Antibodies to the α3 subunit of the ganglionic-type nicotinic acetylcholine receptors in patients with autoimmune encephalitis

Since autonomic dysfunction is closely associated with autoimmune encephalitis (AE), the objective of this study was to determine the autonomic symptoms and the prevalence of anti-α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (gAChRα3) antibodies in the patients with AE. We reviewed the clinical features of 19 AE patients, and specifically analyzed sera for anti-gAChRα3 antibodies using the luciferase immunoprecipitation system (LIPS) assay. Cardiovascular autonomic symptoms were found to be common in patients with AE, and hypersalivation was seen only in patients with NMDAR encephalitis. LIPS detected anti-gAChRα3 antibodies in the sera from patients with AE (5/29, 26%). This study is the first to demonstrate that clinical characteristics including autonomic symptoms of AE patients with seropositivity for gAChR autoantibodies. It will be important to verify the role of gAChR antibodies in autonomic dysfunction and brain symptoms to clarify the pathogenesis of AE.

Clinical efficacy of haematopoietic stem cell transplantation for adult adrenoleukodystrophy

Accumulated experience supports the efficacy of allogenic haematopoietic stem cell transplantation in arresting the progression of childhood-onset cerebral form of adrenoleukodystrophy in early stages. For adulthood-onset cerebral form of adrenoleukodystrophy, however, there have been only a few reports on haematopoietic stem cell transplantation and the clinical efficacy and safety of that for adulthood-onset cerebral form of adrenoleukodystrophy remain to be established. To evaluate the clinical efficacy and safety of haematopoietic stem cell transplantation, we conducted haematopoietic stem cell transplantation on 12 patients with adolescent-/adult-onset cerebral form/cerebello-brainstem form of adrenoleukodystrophy in a single-institution-based prospective study. Through careful prospective follow-up of 45 male adrenoleukodystrophy patients, we aimed to enrol patients with adolescent-/adult-onset cerebral form/cerebello-brainstem form of adrenoleukodystrophy at early stages. Indications for haematopoietic stem cell transplantation included cerebral form of adrenoleukodystrophy or cerebello-brainstem form of adrenoleukodystrophy with Loes scores up to 13, the presence of progressively enlarging white matter lesions and/or lesions with gadolinium enhancement on brain MRI. Clinical outcomes of haematopoietic stem cell transplantation were evaluated by the survival rate as well as by serial evaluation of clinical rating scale scores and neurological and MRI findings. Clinical courses of eight patients who did not undergo haematopoietic stem cell transplantation were also evaluated for comparison of the survival rate. All the patients who underwent haematopoietic stem cell transplantation survived to date with a median follow-up period of 28.6 months (4.2–125.3 months) without fatality. Neurological findings attributable to cerebral/cerebellar/brainstem lesions became stable or partially improved in all the patients. Gadolinium-enhanced brain lesions disappeared or became obscure within 3.5 months and the white matter lesions of MRI became stable or small. The median Loes scores before haematopoietic stem cell transplantation and at the last follow-up visit were 6.0 and 5.25, respectively. Of the eight patients who did not undergo haematopoietic stem cell transplantation, six patients died 69.1 months (median period; range 16.0–104.1 months) after the onset of the cerebral/cerebellar/brainstem lesions, confirming that the survival probability was significantly higher in patients with haematopoietic stem cell transplantation compared with that in patients without haematopoietic stem cell transplantation (P = 0.0089). The present study showed that haematopoietic stem cell transplantation was conducted safely and arrested the inflammatory demyelination in all the patients with adolescent-/adult-onset cerebral form/cerebello-brainstem form of adrenoleukodystrophy when haematopoietic stem cell transplantation was conducted in the early stages. Further studies are warranted to optimize the procedures of haematopoietic stem cell transplantation for adolescent-/adult-onset cerebral form/cerebello-brainstem form of adrenoleukodystrophy.

Risk Factors Associated with Retinal Lesions Resulting from Widespread Systemic Infection

PURPOSE

To clarify the prevalence, microbiologic features, and risk factors of endogenous intraocular infections in patients with positive fungal or bacterial blood culture results.

DESIGN

Retrospective case series.

PARTICIPANTS

Inpatients (n = 433) with positive blood culture results who underwent an ophthalmology consultation between January 2006 and September 2012 in Japan.

METHODS

We retrospectively reviewed the ophthalmology consultations of 433 inpatients with positive blood culture results. Clinical features of patients with confirmed chorioretinitis or endophthalmitis were analyzed through descriptive statistical methods and univariate and multivariate models.

MAIN OUTCOME MEASURES

Correlation of clinical features with retinal lesions of disseminated bacteremia or fungemia.

RESULTS

Among 433 inpatients with positive blood culture results, 116 (26.8%) were unresponsive and 27 (6.2%) had subjective ocular symptoms. Eighty-four (19.4%) had candidemia, including 16 (3.7%) with retinal lesions. Additionally, 34 patients (7.8%) had chorioretinitis or endophthalmitis in 1 eye (17 patients [3.9%]) or both eyes (17 eyes [3.9%]; 51 eyes total). Of these 34 patients, 20 (58.8%) and 17 (50%) had systemic bacterial and fungal infections, respectively (both infections were noted in 3 patients [8.8%]). Staphylococcus aureus was the most common bacteria. Candida albicans was the most common fungus, followed by Candida glabrata. Catheter-related bloodstream infections were the most common source of infection among the 34 patients with chorioretinitis or endophthalmitis, followed by infective endocarditis, urinary tract infection, and soft-tissue and bone disease. Among the 114 bacteremic patients who underwent an ophthalmology consultation because of suspicion of infective endocarditis, only 16 (14%) had infective endocarditis, of whom only 1 (0.88%) had retinal lesions. Nineteen of 34 patients (55.9%) with retinal lesions survived sepsis. Among them, only 1 patient (5.3%) with bacteremia lost significant vision (no light perception), and the remaining 18 patients (94.7%) regained vision. No patient with candidemia had vision loss. Multivariate analysis revealed that candidemia, infective endocarditis, broad-spectrum antibiotic use, and eye symptoms were independent predictors of retinal lesions (all P < 0.05).

CONCLUSIONS

An ophthalmology consultation may be useful for patients with candidemia, infective endocarditis, broad-spectrum antibiotic use, or ocular symptoms. However, routine ophthalmologic evaluation may be less efficient for bacteremic patients without definitive infective endocarditis lacking other risk factors.

Impact of anastomotic complications on outcome after laparoscopic gastrectomy for early gastric cancer

BACKGROUND

The effects of anastomotic complications after laparoscopically assisted gastrectomy (LAG) have not been studied widely. The aims of this observational study were to identify potential factors that predict anastomotic complications and investigate the impact of anastomotic complications in patients undergoing gastrectomy for early gastric cancer.

METHODS

The study included consecutive patients with histologically proven T1 gastric adenocarcinoma treated by LAG with regional lymphadenectomy between August 1997 and March 2008, who had not received neoadjuvant chemotherapy. Anastomotic complications included anastomotic leakage, stricture and remnant gastric stasis of grade II or higher (modified Clavien classification) and were identified by clinical assessment and confirmatory investigation. Predictive factors for the development of anastomotic complications were identified by univariable and multivariable analyses. Long-term survival with or without anastomotic complications was examined.

RESULTS

Anastomotic complications occurred in 37 (9·3 per cent) of 400 patients. Multivariable analysis indicated surgeon experience as the only independent predictor of anastomotic complications (hazard ratio 4·40, 95 per cent confidence interval 2·04 to 9·53; P < 0·001). Patients with anastomotic complications had a significantly worse overall 5-year survival rate than those without (81 versus 94·2 per cent; P = 0·009).

CONCLUSION

Anastomotic complications after LAG lead to worse long-term survival.

Ischemic heart disease due to compression of the coronary arteries by malignant lymphoma

A 76-year-old man presented with a two-month history of angina pectoris. Computed tomography (CT) revealed a serial enlargement of the supraclavicular and mediastinal lymph nodes compressing the heart, pulmonary artery and aorta. CT angiography (CTA) showed stenosis of the coronary arteries as a result of compression by the enlarged lymph nodes. First-pass contrast-enhanced cardiac magnetic resonance imaging (MRI) at rest revealed a perfusion defect, thus indicating myocardial ischemia. Diffuse large B-cell lymphoma was diagnosed and multidrug combination chemotherapy led to prompt improvement of the symptoms. Relief of the stenosis in the coronary arteries and improvements in myocardial perfusion were noted on follow-up CTA and MRI.

Iron-binding properties of bovine lactoferrin in iron-rich solution

The iron-binding properties of bovine lactoferrin in iron-rich solution were investigated. Ferrous iron was not stable in solution and was easily changed to the insoluble ferric state, but solubility of ferrous iron was stabilized by the presence of lactoferrin. However, casein hydrolysate or BSA was not effective in stabilizing iron in solution. As indicated by use of cibacron blue affinity gel, iron bound to lactoferrin, and the charge of supersaturated lactoferrin was higher than that of normal iron-saturated lactoferrin according to native PAGE electrophoresis. The evidence suggests that lactoferrin can bind iron at sites other than its chelate-binding sites, thereby stabilizing iron in solution.

[Studies on postoperative arterial infusion chemotherapy using implanted reservoir for hepatocellular carcinoma]

The effect of postoperative arterial infusion therapy using implanted reservoir was evaluated in 28 cases of resected hepatocellular carcinoma which showed at least one of those findings as Vp (+), Vv (+), IM (+) and more than 5 cm in tumor diameter. Ten of them underwent arterial infusion therapy with combination ADM and CDDP after hepatic resection (IA group) and the rest underwent no regional chemotherapy (control group). The one-, two- and three-year cumulative disease-free survival rates between control group and IA group were 55.6% against 80.0%, 25.4% against 70.0%, and 16.9% against 37.3%, respectively. The one-, two- and three-year cumulative survival rates between control group and IA group were 71.8% against 90.0%, 51.8% against 70.0% and 41.5% against 56.0%, respectively, a difference that was not statistically significant. We suggest this therapy can prevent intrahepatic recurrence, although it does not improve prognosis. To achieve a better prognosis, a new arterial infusion chemotherapy more effective than this one must be developed.