

The availability of reliable noninvasive markers for infarct-related artery (IRA) patency status are very limited, otherwise could allow early identification of patients with patent IRA, for whom repeat thrombolysis or rescue percutaneous coronary intervention (PCI) are not necessary.

METHODS

We conducted a single centered retrospective study of STEMI patients undergoing primary PCI to determine how various factors such as demographic characteristics, risk markers of coronary heart disease, clinical and blood parameters present differently in patients with higher coronary flow and patent infarct related artery from patients with total occlusion at the time of initial angiography and how they affect in outcome of the disease.

RESULTS

MPV level (11.96 fL vs. 10.92 fL, P < 0.001), Lp (a) level (179.57 nmol/l vs 141.16 nmol/l , p < 0.001), CK-MB (290.2 vs. 190.98, P < 0.001), total cholesterol level (4.11 mmol/L vs. 3.8 mmol/L, p < 0.02) in total occlusion group were higher than in the patent IRA group. Wall motion abnormality was 77.2% for 203 patients with total occlusion group and 54.2% for 83 patients with patent IRA group (P<0.01). Mean hospital stay days were higher in total occlusion group as compared to the patent IRA group P < 0.01.

CONCLUSIONS

MVP, Lp (a), TC, and CK-MB levels and myocardial wall motion at the presentation may play the role of markers for IRA patency status that will help in early identification of patients with IRA, for whom repeat thrombolysis or rescue PCI may not be required.

SIDE EFFECTS OF TUBERCULOSIS TREATMENT WITH FIXED-DOSE COMBINATIONS

This paper aimed to explore the therapeutic effect and safety of Fixed-dose Combinations (FDCs) on tuberculosis. A computer search was carried out to review the literature related to clinical randomized controlled trials (RCTs) and clinical controlled trails (CCTs) on the curative effect and safety of treating pulmonary tuberculosis with FDCs. The results demonstrated that, in the 22 studies examined, comparison of sputum negative conservation rate of treating smear-positive pulmonary tuberculosis with FDCs and single drug, the relative risk (RR) value and 95% confidence interval (CI) were 1.02 (1.01, 1.03) and 1.01 (1.00, 1.02), respectively, at the end of the 2nd month and 6th month (P<0.05), while comparison of the relapse rate within six months showed that RR value and 95% CI was 1.72 (0.98, 3.02) (P>0.05). No statistically significant differences were found between the two groups in total occurrence of the rates of side effects pertaining to skin reaction, gastrointestinal tract side reaction, occurrence rate of liver and gall side reaction or occurrence rate of drug withdrawal because of side effects (P>0.05). After sensitivity analysis, it was found that occurrence rate of gastrointestinal tract side effects and occurrence rate of liver and gall side effects were unstable. All the findings suggest that the curative effect of treating tuberculosis with FDCs is better than that of a single drug. More reliable evidence is required since the safety evaluation results are not stable.

Rescue effects: irradiated cells helped by unirradiated bystander cells

The rescue effect describes the phenomenon where irradiated cells or organisms derive benefits from the feedback signals sent from the bystander unirradiated cells or organisms. An example of the benefit is the mitigation of radiation-induced DNA damages in the irradiated cells. The rescue effect can compromise the efficacy of radioimmunotherapy (RIT) (and actually all radiotherapy). In this paper, the discovery and subsequent confirmation studies on the rescue effect were reviewed. The mechanisms and the chemical messengers responsible for the rescue effect studied to date were summarized. The rescue effect between irradiated and bystander unirradiated zebrafish embryos in vivo sharing the same medium was also described. In the discussion section, the mechanism proposed for the rescue effect involving activation of the nuclear factor κB (NF-κB) pathway was scrutinized. This mechanism could explain the promotion of cellular survival and correct repair of DNA damage, dependence on cyclic adenosine monophosphate (cAMP) and modulation of intracellular reactive oxygen species (ROS) level in irradiated cells. Exploitation of the NF-κB pathway to improve the effectiveness of RIT was proposed. Finally, the possibility of using zebrafish embryos as the model to study the efficacy of RIT in treating solid tumors was also discussed.

A Case Report of Spontaneous Lesser Omental Haemorrhage

Spontaneous rupture of the lesser omental artery in the absence of identifiable causes is rare. We describe a case of abdominal apoplexy secondary to a spontaneous lesser omental artery rupture. A 73-year-old woman presented to our emergency department for acute abdominal pain with persistent nausea and vomiting. Abdominal examination revealed mild epigastric tenderness but no signs of peritonitis. Computed tomography of the abdomen suggested a massive volume of blood in the peritoneal and pelvic cavity. The diagnosis was made by exploratory laparotomy revealing haemoperitoneum, a haematoma in the lesser omentum near the antrum with an active bleeder. Choices of investigation modality for diagnosis and treatment are discussed. (Hong Kong j.emerg.med. 2015;22:53-56)

Glutathione S-transferase M1 modulates allergen-induced NF-κB activation in asthmatic airway epithelium

BACKGROUND

Glutathione S-transferase M1 (GSTM1) is a phase II enzyme and regulator of inflammatory signaling in airway epithelial cells. We have found upregulation of neutrophilic airway inflammation in atopic asthmatics expressing GSTM1 gene (GSTM1+) compared to GSTM1null asthmatics. We hypothesized that GSTM1 modulates NF-κB activation in bronchial epithelium in atopic asthmatics. We determined regulation of allergen-induced NF-κB activation in bronchial epithelium by GSTM1 in human atopic asthmatics in vivo.

METHODS

Endobronchial biopsies and bronchoalveolar lavage fluid samples were collected from 13 GSTM1+ and 12 GSTM1null human atopic asthmatics at baseline and 24 h after segmental allergen challenge. A quantitative analysis of NF-κB activation in airway epithelium was accomplished using a polyclonal antibody against the phosphorylated p65 component of NF-κB. Elastase-positive neutrophils in the bronchial wall were quantified.

RESULTS

Postallergen neutrophilia in airway subepithelium and epithelial lining fluid was greater in GSTM1+ compared to GSTM1null asthmatics. Airway eosinophilia was similar in GSTM1+ and GSTM1null asthmatics. Allergen-provoked NF-κB induction in bronchial epithelium was significantly greater in GSTM1+ compared to GSTM1null asthmatics. Activation of NF-κB activation in airway epithelial cells correlated with interleukin-8 concentrations and absolute neutrophil numbers in bronchoalveolar lavage fluid in GSTM1+ but not GSTM1null asthmatics.

CONCLUSIONS

Allergen-induced neutrophilic airway inflammation in GSTM1+ asthmatics is associated with NF-κB activation in airway epithelial cells in vivo. These novel data provide a potential mechanism of the genomic link between GSTM1 polymorphism and airway neutrophilia in atopic asthma.

Investigating the role of angiogenesis in systemic lupus erythematosus

OBJECTIVE

We aimed to elucidate the roles of six pro-angiogenic factors, namely, basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), placental growth factor (PlGF), hepatocyte growth factor (HGF), transforming growth factor-beta (TGF-beta) and tumor necrosis factor-alpha (TNF-alpha), in the pathogenesis of systemic lupus erythematosus (SLE).

METHODS

A group of 75 patients with SLE and a control group of 40 healthy volunteers were recruited. Angiogenic factors were tested through enzyme-linked immunosorbent assay (ELISA) measurement. The angiogenic activities of the patients with SLE and the healthy controls were assessed and a correlation analysis of these angiogenic factors was conducted.

RESULTS

A much higher level of angiogenic activity was shown in the serum of patients with SLE than that of the healthy controls, yet no statistically significant difference was found in the angiogenic activities of active SLE and inactive SLE. Serum VEGF level in the active SLE group was significantly higher than that in the control group and the inactive SLE group, and serum HGF level was strongly positively correlated with VEGF in all SLE groups; meanwhile, there was also a statistically significant positive correlation between TNF-alpha and VEGF in all SLE groups. There was a statistically significant positive correlation between serum VEGF level and bFGF level in the active SLE group. There was a slightly negative correlation between serum HGF level and TGF-beta level in the SLE group, but this negativity did not reach the significance level. Likewise, positive correlation was also shown in the serum VEGF level and PlGF level, yet not in bFGF with PlGF.

CONCLUSION

Circulating serum angiogenic cytokines may be disease markers of SLE activity. Anti-angiogenic agents such as thalidomide and endogenous angiogenesis inhibitors such as endostatin are potentially effective and promising therapies in the treatment of SLE.

Low molecular weight polyethylenimine as a transgenic vector for tumor gene therapy

We constructed a polymer composed of a series of small molecule polyethylenimine (PEI) using 4-arm polyethylenimine (PEG) as a core for tumor gene therapy. N,N'-carbonyldiimidazole and N-succinimidyl-3-(2-pyridyldithio) propionate were used as chemical connecting reagents to synthesize 4-arm PEG-PEI2000 and 4-arm PEG-PEI2000-MC11. Chemical characterization was performed using (1)H-NMR. The retardation effect of polymers on plasmid DNA was observed using electrophoretic mobility shift and MTT assays to test the toxicity of the polymers. The gene delivery capability of 4-arm PEG-PEI2000 and 4-arm PEG-PEI2000-MC11, and the effect of MC11 were determined by an in vitro gene delivery experiment with human hepatoma HepG2 cells. At a N:P ratio of 3, the 4-arm PEG-PEI2000 could retard successfully plasmid DNA with low toxicity. In experiments in vitro, when the N:P ratio was 30, the gene delivery efficiency of 4-arm PEG-PEI2000 in HepG2 cells was five times that of PEI2000; After connecting ligand MC11, however, the gene delivery efficiency was twice as great. Free MC11 effectively inhibited the gene delivery efficiency of the 4-arm PEG-PEI2000-MC11. Four-arm PEG-PEI2000 has low toxicity and high gene delivery efficiency, and is an effective gene delivery vector after linking ligand MC11.

Mass effect and signal intensity alteration in the suprapatellar fat pad: associations with knee symptoms and structure

OBJECTIVE

To describe cross-sectional associations between mass effect or signal intensity alteration of the suprapatellar fat pad (SPFP) with knee symptoms and structure in older adults.

METHODS

A cross-sectional sample of 904 randomly selected subjects (mean 62.4 years, 49.9% female) was studied. T1- or T2-weighted fat suppressed magnetic resonance imaging (MRI) was used to assess mass effect or signal intensity alteration of SPFP, cartilage volume, cartilage defects, and bone marrow lesions (BMLs). Knee pain was assessed by self-administered Western Ontario McMaster Osteoarthritis Index (WOMAC) questionnaire. The Osteoarthritis Research Society International (OARSI) atlas was used to assess knee osteophyte, joint space narrowing (JSN) and radiographic osteoarthritis (ROA). Univariable and multivariable linear or logistic regression analyses were used to examine the associations.

RESULTS

After adjustment for confounders including age, sex, body mass index (BMI), disease status, tibial bone area and/or ROA, the presence of SPFP mass effect was significantly associated with any knee pain (OR: 2.39; 95% confidence interval (CI): 1.54, 3.70) and ROA (OR: 2.10; 95% CI: 1.33, 3.31) but not with cartilage volume, cartilage defects or BMLs. The presence of SPFP signal intensity alteration was significantly associated with any knee pain (OR: 1.90; 95% CI: 1.43, 2.53), ROA (OR: 1.83; 95% CI: 1.37, 2.45), any BMLs (OR: 1.55; 95% CI: 1.17, 2.06) but not with cartilage volume and cartilage defects. Significant associations with knee pain and BMLs were more evident in subjects with ROA. Presence of SPFP mass effect and/or signal intensity alteration combined was associated with any tibial cartilage defects (OR: 1.45; 95% CI: 1.04, 2.04).

CONCLUSIONS

SPFP mass effect and/or signal intensity alterations are deleteriously associated with knee pain, radiographic OA and BMLs in this cross-sectional study, suggesting that SPFP abnormalities may contribute to pain and structural abnormalities in the knee.

Effects of high thoracic epidural anesthesia on ischemic cardiomyopathy cardiac function and autonomic neural function

We aimed at observing the effects of high thoracic epidural anesthesia (HTEA) on cardiac structure and function, heart rate variability (HRV), and QT interval variation (QTV) in ischemic cardiomyopathy (ICM) patients with chronic heart failure. We divided 30 ICM patients into HTEA (N = 16) and control (N = 14) groups.The control group was treated with medication, and the HTEA group was treated with HTEA and medication for 4 weeks. We measured the changes in the left-ventricular end-diastolic diameter (LVEDd) and left-ventricular ejection fraction (LVEF) before and after treatment by using echocardiography and examined changes in HRV and QTV using ambulatory electrocardiogram. HTEA significantly narrowed the LVEDd, improved LVEF, significantly increased the HRV, and significantly reduced the QTV in the ICM group compared to the control group. HTEA significantly narrowed the ventricular chamber diameter size of ICM patients, enhanced myocardial contractility, increased myocardial electrical stability, and improved the cardiac structure and function.

Clozapine directly increases insulin and glucagon secretion from islets: implications for impairment of glucose tolerance

Second generation antipsychotics cause derangements in glucose metabolism that are often interpreted as insulin resistance. In previous studies we have shown that this is not classical insulin resistance but the drugs were actually inducing a hyperglycaemic state associated with elevated hepatic glucose output (HGO) and increased levels of glucagon and insulin. However, it remains unclear whether these effects are directly elicited by drug actions in the liver and pancreas, or whether they are indirectly mediated. Here we investigated if clozapine is capable of inducing insulin resistance in the liver or enhancing insulin and glucagon secretion from the pancreas. It was observed that insulin signalling was elevated in livers from animals treated with clozapine indicating there was no insulin resistance in the early steps of insulin signalling. To explore whether the defects arise at later stages of insulin action we used an isolated perfused liver system. In this model, clozapine had no direct effect on insulin's counter regulatory effect on epinephrine-induced HGO. In isolated mouse islets clozapine significantly increased glucose-stimulated insulin secretion while simultaneously blocking glucose-induced reductions in glucagon secretion. We also show that the non-peptidic glucagon receptor like peptide-1 (GLP-1) receptor agonist Boc5 was able to overcome the inhibitory effects of clozapine on glucose metabolism. Taken together these results suggest that clozapine does not have any direct effect on glucose metabolism in the liver but it simultaneously stimulates insulin and glucagon secretion, a situation that would allow for the concurrent presence of high glucose and high insulin levels in treated animals.