Usefulness of computed tomography during cholangiography for the diagnosis of multiple hepatic peribiliary cysts: a report of three cases with chronic liver disease

Hepatic peribiliary cysts are composed of multiple tiny cysts along the larger portal tracts and have been reported to be harmless. On clinical images, peribiliary cysts resemble other diseases such as biliary dilatations, cholangitis, or periportal edema. Therefore, it is important to distinguish peribiliary cysts from these diseases using a combination of several imaging modalities. Herein, we report three cases of peribiliary cysts. The first case underwent laparotomy for the presumptive diagnosis of intrahepatic cholangiocarcinoma. In the remaining two cases, hepatic peribiliary cysts were diagnosed and laparotomy was avoided. Magnetic resonance cholangiography contributed to the diagnosis, owing to their characteristic distribution. In addition, computed tomography during cholangiography (cholangio-CT) demonstrated that the cysts had no communication with the intrahepatic biliary system. Therefore, cholangio-CT is considered to be the most useful modality for the diagnosis of peribiliary cysts.     

The Benefits of High‐flow Management in Children With Pulmonary Atresia

The high‐flow management of cardiopulmonary bypass (CPB; ≥2.4 L/min/m²) is a standard strategy used at this institute for children with pulmonary atresia (PA) due to a fear that the blood flow may be diverted by the major/minor aortopulmonary‐collateral‐arteries and hypervascularization due to long‐term hypoxia. The purpose of this study was to describe the validity of high‐flow management in children with PA. The CPB records of 23 children with PA who underwent a definitive biventricular repair between Feb 2006 and Nov 2008 were retrospectively reviewed. The mean age at the operation was 33 ± 22 months. The blood‐pressure during bypass was controlled with the same protocol. The mean cooling‐temperature was 28.4 ± 3.7°C. The mean minimum hematocrit was 25.0 ± 3.4%. The mean maximum bypass flow index at the initiation, the mean maximum flow index during aortic cross‐clamping, the mean minimum flow index during aortic cross‐clamping, and the mean maximum flow index after rewarming were 3.1 ± 0.5, 3.1 ± 0.5, 2.6 ± 0.4, and 3.2 ± 0.4 L/min/m², respectively. The higher bypass flow indexes significantly correlated with the lower serum lactate levels. The lowest oxygen delivery during CPB had significant influences on the urine output during bypass (R = 0.547, P = 0.007), the serum lactate levels at the end of CPB (R = ?0.442, P = 0.035), and the postoperative thoracic effusion (R = ?0.459, P = 0.028). A bypass flow index of 2.4 L/min/m² may not be sufficient and the maximum requirement of bypass flow index may be 3.2 L/min/m² or more in this patient population.     

The Rewarming Index Formula for Pediatric Cardiopulmonary Perfusion

Careful rewarming of perfusion blood following cardiopulmonary bypass surgery is critical to a successful outcome, but the optimal rewarming strategy is not clear. The purpose of this study was to derive a formula for a rewarming index (defined as [rewarming time × perfusion flow]/[body weight × body surface area]) that would enable the calculation of the ideal rewarming conditions for pediatric cardiopulmonary perfusion. We retrospectively investigated 220 pediatric cardiopulmonary bypass operations conducted from July 2005 to June 2008 in Okayama University Hospital, Japan. We determined the formula as Φ = (T × Q)/(R × S) = |0.9127P ? 0.0152|, where Φ = rewarming index, T = rewarming time (min), Q = perfusion volume (L), R = body weight (kg), S = body surface area (m²), and P = temperature gap (). The formula will help those who perform pediatric cardiopulmonary bypass surgery to establish ideal perfusion flow conditions and to control physiological temperature during rewarming.     

A multicenter study of leukocytapheresis in rheumatoid arthritis

OBJECTIVE:To evaluate the efficacy and safety of leukocytapheresis (LCAP) in patients with rheumatoid arthritis (RA) that is refractory to disease modifying antirheumatic drugs (DMARDs), we conducted a prospective, multicenter, open-label clinical trial.METHODS:We enrolled 38 active RA patients, including 32 patients who showed an inadequate response to > or = 2 DMARDs and 6 patients with rapidly progressive RA. All patients continued drug therapy and were treated with 5 LCAP sessions conducted at 1-week intervals. The clinical response was evaluated at baseline before starting LCAP and at 4 weeks after the completion of all the LCAP sessions using the American College of Rheumatology (ACR) criteria and the 28-joint disease activity score (DAS28) of the European League Against Rheumatism (EULAR).RESULTS:Of the 35 patients who fulfilled the study's eligibility criteria, 24 (69%), 10 (29%), and 23 (66%) patients achieved 20% (ACR20), 50% (ACR50), and DAS28-C-reactive protein (CRP) EULAR improvement, respectively. The mean DAS28-CRP score of the 35 patients decreased significantly from 5.99 +/- 0.92 at baseline to 4.54 +/- 1.39 after treatment. Comparison analysis of the ACR20 responders and non-responders to LCAP revealed that 22 of 24 responders (92%) concomitantly received methotrexate, whereas significantly fewer, that is, 6 of 11 non-responders (55%) received methotrexate. Less frequent and transient mild-to-moderate adverse events, including nausea and headache, were seen in 12 of 189 LCAP sessions (6.3%).CONCLUSION:These results demonstrate the usefulness of LCAP in combination with DMARDs, particularly methotrexate, as an effective and safe treatment for refractory RA.     

Disease Activity Score 28 (DAS28) using C-reactive protein underestimates disease activity and overestimates EULAR response criteria compared with DAS28 using erythrocyte sedimentation rate in a large observational cohort of rheumatoid arthritis patients in Japan

OBJECTIVES: To compare disease activity and the improvement of disease activity evaluated between by Disease Activity Score 28 using erythrocyte sedimentation rate (DAS28-ESR) and by DAS28 using C-reactive protein (DAS28-CRP) in Japanese patients with rheumatoid arthritis (RA). METHODS: Data from 3073 RA patients registered in the large cohort database (NinJa: National Database of Rheumatic Diseases by iR-net in Japan) of 2003 was used to calculate DAS28-ESR and DAS28-CRP and disease activities were evaluated. Improvements in disease activities were also evaluated according to the European League Against Rheumatism (EULAR) response criteria in 1482 RA patients whose DAS28-ESR and DAS28-CRP could be calculated from data for both 2002 and 2003. RESULTS: The mean value of DAS28-CRP (3.59, SD 1.25) was significantly smaller than that of mean DAS28-ESR (4.31, SD 1.32) (p < 0.0001). The number of patients who satisfied the criteria of remission was 297 (9.7%) in DAS28-ESR versus 705 (22.9%) in DAS28-CRP and the number of patients with high disease activity was 842 (27.4%) versus 357 (11.6%) for DAS28-ESR and DAS28-CRP, respectively; there was a significant difference between the two (p < 0.0001). Change of respective DAS28 was significantly correlated (DeltaDAS28-ESR -0.05, SD 1.14 versus DeltaDAS28-CRP -0.10, SD 1.10) (p < 0.0001); however, the number of "good response" patients was significantly different (p < 0.03) between DAS28-ESR (97 patients, 6.5%) and DAS28-CRP (136 patients, 9.2%). CONCLUSIONS: DAS28-CRP significantly underestimated disease activity and overestimated the improvement in disease activity compared with DAS28-ESR. DAS28-CRP should be evaluated using different criteria from that for DAS28-ESR.     

Two cases of acute coronary occlusion after successful coronary angioplasty associated with a treadmill stress testing

We presented two cases of acute coronary occlusion after successful percutaneous transluminal coronary angioplasty (PTCA) associated with a treadmill stress testing. Case 1: A 54-year-old man with effort angina was referred to our hospital for cardiac catheterization. At the time of cardiac catheterization, the proximal RCA had a 99% diameter narrowing, and the proximal LCX had a 90% diameter narrowing. PTCA was performed and both lesions were successfully dilated. Eight days after PTCA, he had a symptom-limited treadmill stress testing, using the Bruce protocol. The exercise was terminated at a peak heart rate of 173/min (103% of aged-predicted maximal heart rate), and at a maximal systolic blood pressure of 140 mmHg. A few minutes after the end of exercise, he developed a severe chest pain and ECG changes, which showed ST elevation in leads II, III, aVF and ST depression in leads V4-V6. Emergency coronary angiography disclosed an acute coronary occlusion of RCA at the site of PTCA. Emergency PTCA was performed and the lesion was successfully re-dilated. Case 2: A 68-year-old man was referred to our hospital for cardiac catheterization a month after subendocardial anterior myocardial infarction. At the time of cardiac catheterization, the proximal LAD have a 99% diameter narrowing. PTCA was performed and the lesion was successfully dilated. 18 days after PTCA, he had a symptom-limited treadmill stress testing, using the Bruce protocol. The exercise was terminated at a peak heart rate of 158/min (102% of aged-predicted maximal heart rate), and at a maximal systolic blood pressure of 218 mmHg. Ten minutes after the one of 218 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)     

1 beta-hydroxylated bile acids in the urine of healthy neonates.

In order to clarify the metabolism of bile acids in neonates, 1 beta-hydroxylated bile acids in the urine of healthy newborns were examined by gas chromatography-mass spectrometry. The results showed that the percentage of total 1 beta-hydroxylated bile acids, 3 beta, 12 alpha-dihydroxy-5-cholenoic acid and hyocholic acid in neonates was significantly higher than in older children. The ratio of 1 beta-hydroxylated bile acids to their comparable primary bile acids was also higher in neonates than in older children. These results suggest that 1 beta- and 6 alpha-hydroxylation of bile acids are the predominant pathways of bile acid metabolism in neonates.     

Expression and distribution of CD11a/CD18 and CD54 during human T cell-B cell interactions.

Interactions between intercellular adhesion molecule 1 (ICAM-1, CD54) and leukocyte function-associated antigen 1 (LFA-1, CD11a/CD18) play a critical role in T cell-B cell collaboration. The current experiments were carried out to determine the expression and distribution of these adhesion molecules on human peripheral T cells and B cells during T cell-B cell collaboration. Resting CD4+ T cells were largely ICAM-1 negative, whereas immobilized anti-CD3 monoclonal antibody (mAb) rapidly induced ICAM-1 expression. By contrast, most B cells expressed ICAM-1 before activation, and further increases in density were noted with stimulation. Both B cells and CD4+ T cells expressed LFA-1 before activation, although the density on CD4+ T cells was considerably greater. A double staining method for electron microscopic analysis was developed that permitted analysis of the expression and distribution of ICAM-1 to be assessed during T cell-B cell collaboration. Under the experimental conditions examined, B cells showed a uniform distribution of ICAM-1. In contrast, ICAM-1 was highly mobile on the surface of CD4+ T cells. If the T cells were not fixed, staining, even at 4 degrees C, caused rapid redistribution of ICAM-1 into aggregates. However, by fixing cells before the staining procedures, the distribution of ICAM-1 on CD4+ T cells could be accurately assessed. Most (85%) of the fixed activated CD4+ T cells showed a uniform distribution of ICAM-1. However, when activated CD4+ T cells were cocultured with B cells, redistribution of ICAM-1 on CD4+ T cells but not B cells occurred, such that the majority (85%) was found at or immediately adjacent to the point of attachment to the B cells. No redistribution of LFA-1 on either T cells or B cells was found. These findings suggest that rapid changes in density of ICAM-1 expression and the mobility of ICAM-1 on activated T cells may play a role in providing activation signals to B cells during T cell-B cell collaboration.     

T helper type 2 differentiation and intracellular trafficking of the interleukin 4 receptor-alpha subunit controlled by the Rac activator Dock2

The lineage commitment of CD4+ T cells is coordinately regulated by signals through the T cell receptor and cytokine receptors, yet how these signals are integrated remains elusive. Here we find that mice lacking Dock2, a Rac activator in lymphocytes, developed allergic disease through a mechanism dependent on CD4+ T cells and the interleukin 4 receptor (IL-4R). Dock2-deficient CD4+ T cells showed impaired antigen-driven downregulation of IL-4Ralpha surface expression, resulting in sustained IL-4R signaling and excessive T helper type 2 responses. Dock2 was required for T cell receptor-mediated phosphorylation of the microtubule-destabilizing protein stathmin and for lysosomal trafficking and the degradation of IL-4Ralpha. Thus, Dock2 links T cell receptor signals to downregulation of IL-4Ralpha to control the lineage commitment of CD4+ T cells.