Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones

In the Far East, hepatic resection is the definitive treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure. A retrospective comparative study was undertaken to clarify the long-term efficacy of hepatic resection for treatment of IHS and to investigate the clinical significance of intrahepatic biliary stricture in treatment failure after hepatic resection performed in 44 patients with symptomatic IHS. The patients were divided into two study groups: group A, with intrahepatic biliary stricture (n = 28) and group B, without stricture (n = 16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between the two groups. The patients were followed up for a median duration of 65 months after hepatectomy. The overall incidence of residual or recurrent stones was 36% and 11%, respectively, in groups A and B. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture recurred in 46% of patients in group A, while none of the group B patients had biliary stricture recurrence (P = 0.001). More than two-thirds of the restrictures in group A were identified at the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%) (P = 0.002). Three-quarters of the patients with cholangitis in group A had severe cholangitis, that was recurrent, and related to stones and strictures (n = 11). They and 2 asymptomatic patients in group B required secondary procedures done at a median of 12 months after hepatectomy. Final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of our 44 patients. Most recurrent cholangitis after hepatectomy in patients with IHS was related to recurrent intrahepatic ductal strictures. Therefore, to be effective, hepatic resection should include the strictured duct. However, with hepatectomy alone it is difficult to clear the IHS or relieve the ductal strictures completely, particularly in patients with bilateral IHS, so perioperative team approaches that include both radiologic and cholangioscopic interventions should be combined for the effective management of IHS.     

Interleukin-10 promoter polymorphisms in rheumatoid arthritis and Felty's syndrome

OBJECTIVE: To examine whether promoter polymorphisms associated with variation in interleukin-10 (IL-10) production are relevant to the development of rheumatoid arthritis (RA) or Felty's syndrome (FS). METHODS: DNA was obtained from 44 FS patients, 117 RA patients and 295 controls. The promoter region between -533 and - 1120 was amplified by polymerase chain reaction, and polymorphisms detected by restriction enzyme digest or sequence-specific oligonucleotide probing. RESULTS: We found no significant difference in allele or haplotype frequencies between the groups. CONCLUSION: There is no association between FS or RA and these recently identified IL-10 promoter polymorphisms. Other genetic or environmental factors could explain the alterations in IL-10 levels seen in these conditions.      

TNM staging of hilar cholangiocarcinoma]

Hilar cholangiocarcinoma represent the majority of cholangiocarcinoma, accounting for 40-60% of whole cases. Complete resection remains the most effective and only potentially curative therapy for cholangiocarcinoma. Important factors for resection of cholangiocarcinoma such as diagnostic methods and clinical staging has been improved. Cancer staging system should be useful for guiding treatment and predicting the chance of survival. After Bismuth-Corlette classification was reported, several staging systems has been proposed and updated to accomplish this purpose. Currently 6(th) ed. American Joint Committee on Cancer (AJCC) staging, 2nd ed. Japanese Society of Biliary Surgery (JSBS) classification and modified Memorial Sloan-Kettering Cancer Center (MSKCC) classification are used worldwide for staging of hilar cholangiocarcinoma. These systems consider not only the tumor extent but also local biological factors that affect the resectability, but the priority among them has not yet been evaluated and randomized studies are being expected to verify this.     

Plant sterols as cholesterol-lowering agents: clinical trials in patients with hypercholesterolemia and studies of sterol balance

We have evaluated the efficacy of plant sterol preparations from two different sources and in two different physical forms in lowering the plasma cholesterol of a total of 46 patients with type II hyperlipoproteinemia when given in addition to appropriate diet therapy. In addition, the mechanisms of the hypocholesterolemic effect were investigated in 7 patients by a sterol balance technique. The maximal mean cholesterol lowering in response to any preparation was 12 percent, although it was much greater in some individual patients. Sterol balance data showed that plant sterols inhibit cholesterol absorption with maximal negative cholesterol balance in adults at a dose of 3 g/day of a tall oil sterol suspension. Interestingly, maximal plasma cholesterol reduction in the adult outpatients on this preparation was seen at the same dose level. Since the tall oil sterol suspension is relatively palatable and is poorly absorbed, it has potential value as an adjunct to dietary therapy in patients with mild hypercholesterolemia for whom long-term drug therapy is deemed advisable.     

Effect of LDL apheresis on oxygen tension in skeletal muscle in patients with cardiac allograft vasculopathy and severe lipid disorder

In this study, the extent to which intramuscular pO2 is influenced by a single HELP-apheresis (Heparin-induced Extracorporeal LDL Precipitation) was investigated in 10 patients with cardiac allograft vasculopathy (CAV) and severe lipid disorder. For this purpose, a sterile flexible pO2 microcatheter was inserted into the anterior tibial muscle and pO2 monitoring was begun 10 minutes before starting apheresis treatment. The intramuscular pO2 values were recorded continuously until the end of apheresis treatment and a subsequent 30-minute further observation phase. The patients with CAV and severe lipid disorder presented with 11.6+/-3.8 mmHg significantly and pathologically reduced intramuscular pO2 (p<0.001). LDL apheresis resulted in a significant increase in pO2 in the anterior tibial muscle. Thirty minutes after the end of HELP-apheresis, intramuscular partial oxygen pressure had increased by 162% and showed values at this point, 30.3+/-9.8 mmHg, similar to those found in healthy subjects.     

Influence of a new monomeric nonionic radiographic contrast medium (iobitridol-350 versus NaCl) on cutaneous microcirculation: single-center, prospective, randomized, double-blind phase IV study in parallel group design

This single-center, prospective, randomized, double-blind phase IV study with parallel-group design was performed to test whether injection of a newly designed non-ionic monomeric radiographic contrast medium in the axillary artery influences the ipsilateral cutaneous microcirculation. Twenty patients with coronary heart disease or suspected coronary heart disease were investigated. Ten patients received iobitridol and 10 normal saline solution. The confirmatory target variable was the capillary erythrocyte velocity (v(RBC)). The v(RBC) was continuously recorded before and up to 3 min after the injection of iobitridol or normal saline solution and subsequently evaluated off-line. Thirty seconds after injection of 20 ml iobitridol, v(RBC) was reduced by 32% (P < 0.05). This was the strongest reduction, but v(RBC) was reduced at all time points measured up to 180 s following the injection (P < 0.05 up to 180 s). The overall reduction in v(RBC) was also statistically significant (P 0.0446). In contrast, there was a tendency toward an increase in v(RBC) following injection of 20 ml normal saline (P 0.0512). There was also a tendency toward a difference in the time course of changes in v(RBC) following injection of iobitridol compared to normal saline (P 0.0607). The decrease in v(RBC) following iobitridol injection (standardized difference (SD) according to Cohen, 0.67) can be regarded as biometrically weak, and the increase following normal saline injection (SD, 0.24) as very weak. The microcirculatory disturbance induced by iobitridol injection is less severe than that due to comparable high-viscosity contrast media.     

Persistent polyclonal B lymphocytosis with binucleated lymphocytes: a study of 25 cases. Groupe Français d'Hématologie Cellulaire

Persistent and polyclonal lymphocytosis of B lymphocytes (PPBL) with binucleated lymphocytes is an entity characterized by a polyclonal lymphocytosis. The lymphocytosis is stable for years and binucleated lymphocytes are detected on peripheral blood smears. We previously described +i(3q) as a recurrent chromosomal abnormality in seven PPBL patients. In this study we report a large series of 25 PPBL patients and demonstrated that PPBL was associated with +i(3q) in 77% of cases, premature chromosome condensation (PCC) in 50% and both abnormalities in 41% of cases. Furthermore, we demonstrated that i(3q) was present in a minority of B cells, restricted to B lymphocytes independently of the kappa or lambda light Ig chain expression, and exclusively observed in non-binucleated cells. The benign clinical course of PPBL and the lack of biological evolution in the majority of cases suggest that recognition of these disorders is so important that aggressive therapy in PPBL has to be avoided. Whether this syndrome represents a premalignant or benign disease remains unclear. The persistence of cytogenetic abnormalities after stopping tobacco use suggests no association with cigarette smoking.     

Some hypothalamic hamartomas contain transforming growth factor alpha, a puberty-inducing growth factor, but not luteinizing hormone-releasing hormone neurons

Activation of LH-releasing hormone (LHRH) secretion, essential for the initiation of puberty, is brought about by the interaction of neurotransmitters and astroglia-derived substances. One of these substances, transforming growth factor alpha (TGFalpha), has been implicated as a facilitatory component of the glia-to-neuron signaling process controlling the onset of female puberty in rodents and nonhuman primates. Hypothalamic hamartomas (HH) are tumors frequently associated with precocious puberty in humans. The detection of LHRH-containing neurons in some hamartomas has led to the concept that hamartomas advance puberty because they contain an ectopic LHRH pulse generator. Examination of two HH associated with female sexual precocity revealed that neither tumor had LHRH neurons, but both contained astroglial cells expressing TGFalpha and its receptor. Thus, some HH may induce precocious puberty, not by secreting LHRH, but via the production of trophic factors--such as TGFalpha--able to activate the normal LHRH neuronal network in the patient's hypothalamus.     

A case of severe skin eruption caused by Lamivudine in a patient with chronic hepatitis B]

Lamivudine is widely used for the treatment of chronic hepatitis B infection because of it's remarkable antiviral efficacy and safety. We report a case of severe skin eruption caused by lamivudine. A 47-year-old female was admitted because of jaundice and itching sensation. She was diagnosed as chronic hepatitis B infection a few years ago but did not receive any specific treatment. Laboratory data showed acute deterioration of chronic hepatitis B infection. We prescribed lamivudine as a rescue therapy. Her general condition improved and lab data showed improvement in liver function test thereafter. However, she complained of severe skin eruption and itching sensation a few days after the discharge. We stopped lamivudine because the symptoms did not improve despite the use of anti-histamine. Skin biopsy showed interface dermatitis. After stopping lamivudine, her symptoms improved. However, the skin eruption developed again after lamivudine was restarted. Adefovir was used instead, and the patient did not experience any further skin problems since then.