Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review

RATIONALE

Coronavirus disease 2019 (COVID-19) is an infectious disease that often causes complications in multiple organs and thrombosis due to abnormal blood coagulation. This case report aimed to describe the clinical course of COVID-19-associated thrombotic microangiopathy (TMA) and reviewed the comprehensive information on TMA, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome associated with COVID-19 in the past literature.

PATIENT CONCERNS

A 46-year-old Japanese man was diagnosed with human immunodeficiency virus infection 10 years ago and treated with antiretroviral therapy. The patient presented with fever, malaise, hematuria, and bilateral upper abdominal discomfort for the past 4 days.

DIAGNOSES

COVID-19-associated TMA was diagnosed based on a positive polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 and laboratory findings such as thrombocytopenia, acute kidney injury, and hemolytic anemia. Malignant hypertension and human immunodeficiency virus infection were also considered as differential diagnoses of TMA.

INTERVENTIONS

Considering the possibility of TTP, plasma exchange was performed, and glucocorticoids were administered. Hemodialysis was performed for acute kidney injury. Antihypertensive drugs were administered to control the high blood pressure.

OUTCOMES

Platelet count and renal function improved, and hemodialysis was no longer required. The patient was in good general condition and was discharged from the hospital.

LESSONS

COVID-19-associated TMA should be considered as a differential diagnosis during the COVID-19 epidemic. Excessive inflammation and severe COVID-19 are not essential for TMA development. Early intervention using conventional TMA treatments, such as plasma exchange and corticosteroids, might be important in improving prognosis while differentiating between TTP and atypical hemolytic uremic syndrome. Antihypertensive therapy may be helpful in the treatment of COVID-19-associated TMA.

Changes in rapid plasma reagin titers in patients with syphilis before and after treatment: A retrospective cohort study in an HIV/AIDS referral hospital in Tokyo

INTRODUCTION

Although the rapid plasma reagin (RPR) test is used to determine treatment efficacy for syphilis, animal studies show that it decreases gradually after an initial increase even without treatment. Pre-treatment changes in RPR titer in humans and its relationship with post-treatment changes in RPR titer are not well known.

METHODS

We retrospectively analyzed the clinical records of syphilitic patients who underwent automated RPR (Mediace) testing twice before treatment (i.e., at diagnosis and treatment initiation) within 1-3 months at an HIV/AIDS referral hospital in Japan between 2006 and 2018. The RPR values were expressed as the ratio to the value at treatment initiation. The mean monthly relative change in the RPR after treatment was calculated on the log2 scale for each patient and analyzed by multivariable linear regression.

RESULTS

Sixty-eight patients were identified. The median age was 45 (interquartile range [IQR], 38-50), 98.5% (67/68) were men, and 97.1% (66/68) had HIV. The median RPR titer ratio at treatment initiation/diagnosis was 0.87 (IQR, 0.48-1.30). The RPR titer decreased more than twofold in 26.5% (18/68) and more than fourfold in 10.3% (7/68) before treatment. In the multivariable analysis, higher age (predicted monthly RPR relative change on the log2 scale 0.23/10 years [95% confidence interval [CI], 0.090-0.37]), history of syphilis (0.36 [95% CI, 0.07-0.65]), and a lower ratio of RPR at treatment initiation/diagnosis (-0.52/every 10-fold increase [95% CI, -0.81 to -0.22]) were associated with a slower RPR decrease after treatment.

CONCLUSIONS

In a mostly HIV patient population, RPR titer can show more than four-fold spontaneous increase or decrease within 1-3 months. Pre-treatment spontaneous decrease of RPR titer was associated with a slower decrease in post-treatment RPR titer.

Successful dual antiviral therapy with remdesivir and ensitrelvir in a case of prolonged COVID-19 following B-cell depleting immunotherapy for malignant lymphoma

Prolonged COVID-19 following B-cell depleting immunotherapy for malignant lymphoma is characterized by repeated cycles of remission followed by symptom recurrence, persistent detection of SARS-CoV-2, and profound humoral immunodeficiency. To the best of our knowledge, the present report is the first to describe dual antiviral therapy with remdesivir and ensitrelvir for prolonged COVID-19 following B-cell depleting immunotherapy for malignant lymphoma. A 59-year-old, female patient with a history of follicular lymphoma treated with obinutuzumab and bendamustine contracted COVID-19 despite receiving a single course of standard remdesivir therapy. She received dual antiviral therapy with remdesivir following a five-day course of oral ensitrelvir, which improved her clinical symptoms and chest radiology findings and cleared SARS-CoV-2 from respiratory samples. Dual antiviral therapy with remdesivir and ensitrelvir may be sufficient to stop viral replication and promote clinical resolution in prolonged COVID-19 following B-cell depleting immunotherapy for malignant lymphoma.

[Outcomes of COVID-19 due to omicron variant infection complicated with hematological disorders]

When the omicron variant became the most dominant severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) variant causing coronavirus disease 2019 (COVID-19) in Japan, 11 patients with hematological diseases infected with this new variant were treated at our institution. Among them, four of the five patients who had been treated with chemotherapy progressed to moderate-II COVID-19, and two of them died. In contrast, five of the six patients who did not receive the treatment remained at mild to moderate-I stage of COVID-19, except for a single case progressing to moderate-II COVID-19. While all four patients infused with anti-coronavirus monoclonal antibodies within 8 days after the onset survived, the other two patients, being withheld from treatment or treated later, died. In these two cases, anti-SARS-Cov-2 immunoglobulin G antibodies remained at low titers. Although the omicron variant is considered a less harmful SARS-Cov-2 variant, patients with hematological disorders, particularly those who are immunosuppressed caused by chemotherapy, should be continuously cared for as they remain at a higher risk of severe COVID-19 due to insufficient or delayed anti-viral humoral immunity development. Thus, the rapid introduction of antiviral monoclonal antibodies together with anti-viral reagents may rescue these patients.

Nationwide Descriptive Epidemiological Study of Patients with COVID-19 Evacuated from Wuhan, China to Japan from January to February, 2020

We investigated the epidemiological findings regarding the route of coronavirus disease 2019 (COVID-19) and infection prevention and control (IPC) measures among returnees in the emergency evacuation from Wuhan, China to Japan during the COVID-19 outbreak in 2020. A total of 12 of the 14 returnees (median age [range]: 49.5 years [29-65 years]; 9 men [75%]) had confirmed COVID-19. The proportion of returnees with COVID-19 was 12/566 (2.1%) in Flights 1-3 and 2/263 (0.8%) in Flights 4 and 5. Six patients were asymptomatic on admission, while 3 patients developed symptoms thereafter. None of the participants reported a specific history of contact with animals, going to seafood markets, or visiting medical facilities. Two patients were in contact with an individual who was confirmed or suspected of having COVID-19. Most patients resided in hotels in the center of Wuhan City, taking taxis and trains for commute. Patients relatively adhered to IPC measures such as wearing a mask and hand hygiene. However, emphasis on IPC measures such as universal masking and more rigorous avoidance of exposure risk might have been necessary to prevent infection. In addition, forced social distancing due to lockdown might have contributed to the lower infection rates in Flights 4 and 5, compared to Flights 1-3.

Assessing countermeasures during a hepatitis A virus outbreak among men who have sex with men

Background

A hepatitis A epidemic occurred among men who have sex with men (MSM) in Japan in 2017–2018. In this study, we employ a parsimonious mathematical model to epidemiologically investigate the dynamics of infection, aiming to evaluate the effectiveness of campaign-based interventions among MSM to raise awareness of the situation.

Methods

A mathematical model describing a mixture of human-to-human transmission and environmental transmission was fitted to surveillance data. Taking seasonally varying environmental transmission into account, we estimated the reproduction number of hepatitis A virus during the course of epidemic, and, especially, the abrupt decline in this reproduction number following campaign-based interventions.

Results

The reproduction number prior to the countermeasures ranged from 2.6 to 3.1 and then began to decrease following campaign-based interventions. After the first countermeasure, the reproduction number decreased, but the epidemic remained supercritical (i.e., R_t > 1). The value of R_t dropped well below one following the second countermeasure, which used web articles to widely disseminate information about the epidemic risk.

Conclusions

Although the effective reproduction number, R_t, changes because of both intrinsic and extrinsic factors, the timing of the examined countermeasures against hepatitis A in the MSM population was consistent with the abrupt declines observed in R_t. Even without vaccination, the epidemic was brought under control, and risky behaviors may have been changed by the increase in situation awareness reached through web articles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12976-021-00150-1.

Proactive Engagement of the Expert Meeting in Managing the Early Phase of the COVID-19 Epidemic, Japan, February-June 2020

To deal with the risk of emerging diseases with many unknowns, close and timely collaboration and communication between science experts and policymakers are crucial to developing and implementing an effective science-based intervention strategy. The Expert Meeting, an ad hoc medical advisory body, was established in February 2020 to advise Japan’s COVID-19 Response Headquarters. The group played an important role in the policymaking process, promoting timely situation awareness and developing science-based proposals on interventions that were promptly reflected in government actions. However, this expert group may have been overly proactive in taking on the government’s role in crisis management. For the next stage of managing the coronavirus disease pandemic and future pandemics, the respective roles of the government and its advisory bodies need to be clearly defined. Leadership and strategic risk communication by the government are key.

How many coinfected patients with influenza and COVID-19 are there in a single Japanese hospital during the first wave?

Coronavirus disease 2019 (COVID-19) and influenza may infect a person simultaneously; hence, adequate measures must be prepared for the next winter in Japan. In preparation for the future, this study aimed to clarify the rate of influenza coinfection in patients with COVID-19 in previous winter. We conducted a retrospective study of the medical records of 193 patients diagnosed as having COVID-19 between January 31, 2020, and April 23, 2020, in a single hospital. We measured the rate of coinfection with COVID-19 and influenza. We found no patient was coinfected with influenza using rapid diagnostic testing. The occurrence of coinfection with influenza and COVID-19 seems to be rare in the past winter in Japan.

An analysis of the radiological factors associated with respiratory failure in COVID-19 pneumonia and the CT features among different age categories

Purpose

To investigate CT patterns of COVID-19 pneumonia associated with respiratory failure (RF) focused on the distribution of lesions.

Materials and methods

Eighty-five patients with COVID-19 pneumonia were reviewed. CT findings were classified as follows: Type A; patchy ground glass attenuation (GGA) with/without air-space consolidation, Type B; non-segmental GGA with/without air-space consolidation in both the central and peripheral lung portions especially with subpleural spare, and Type C; non-segmental GGA with/without air-space consolidation predominantly distributed in the peripheral lung portion without subpleural spare. We analyzed CT patterns and clinical factors associated with RF, including age categories.

Results

The number of patients with Type A, B and C was 31 (37%), 24 (28%) and 30 (35%), respectively. Type C and hypertension were independently associated with RF. On comparing between Types B and C, the frequency of traction bronchiectasis was higher in Type C than in Type B (P < 0.001). The ratio of Type C in patients ≥ 65 years old (66%) was higher than in patients < 40 years old (P < 0.001) and 40–49 years old (P = 0.001).

Conclusion

The Type C, increasing with age, was associated with RF. Traction bronchiectasis in the lesion was more frequent in Type C than in Type B.

Secondary abstract

A lesion adjacent to the pleura and hypertension is associated with respiratory failure in patients with COVID-19. The frequency of a lesion adjacent to the pleura increased with age. The distribution of lesions is a useful parameter to predict respiratory failure.

Clinical efficacy and tolerability of 1.5 g/day oral amoxicillin therapy without probenecid for the treatment of syphilis

OBJECTIVES

Intramuscular benzathine penicillin G is not available in certain countries. In a previous report, 3 g/day amoxicillin with probenecid was shown to be effective in treating syphilis in patients with HIV; however, 7.3% of patients changed their therapy owing to adverse events. The objective of this study was to assess the clinical efficacy and tolerability of 1.5 g/day amoxicillin without probenecid for the treatment of syphilis.

METHODS

The routine clinical records of patients diagnosed with syphilis and treated with 1.5 g/day amoxicillin at a tertiary care hospital between 2006 and 2018 were retrospectively analysed. Syphilis was diagnosed if serum rapid plasma reagin (RPR) titres were ≥8 RU and the Treponema pallidum latex-agglutination test was positive. Serological cure was defined as a ≥fourfold decrease in the RPR titre within 12 months in symptomatic early syphilis and within 24 months in latent syphilis.

RESULTS

Overall, 138 patients (112 with HIV) were analysed. The percentages of primary, secondary, early latent, late latent and latent syphilis of unknown duration were 8.0%, 50.0%, 25.4%, 5.8% and 10.9%, respectively. The median treatment duration was 4.5 weeks (IQR 4-8 weeks), which was not related to the stage of syphilis. Two patients (1.5%) changed treatment due to skin rash. The rate of serological cure was 94.9% (131/138; 95% CI 89.8% to 97.9%) overall; 93.8% (105/112; 95% CI 87.5% to 97.5%) in patients with HIV and 100% (26/26; 95% CI 86.8% to 100%) in patients without HIV. Treatment duration was not related to the treatment efficacy.

CONCLUSION

The regimen of 1.5 g/day amoxicillin without probenecid is highly effective with a low switch rate in patients with and without HIV.

Characteristics and outcomes of coronavirus disease 2019 (COVID-19) patients with cancer: a single-center retrospective observational study in Tokyo, Japan

BACKGROUND

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused an international outbreak of coronavirus disease 2019 (COVID-19), data on the clinical characteristics of COVID-19 patients with cancer are limited. This study aimed to evaluate the clinical characteristics and outcomes including mortality and viral shedding period in COVID-19 patients with cancer in Japan.

METHODS

We retrospectively analyzed 32 patients with a history of cancer who were referred to our hospital between January 31, 2020 and May 25, 2020. We evaluated the association between clinical outcomes and potential prognostic factors using univariate analyses.

RESULTS

The median age was 74.5 (range 24-90) years and 22 patients (69%) were men. A total of 11 patients (34%) died. Our analyses demonstrated that the mortality was significantly associated with lymphocyte count, albumin, lactate dehydrogenase, serum ferritin, and C-reactive protein on admission. The median period between illness onset and the first effective negative SARS-CoV-2 PCR result was 22 days (interquartile range 18-25) in survivors. Of four patients with hematological malignancy who developed COVID-19 within the rest period of chemotherapy, three died and the other patient, who received bendamustine plus rituximab therapy, had the longest duration of viral shedding (56 days).

CONCLUSION

Our study suggested that the risk factors for mortality previously reported in general COVID-19 patients, including lymphocytopenia, were also effective in cancer patients. Patients who received cytotoxic chemotherapy recently or were treated with chemotherapy, which can lead to lymphocyte reduction, had poor prognosis and prolonged periods of viral shedding.

Prevalence of thromboembolic events and status of prophylactic anticoagulant therapy in hospitalized patients with COVID-19 in Japan

Introduction

One of the most prominent and concerning complications associated with coronavirus disease 2019 (COVID-19) is venous and arterial thromboembolisms. The aim of the present study was to delineate the prevalence of thromboembolic events and the current status of prophylactic anticoagulation therapy in patients with COVID-19 in Japan.

Methods

Between February 1 and August 31, 2020, we performed a dual-center, retrospective cohort study based on data obtained from the medical charts of COVID-19 patients admitted to healthcare facilities in Japan. The primary outcome was any thromboembolic event including pulmonary embolism (PE), deep vein thrombosis (DVT), myocardial infarction, ischemic stroke and other systemic thromboemboli.

Results

During the study period, we extracted 628 consecutive patients admitted for COVID-19. Prophylactic anticoagulant therapy was administered in 63 (10%) patients of whom 20 (31.7%) were admitted to the intensive care unit (ICU). Thromboembolic events occurred in 18 (2.9%) patients (14.3% of patients in ICU and 2.2% of patients in the general wards). DVT were detected in 13 (2.1%) patients, PE in 11 (1.8%), and both DVT and PE in 6 (0.96%) patients. An increasing prevalence in thromboembolic events was noted with progressive clinical severity. Overall in-hospital mortality was 4.8%.

Conclusions

Prophylactic anticoagulation therapy was administered in only 10% of all hospitalized COVID-19 patients. The prevalence of any thromboembolic events was 2.9% in COVID-19 patients with most events occurring in severe and critical patients. Therefore, prophylactic anticoagulation therapy may be warranted in severe and critical patients but in asymptomatic to moderate patients the practice remains controversial.

Development of a Risk Prediction Score to Identify High-Risk Groups for the Critical Coronavirus Disease 2019 (COVID-19) in Japan

Coronavirus disease 2019 (COVID-19) emerged in mid-December 2019 and has rapidly spread worldwide. We conducted a retrospective analysis of data from patients with COVID-19 to construct a simple risk prediction score to be implemented in prehospital settings. Patients were classified into critical and non-critical groups based on disease severity during hospitalization. Multivariate analysis was performed to identify independent risk factors and develop a risk prediction score. A total of 234 patients were included in the study. The median age of the critical group was significantly older than that of the non-critical group (68.0 and 44.0 years, respectively), and the percentage of males in the critical group was higher than that in the non-critical group (90.2% and 60.6%, respectively). Multivariate analysis revealed that factors such as age ≥ 45 years, male sex, comorbidities such as hypertension and cancer, and having fever and dyspnea on admission were independently associated with the critical COVID-19 infection. No critical events were noted in patients with a total risk factor score of ≤ 2. Contrastingly, patients with a total risk factor score ≥ 4 were more likely to have critical COVID-19 infection. This risk prediction score may be useful in identifying critical COVID-19 infections.

SARS-CoV-2 Screening Test for Japanese Returnees From Wuhan, China, January 2020

Background

Severe acute respiratory syndrome–related coronavirus 2 (SARS-CoV-2) was found to be the causative microorganism of coronavirus disease 2019 (COVID-19), which started to spread in Wuhan, China. This study was to evaluate the effectiveness of questionnaire, symptoms-based screening, and polymerase chain reaction (PCR) screening of returnees from COVID-19-endemic areas on a chartered flight, to examine the proportion of infected persons and the proportion of asymptomatic persons among infected persons who returned from Wuhan.

Methods

A retrospective cohort study was done in 7 tertiary medical institutions in Japan. A total of 566 Japanese who returned from Wuhan participated in the study.

Results

Overall, 11 of the 566 passengers had a positive SARS-CoV-2 PCR result for pharyngeal swabs and 6 were asymptomatic. Only fever differed between SARS-CoV-2-positive and -negative individuals (P < .043). Six of the 11 PCR-positive individuals were asymptomatic; 4 remained positive on day 10, and 1 asymptomatic person tested positive up to day 27. Two of the 11 were negative on the first PCR test and positive on the second.

Conclusions

Our results will be important insights on screening returnees from locked-down cities, as well as providing important data on the proportion of asymptomatic individuals infected with SARS-CoV-2. A 13-day observation period and a second round of PCR may be effective to screen patients, including asymptomatic infections.

Estimating the syphilis incidence and diagnosis rate in Japan: a mathematical modelling study

OBJECTIVES

The reported number of syphilis cases is increasing in Japan. In this study, we aimed to estimate both the incidence of infection and diagnosis-and-reporting rate using a mathematical model that captures the time course of infection.

METHODS

We analysed yearly notification data from 1961 to 2016 and stratified according to clinical stage and sex. We built a compartmental ordinary differential equations model to describe the natural epidemiological course of syphilis in which the incidence of infection and diagnosis-and-reporting rate were included as time-varying parameters that we estimated via the maximum likelihood method.

RESULTS

From 2008 to 2016, the estimated number of new syphilis cases among men and women was 1070 (95% CI 1037 to 1104) and 302 (95% CI 287 to 318), respectively, which was increased from the previous period (1999-2007) with 269 (95% CI 256 to 282) and 71 (95% CI 64 to 78) cases, respectively. The diagnosis-and-reporting rate did not vary greatly over time. We estimated the number of undiagnosed syphilis cases from either incubating or early clinical (ie, primary or secondary) infections in 2016 to be 262 (95% CI 249 to 275) and 79 (95% CI 74 to 84) for men and women, respectively.

CONCLUSIONS

The recent increase in reported cases of syphilis is owing to an increase in the number of infections. We found no evidence of time-dependent improvement in detection or reporting.

Investigation of the Proportion of Diagnosed People Living with HIV/AIDS among Foreign Residents in Japan

Foreign residents represent an increasing proportion of newly diagnosed human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) cases in Japan, though scant research has addressed this. This study aimed to estimate the diagnosed proportion of people living with HIV/AIDS (PLWHA) among foreign residents in Japan, covering 1990–2017 and stratifying by geographic region of the country of origin. A balance equation model was employed to statistically estimate the diagnosed proportion as a single parameter. This used published estimates of HIV incidence and prevalence, population size, visit duration, travel volume, as well as surveillance data on HIV/AIDS in Japan. The proportion varied widely by region: People from Western Europe, East Asia and the Pacific, Australia and New Zealand, and North America were underdiagnosed, while those from sub-Saharan Africa, South and South-East Asia, and Latin America were more frequently diagnosed. Overall, the diagnosed proportion of PLWHA among foreign residents in Japan has increased, but the latest estimate in 2017 was as low as 55.3%; lower than the estimate among Japanese on the order of 80% and far below the quoted goal of 90%. This finding indicates a critical need to investigate the underlying mechanisms, including disparate access to HIV testing.

Pre-transfusion testing for Ebola virus disease patients in serious communicable infectious diseases hospitals in Tokyo: A cross-sectional study

BACKGROUND

Ebola virus disease (EVD) was endemic to Africa in 2014-2016. Supportive therapies have been shown to improve the outcome of EVD, and additional supportive therapy including blood transfusion therapy and external circulation could be needed in the event of a future global outbreak. However, pre-transfusion testing policies and guidelines have not yet been established in Japan.

METHODS

We conducted a cross-sectional study of blood transfusion therapy for EVD patients at three designated hospitals for serious communicable diseases in Tokyo. In each hospital, we surveyed blood transfusion therapy policy, blood transfusion protocol, presence of a specialist in the department of transfusion medicine, facility capacity for pre-transfusion compatibility testing, and types of personal protective equipment available.

RESULTS

One hospital had a cross-matched compatible blood transfusion policy, one had a cross-matched compatible blood transfusion policy only when the patient's ABO and RhD type is previously known, and the third had not created a policy. Two hospitals had a department of transfusion medicine. These two hospitals had a special testing unit for serious communicable diseases, while the other had a portable unit for testing. There were no major differences noted in available personal protective equipment.

CONCLUSION

Policies and protocols differ among hospitals. The choice of blood transfusion policy and pre-transfusion testing is largely dependent on equipment and human resources. Further discussion is required to develop national guidelines for blood transfusion therapy in patients with serious communicable diseases, including countermeasures against complications and ethical issues related to the safety of patients and healthcare workers.

Rat-bite fever due to Streptobacillus notomytis isolated from a human specimen

Rat-bite fever (RBF) is a disease that usually presents with fever, arthralgia and skin rash. Streptobacillus moniliformis was considered the main cause of RBF among the genus Streptobacillus. Although with similar clinical presentation, RBF due to Streptobacillus notomytis is unusual in humans. To the best of our knowledge, we present a case involving the first isolate of S. notomytis in humans. A 63-year-old woman was admitted to our hospital with fever, rash and polyarthritis. She recalled being bitten by a rat on her finger 5 days before presentation. Clinical manifestations were compatible with rat-bite fever (RBF) and the diagnosis was confirmed by the detection of Streptobacillus species from both blood and pustule samples. Initial polymerase chain reaction tests revealed that the organism was S. moniliformis. However, thorough genetic analysis revealed the organism to be S. notomytis. The condition was successfully treated with ampicillin.

Test-and-treat approach to HIV/AIDS: a primer for mathematical modeling

The public benefit of test-and-treat has induced a need to justify goodness for the public, and mathematical modeling studies have played a key role in designing and evaluating the test-and-treat strategy for controlling HIV/AIDS. Here we briefly and comprehensively review the essence of contemporary understanding of the test-and-treat policy through mathematical modeling approaches and identify key pitfalls that have been identified to date. While the decrease in HIV incidence is achieved with certain coverages of diagnosis, care and continued treatment, HIV prevalence is not necessarily decreased and sometimes the test-and-treat is accompanied by increased long-term cost of antiretroviral therapy (ART). To confront with the complexity of assessment on this policy, the elimination threshold or the effective reproduction number has been proposed for its use in determining the overall success to anticipate the eventual elimination. Since the publication of original model in 2009, key issues of test-and-treat modeling studies have been identified, including theoretical problems surrounding the sexual partnership network, heterogeneities in the transmission dynamics, and realistic issues of achieving and maintaining high treatment coverage in the most hard-to-reach populations. To explicitly design country-specific control policy, quantitative modeling approaches to each single setting with differing epidemiological context would require multi-disciplinary collaborations among clinicians, public health practitioners, laboratory technologists, epidemiologists and mathematical modelers.

Unexpected Acute Necrotizing Ulcerative Gingivitis in a Well-controlled HIV-infected Case

We herein report the case of a 41-year-old Japanese man with well-controlled HIV who presented with diagnostically difficult acute necrotizing ulcerative gingivitis (ANUG). After diet-induced weight loss, he developed oral pain and disturbance of mouth opening, and was admitted to our hospital. Based on preconceptions of HIV-associated diseases, fluconazole was initiated for candidiasis. However, no improvement was seen and ANUG was finally diagnosed. This case suggests that physicians should consider ANUG in HIV-infected individuals when several risk factors are present, even if CD4+ T-lymphocyte counts have remained stable owing to long-term anti-retroviral therapy.

Single-institutional experience of clinicopathological analysis and treatment for lung cancer patients with human immunodeficiency virus infection

The advent of antiretroviral therapy has changed the disease spectrum constitution among patients living with human immunodeficiency virus (HIV), while the incidence of death due to non-AIDS-defining cancers, particularly lung cancer, continues to increase in the USA and Europe. However, the availability of detailed reports of the clinical characteristics of lung cancer among Asian populations is limited. The present study retrospectively analyzed the clinical characteristics, treatment regimens and outcomes of lung cancer patients with HIV who were treated in a single institution between 1988 and 2013. Of the 20 lung cancer patients living with HIV included in this study, 90% were diagnosed since 1996 in the post-antiretroviral era. The median CD4+ cell count was 373.5/µl, whereas 65% of the patients were diagnosed with adenocarcinoma and 30% with squamous cell carcinoma. Epidermal growth factor receptor mutations were detected in 3 (27%) of the 11 specimens for which data were available, of which 65% had advanced-stage disease. Of the 20 patients, 9 underwent surgery, 6 received radiotherapy and 5 received chemotherapy as a first-line treatment. Treatment was generally well-tolerated. The median survival period was 35.8 months for all stages and 14.0 months for advanced stages. The treatment outcomes in our institution were favorable in comparison with previous studies from the USA and Europe, although these findings may be due to ethnic differences or the efficacy of treatment for HIV and lung cancer.

[Ocular Syphilis Complicated with HIV Infection: A Report of 3 Cases]

We present 3 cases of ocular syphilis in patients who had been newly diagnosed as having HIV. All the patients had only complained of ophthalmologic symptoms at the time of their initial visit. Treatment with penicillin was successful, resulting in no significant sequelae. Ocular syphilis may lead to reduced visual acuity or even blindness if left untreated. However, the diagnosis may be challenging, since patients may lack symptoms that are commonly observed in cases with primary and secondary syphilis. Considering the recent increase in the number of syphilis patients, clinicians should be aware of ocular syphilis and should have a high index of suspicion for syphilis in any patient at risk so as to ensure a prompt diagnosis.

[Administration of S-1 Monotherapy as Adjuvant Chemotherapy in a Patient with Advanced Gastric Cancer with HIV Infection]

A 64-year-old man with advanced gastric cancer presented with chief complaints of chest pain. His preoperative blood examination revealed positive results for serum HIV-antibody. His HIV-RNA level was 1.0×10 / 5 copies/mL, and his CD4lymphocyte count was 491 cell/mL; the patient was diagnosed with advanced gastric cancer and HIV infection. Distal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction were performed for treatment of the gastric cancer. Pathological examination revealed T3(SS)N3aM0, Stage III C cancer. After surgery, the patient was administered S-1 monotherapy as adjuvant treatment with antiretroviral therapy including tenofovir/emtricitabine and raltegravir. He completed 8 courses of S- 1 chemotherapy with no adverse events, such as a decrease in the CD4lymphocyte count or an increase in the HIV-RNA level. This patient with gastric cancer and HIV infection was safely treated using both antiretroviral therapy and chemotherapy owing to treatment intervention by chemotherapy and infectious diseases specialists.

Severe Thrombocytopenia and Acute Cytomegalovirus Colitis during Primary Human Immunodeficiency Virus Infection

We herein report the case of a 25-year-old man who was referred to our hospital due to acute cytomegalovirus (CMV) colitis. The initial blood tests showed that the patient had concurrent primary human immunodeficiency virus (HIV) infection and severe thrombocytopenia. Raltegravir-based antiretroviral therapy (ART) was initiated without the use of ganciclovir or corticosteroids and resulted in a rapid clinical improvement. Platelet transfusions were only necessary for a short period, and subsequent colonoscopy revealed a completely healed ulcer. This case implies that ART alone could be effective for treating severe thrombocytopenia during primary HIV and CMV coinfection.

Laryngeal Kaposi's Sarcoma Complicated by the Immune Reconstitution Inflammatory Syndrome in an HIV-infected Patient

We herein report a case of laryngeal Kaposi's sarcoma (KS) complicated by immune reconstitution inflammatory syndrome in a human immunodeficiency virus (HIV)-infected patient. The patient initially presented with KS involving the larynx, which was successfully treated with pegylated liposomal doxorubicin (PLD) and antiretroviral therapy (ART). PLD was discontinued after 2 courses because of a marked clinical improvement; however, the patient experienced progressive odynophagia and dyspnea 2 months after the initiation of ART. Laryngoscopy revealed a severely swollen, inflamed epiglottis. The readministration of PLD was successful, and the patient was thereafter discharged without any subsequent complications.

CD8 Encephalitis Caused by Persistently Detectable Drug-resistant HIV

We herein report a 52-year-old man infected with human immunodeficiency virus (HIV) who was referred to our hospital due to the development of severe neurocognitive disorders and bilateral leukoencephalopathy. He has been treated with antiretroviral agents for 17 years, but low-level viremia has been detected consistently prior to admission. Drug resistant testing of the serum and the cerebrospinal fluid (CSF) both demonstrated a M184V mutation. A brain biopsy revealed perivascular CD8(+) T-lymphocyte infiltration, leading to the diagnosis of CD8 encephalitis. The clinical symptoms improved drastically after changing to a nucleoside reverse transcriptase inhibitor sparing regimen, which subsequently decreased the HIV viral load to an undetectable level in both the serum and CSF.

[Reliability and validity of the Japanese version of the DAST-20]

OBJECTIVE

Assessing the degree of problems related to drug abuse is important in each treatment setting. The Drug Abuse Screening Test-20 (DAST-20) is a brief, simple 20-item instrument to measure the degree of problems related to drug use. The objective of the present study is to examine the reliability and validity of the Japanese version of the DAST-20.

METHODS

We translated the DAST-20 into Japanese using back translation. The anonymous self-administered questionnaire was completed by 310 drug users at the Drug Addiction Rehabilitation Centers (DARC group, n = 113) and at HIV/AIDS regional hospitals (HIV group, n = 197) in Japan.

RESULTS

The average DAST-20 score was 7.6 (DARC group = 14.7, HIV group = 2.8). Each item score was highly correlated with the total score (r = 0.45-0.88). A high internal consistency (Cronbach's α = 0.95) was observed (men = 0.95, women = 0.84). Overall test-retest reliability was 0.86 (men = 0.85, women = 0.90). The total DAST-20 score was strongly positively correlated with the Severity of Dependence Scale-J score (r = 0.85), but moderately positively correlated with the Alcohol Use Disorders Identification Test score (r = 0.41). In addition, confirmatory factor analysis indicated an acceptable fit to the data (goodness-of-fit index [GFI] = 0.893, adjusted goodness-of-fit index [AGFI] = 0.854, comparative fit index [CFI] = 0.948, root mean square residual [RMR] = 0.008, root mean square error of approximation [RMSEA] = 0.073).

CONCLUSION

Our results clearly suggest that the Japanese version of the DAST-20 has sufficient internal consistency and acceptable levels of concurrent validity and construct validity.

Atazanavir nephrotoxicity

Atazanavir is commonly used as one of the key drugs in combination antiretroviral therapy for human immunodeficiency virus (HIV). However, atazanavir has the potential to yield its crystalline precipitation in urine and renal interstitial tissues, leading to crystalluria, urolithiasis, acute kidney injury (AKI) or chronic kidney disease (CKD). In epidemiological studies, atazanavir/ritonavir alone or in combination with tenofovir has been associated with increased risk of progression to CKD. However, renal biopsies were not provided in these studies. Case reports showing an association between atazanavir use and tubulointerstitial nephritis among HIV-infected individuals provide clues as to the potential causes of atazanavir nephrotoxicity. We now review atazanavir-related kidney disease including urolithiasis, renal dysfunction and interstitial nephritis and illustrate the review with a further case of atazanavir-associated kidney injury with sequential renal biopsies. There are two forms of atazanavir-associated tubulointerstitial nephritis: acute tubulointerstitial nephritis that may develop AKI rapidly (in weeks) after initiation of atazanavir, and chronic tubulointerstitial nephritis that may develop progressive CKD slowly (in years) with granuloma and intrarenal precipitation of atazanavir crystals as well as crystalluria. Caution should be exercised when prescribing atazanavir to patients at high risk of CKD, and therapy should be reevaluated if renal function deteriorates, especially associated with crystalluria and hematuria.

Lung cancer patients harboring epidermal growth factor receptor mutation among those infected by human immunodeficiency virus

With the advent of antiretroviral therapy, lung cancer has become a crucial health problem among individuals living with human immunodeficiency virus (HIV). In East Asian populations, the frequency of lung cancer patients harboring epidermal growth factor receptor (EGFR) mutations is greater than in other populations. Herein, we present two cases of advanced non-small cell lung cancer with EGFR mutations in patients treated with EGFR-tyrosine kinase inhibitors. Both patients were male, 67 and 59 years of age, with known HIV infection and immunologically stable disease with antiretroviral therapy. Case 1 was treated with erlotinib for recurrent adenocarcinoma metastasizing to the liver and brain harboring EGFR mutation in exon 21 L858R. The duration of treatment efficacy was 9.7 months. Case 2 had an EGFR mutation exon 19 in-frame deletion with bone metastasis and was treated with gefitinib for 22.1 months in combination with antiretroviral therapy. These advanced lung cancer patients living with HIV with EGFR mutations demonstrate the promising effectiveness and safety of EGFR-tyrosine kinase inhibitors concomitant with antiretroviral therapy for an extended period.

[Murine typhus in a Japanese traveler returning from Indonesia: a case report]

We report herein on a 20-year-old Japanese man who was referred to our hospital for fever and diarrhea after returning from Indonesia. On admission, his blood test was essentially normal, besides a slight elevation in inflammatory markers. After excluding malaria and dengue fever, empiric use of ceftriaxone was initiated for suspected enteric fever, which was unsuccessful. However, drastic clinical improvement was observed after initiation of minocycline. The polymerase chain reaction test for Rickettsia typhi was positive from serum samples on admission, confirming the diagnosis of murine typhus. Although rarely seen in Japan, clinicians should be aware of this disease when examining patients with fever coming back from murine typhus endemic areas.

[Evaluation of HIV-infected patients suspected as having HIV-associated neurocognitive disorders]

BACKGROUND

HIV-associated neurocognitive disorders (HAND) have emerged as a problem among HIV-infected individuals in the era of antiretroviral therapy. However, there are insufficient data on HAND regarding its prevalence and clinical features in Japan.

METHODS

A test battery composed of eight neuropsycological tests proposed by the Ministry of Health, Labour and Welfare (MHLW test battery) was applied to assess 30 subjects at Tokyo Metropolitan Komagome Hospital. Among them, 5 subjects were excluded due to central nervous system complications. The background of each patient along with the results of head magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) analysis and neuropsychological tests were compared to each HAND category. In addition, the clinical utility of a combination of neuropsychological tests as an abbreviated test battery of HAND was evaluated.

RESULTS

A total of 19 (76%) subjects were diagnosed as having a HAND. Among them, HIV-associated dementia, mild neurocognitive disorders and asymptomatic neurocognitive disorders were diagnosed in 7, 8, and 4 subjects, respectively. Neither the patient's background nor the results of the head MRI and CSF analysis showed relevance to disease severity. The conventional International HIV Dementia Scale with the Digit Symbol Substitute Test was capable of detecting 94.7% cases of HAND.

CONCLUSIONS

Most HIV-infected subjects clinically suspected as having neurocognitive disorders were diagnosed as having a HAND. Neuropsychological tests of the MHLW test battery were in some part useful to diagnose HAND. However, more precise neuropsychological tests are warranted to screen and diagnose HAND, based on the current criteria.

Pyoderma gangrenosum successfully treated with antiretroviral therapy alone in a human immunodeficiency virus-infected individual

We report a case of a 60-year-old man infected with human immunodeficiency virus (HIV) who was transferred to our hospital for management of multiple non-healing, painful ulcers on the lower extremities. The histological findings of the biopsy specimen were compatible with the diagnosis of pyoderma gangrenosum (PG). An association between HIV infection and the development of PG was considered after a thorough investigation. Antiretroviral therapy without the use of adjunctive immunosuppressive agents resulted in clinical improvement. Our case implies that antiretroviral therapy alone could heal PG in untreated HIV-infected patients.

[A case of spinal tuberculosis in a young Filipino man]

A 19-year-old Filipino man was admitted to our hospital because of persisting fever and back pain. He had recognized his symptoms 6 months previously, but a definite diagnosis was not made. Image testing demonstrated a compressed fracture of the thoracic vertebrae accompanied with a perivertebral abscess. A biopsy specimen revealed granuloma compatible with tuberculosis (TB). Anti-TB drugs were initiated, and his clinical symptoms steadily improved. However, he developed neuropathic symptoms due to exacerbation of the abscess two months after starting the anti-TB drugs. An immediate laminectomy was performed resulting in symptom relief; however severe kyphosis remained. Polymerase chain reaction testing of the abscess collected during the operation was positive for Mycobacterium tuberculosis, confirming the diagnosis of spinal TB. The diagnosis of spinal TB has been a challenge world-wide. Clinicians should be aware of the demographic background as well as the clinical and laboratory features of spinal tuberculosis, facilitating earlier diagnosis.

[Medical study of cases diagnosed as rubella in adults]

BACKGROUND

In 2012, the number of rubella cases sharply increased in Japan. It continued to rise in 2013. Between October 2012 and May 2013, 10 cases of congenital rubella syndrome (CRS) were reported nationwide. This current rubella outbreak comprised mainly males who were between 20 to 39 years of age, and had not received the rubella vaccine. Data have been lacking on the clinical characteristics of adults infected with the rubella virus.

METHODS

Using medical charts, we collected data from 27 patients who were diagnosed with clinically or laboratory-confirmed rubella infection at Tokyo Metropolitan Komagome Hospital from January 2012 to April 2013.

RESULTS

Of the 27 patients studied, their median age was 34.5 years and 70.4% were male between 21-56 years of age. For the 11 cases with known vaccination status, 9 (81.8%) occurred in persons who had not received a rubella vaccine. A total of 33.3% of the patients were hospitalized, due to persistent fever, poor oral intake, or dehydration. Major clinical symptoms were fever (96.3% of cases), lymphadenopathy (92.6%), rash (85.2%), conjunctivitis (77.8%), and headache (63.0%). The mean duration of fever was 5 days (range, 3-9). The exanthema consisted of punctate, pink maculopapules; however, the rash became confluent in 37.0%, and pigmented in 18.5% of the patients. Initial laboratory data were as follows:white cells, 3,800/microL (range: 2,000-8,300); platelets, 129,000/microL (range, 63,000 - 230,000); aspartate aminotransferase, 27IU/L (range, 16 - 49); lactase dehydrogenase, 279IU/L (range, 168-440) [all described in medians]. Rubella-specific immunoglobulin M antibodies from the serum sample obtained at the initial visit were detected in 17 cases (65.4%). Likewise, measles-specific immunoglobulin M antibodies were detected in 7 cases (26.9%), all of which were false-positive.

CONCLUSIONS

The clinical characteristics of rubella in adults resembled measles in some part, which may cause difficulty for physicians to differentiate between the two diseases. Vaccinating rubella-susceptible individuals now is critical to interrupt rubella virus transmission, and to prevent further CRS cases.

[Prevalence of chronic kidney disease among HIV-infected individuals in Japan--a report from two tertiary hospitals]

BACKGROUND

The improved survival of subjects with human immunodeficiency virus (HIV) has been accompanied by an increased prevalence of chronic kidney disease (CKD). Epidemic of CKD among those with HIV has not yet been evaluated in multiple tertiary hospitals in Japan.

METHODS

A cross-sectional study was conducted in 2011 at Tokyo Metropolitan Komagome Hospital (TMKH) and Tokyo Medical University Hospital (TMUH). A total of 1482 HIV-infected subjects (1384 men, 98 female, mean age: 44.2 +/- 11.4 years old) were consecutively enrolled in the study. Random urine and blood samples were collected to study prevalence of CKD. CKD was diagnosed as a decrease in glomerular function and/or proteinuria and classified into 5 stages based on National Kidney Foundation guidelines. The estimated glomerular filtration rate based on serum creatinine was calculated using the 3-variable equation, constructed by the Japanese Society of Nephrology. Proteinuria was defined as > or = 1+ on urine dipstick examination. All electronic medical charts were reviewed to determine comorbidities, including hypertension and diabetes mellitus (DM). The proportion of subjects receiving tenofovir disoproxil fumarate (TDF) was investigated. Risk factors for CKD were determined using multivariate logistic regression analysis.

RESULTS

The mean CD4 cell count was 487 +/- 216/microL and 80.5% had undetectable HIV-RNA level in the combined cohort. Of the 90.2% of subjects taking antiretroviral agents, 61.5% was using TDF. The prevalence of overall CKD and CKD > or = stage 3 was 12.9% and 6.7%, respectively, both of which were nearly 3-fold higher in the TMKH cohort (p < .0001). Mean age and proportional prevalent hypertension and DM were significantly higher in the TKMH cohort than in the TMUH cohort. Multivariate analysis showed significant CKD to be associated with age > or =50 years (odds ratio [OR], 2.81), hypertension (OR, 3.04), and DM (OR, 2.05).

CONCLUSIONS

CKD prevalence was 12.9% among combined cohorts, but differed significantly between them. Differences in age distribution and the proportion of comorbidities, including hypertension and DM, are likely involved.

Concomitant chemoradiotherapy and antiretroviral therapy for HIV-infected patients with locoregionally advanced non-small cell lung cancer: benefit and tolerability of treatment in 2 cases

BACKGROUND

Human immunodeficiency virus (HIV)-infected patients are surviving longer since the advent of antiretroviral therapy. Therefore, more patients are developing non-AIDS-defining cancers which increasingly determine mortality.

CASE REPORTS

Here we present 2 cases of locally advanced non-small cell lung cancer treated initially with concomitant chemoradiotherapy and antiretroviral therapy. Both patients were male, ages 69 and 66, with known HIV infection and immunologically stable on antiretroviral therapy. Presenting symptoms included superior sulcus tumor with left arm immobility and sensory disturbance in case 1 and right lower bronchus constriction in case 2. Symptoms were controlled by chemoradiotherapy.

CONCLUSION

These cases illustrate that intensive anticancer therapy administered to the HIV-infected population can be tolerated even though these patients seem to be too fragile for both chemotherapy and radiotherapy, especially since the potential benefit remains uncertain. Recent improvements in chemoradiotherapy and supportive care have enhanced tolerance for such therapy.

[Necrotizing fasciitis after a cat bite: a case report]

We report on a previously healthy 56-year-old woman who was referred to our hospital with fever and progressive left foot pain. She had been bitten by a cat 7 days previously, and cephalosporins had been prescribed for treatment. However, her clinical symptoms deteriorated, and physical examination on admission was compatible with necrotizing fasciitis. Treatment with ampicillin-sulbactam and clindamycin was initiated. In addition, immediate surgical debridement was performed, resulting in therapeutic success. Culture of the necrotizing tissue grew multiple organisms, including Pasteurella multocida and Bacteroides caccae. Administration of appropriate antibiotics after a cat bite is essential for the prevention of potentially fatal complications.

Estimation of the congestion area volume in potential living donor remnant livers

BACKGROUND

Living donor liver transplantation is widely performed in adult patients. One of the problems in this setting is a small-for-size graft, which results in dysfunction and poor prognosis of a transplantation. A right liver graft was devised to overcome this problem; furthermore, inclusion of the middle hepatic vein (MHV) has been suggested to greatly improve recipient outcomes. However, extended right hepatectomy involves a surgical risk for the living donor in terms of congestion of the left paramedian sector. The volume of the venoocclusive region of a living donor liver possibly varies depending on the collateral patterns of veins draining the cranial part of segment 4 (S4).

PATIENTS AND METHODS

We were analyzed the normal livers of 50 patients who underwent triphasic contrast-enhanced multidetector row computed tomography during preoperative and postoperative examinations. The patient pathologies consisted of gastric cancer (n = 25), colon cancer (n = 1), or renal cancer (n = 24). We calculated the volume of the entire liver as well as those of the right graft and left remnant lobes for comparison with the drainage volume of each hepatic vein and its branches.

RESULTS

On the basis of the anatomic venous drainage of the cranial part of S4 (V4sup), we classified hepatic veins as group A (n = 31), the V4sup joined the left hepatic vein or the MHV distal to the vein draining S8 area (MV8), or group B (n = 19), V4sup joined the MHV proximal to MV8. The mean volume of the congested area was 6.9% in group A and 15.9% in group B. The venoocclusive areas in the remnant livers were estimated to be larger in group B (P < .001).

CONCLUSION

The collateral pattern of V4sup and MV8 as well as preoperative volumetric analysis are important for graft selection to decide the line of transection.

Bilateral emphysematous pyelonephritis with a splenic abscess

The case of a 66-year-old woman with untreated diabetes mellitus who was admitted to our hospital with a fever, hypotension and an altered mental status is herein reported. Computed tomography revealed bilateral emphysematous pyelonephritis along with a splenic abscess. Blood and urine cultures grew Escherichia coli. Treatment with systemic antibiotics combined with the insertion of percutaneous and renoureteral catheters was successful. The patient was discharged and completed treatment without developing any subsequent complications.

[Syphilis proctitis complicated with HIV infection: a case report]

We report on a 26-year-old Japanese man who was referred to our hospital because of anal pain and hematochezia. On admission, in addition to his gastrointestinal symptoms, a generalized maculopapular rash was observed, involving the palms of his hands and soles of his feet. His history and physical examination were compatible with syphilis, confirmed by a high syphilis titer on blood examination. Further tests revealed the presence of HIV infection, with a CD4 cell count of 227/microL. Colonoscopy demonstrated a deep ulcer in the lower rectum, although biopsy specimens did not reveal any syphilis spirochetes, or any other specific microorganisms. Intravenous penicillin G was initiated, resulting in a dramatic improvement of the ulcers along with the skin lesions confirming the diagnosis of syphilis proctitis. A rapid plasma reagin titer test performed 3 months after treatment demonstrated significant decrease, indicating successful treatment.

Real-time monitoring of liver damage during experimental ischaemia–reperfusion using a nitric oxide sensor

Background

Hepatic ischaemia–reperfusion (IR) injury may lead to liver damage during liver surgery, and intrahepatic nitric oxide (NO) levels may play a role in this context. The aim of this study was to demonstrate real-time changes in intrahepatic NO concentration during IR and to correlate potential hepatic NO production with liver damage using a selective NO sensor.

Methods

Wistar rats were exposed to 15 min of hepatic ischaemia followed by reperfusion, after which changes in intrahepatic NO levels were measured using an NO sensor. Additionally, rats were exposed to five successive periods of IR, each consisting of 15 min ischaemia followed by 5 or 15 min reperfusion, and hepatic damage was evaluated by blood tests and histological examination. Hepatic expression of Akt, phosphorylated Akt, endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS was examined at different time points during and after IR by western blot and immunohistochemical analysis.

Results

During ischaemia, intrahepatic NO levels increased and reached a plateau at approximately 10 min. Repeated 15 min ischaemia–5 min reperfusion cycles reduced the maximum amount of NO produced during ischaemia gradually, and almost no NO production was observed during the fifth period of ischaemia. NO production following repeated ischaemia was proportional to the degree of hepatic viability. Phosphorylated eNOS was upregulated and correlated with the level of NO production during hepatic ischaemia.

Conclusion

Intrahepatic NO levels decrease during repeated IR in rats. Real-time monitoring of intrahepatic NO levels is useful for the prediction of IR-related liver injury during experimental liver surgery.