Nitric oxide metabolites are associated with survival in older patients

OBJECTIVES: To assess the efficacy of various vascular endocrinological substances, such as plasma nitric oxide metabolites (NOx), as surrogate markers of survival in older patients. DESIGN: Prospective cohort, observational. SETTING: Nagoya University Hospital and related hospitals, Japan. PARTICIPANTS: One hundred fifty patients aged 70 and older, recruited consecutively from the outpatient clinics of Nagoya University Hospital and related hospitals. MEASUREMENT: Serum biochemical analyses such as albumin and total cholesterol, various prognostic markers, such as tumor necrosis factor (TNF)-alpha, NOx, activities of daily living (ADLs), and instrumental ADLs (IADLs) were evaluated on enrollment. ADLs, IADLs, and comorbidities, especially depression and impaired cognition, were evaluated on enrollment. The main outcome was survival rate over 2.75 years. RESULTS: Forty-nine patients died during the follow-up period. Mann-Whitney U-test showed that hemoglobin, total protein, serum albumin, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high sensitive c-reactive protein, NOx, B-type natriuretic peptide, interleukin-6, and TNF-alpha levels; ADLs; cognitive impairment; and depressive status were significantly different for subjects who survived and those who died. Of the dependent variables in the Cox proportional hazards regression analyses, only ADLs, NOx, and albumin were significantly different. In the Kaplan-Meier analyses of mortality, the prognosis of patients in the third and fourth quartiles of NOx was significantly worse than that of patients in the first or second quartile. The prognosis of patients with impaired ADLs was worse than that of other patients for the overall period. CONCLUSION: Lower levels of NOx may be associated with survival in older patients. It may be an effective marker, like ADLs, which is a well-known marker.     

A case of successful management of repeated recurrent intrahepatic cholangiocarcinoma by repeated hepatectomy and radiofrequency ablations

We herein report a case of a 69-year-old male who received hepatectomy for intrahepatic cholangiocarcinoma, re-hepatectomy for intrahepatic recurrence, re-re-hepatectomy for intrahepatic re-recurrence, percutaneous radiofrequency ablation for intrahepatic re-re-recurrence, and re-re-re-hepatectomy for intrahepatic re-re-re-recurrence. The patient has survived more than 50 months. He also received esophagectomy for coexisting esophageal carcinoma with primary intrahepatic cholangiocarcinoma, and has no symptoms of recurrence. Key words: Intrahepatic cholangiocarcinoma, Repeated hepatectomy     

Advances in apheresis therapy for glomerular diseases

This article is an overview of the immunomodulatory effects of apheresis in renal diseases, especially primary and secondary glomerulonephritis, and the clinical evidence for the efficacy of apheresis therapy. Permeability factor(s) derived from circulating T cells are speculated to have a crucial role in the proteinuria of nephrotic syndrome (NS). Plasma exchange (PE); immunoadsorption plasmapheresis (IAPP), using protein A sepharose cartridges; low-density lipoprotein apheresis; and lymphocytapheresis (LCAP) have been used to remove such factors or pathogenic T cells. Other glomerular diseases induced by specific antibodies such as anti-glomerular basement membrane antibodies, anti-neutrophil cytoplasmic antibodies, and immune-complexes have also been treated with PE, double-filtration plasmapheresis, IAPP, and LCAP. Recommendations, based on the evidence from recent randomized controlled studies, have been established in apheresis therapy for various glomerular diseases.     

Analysis of clinical,radiological and laboratory variables in psoriatic arthritis with 25 Japanese patients

Psoriatic arthritis (PsA) has many clinical and radiological manifestations but lacks a specific laboratory marker. The aim of the present study was to identify noteworthy features in PsA patients on routine clinical examinations. The subjects were 25 PsA patients who were classified based on the Classification of Psoriatic Arthritis (CASPAR) criteria. The clinical and radiological findings and laboratory parameters were analyzed by retrospective chart review. On clinical examination, dactylitis was present in 13 (52%) of 25 patients, swollen and/or tender Achilles tendons were present in nine (36%), and sacroiliitis was present in eight (32%). Of the radiological features, juxta‐articular new bone formation (JANF) was seen in 12 (48%), extra‐articular new bone formation was seen in nine (36%) and sacroiliitis was seen in six (24%). Dactylitis and JANF had the highest prevalence rates. The Psoriasis Area and Severity Index score, swollen and/or tender joint count, erythrocyte sedimentation rate, C‐reactive protein, and matrix metalloproteinase‐3 were higher in patients with sacroiliitis than in those without sacroiliitis (P < 0.05). Dactylitis, JANF and sacroiliitis may be noteworthy manifestations in Japanese patients with PsA.     

Takotsubo syndrome after a minimally invasive tooth extraction in a patient without dental phobia: A case report

Takotsubo syndrome (TTS) is a rare, stress-induced acute cardiac disorder. Its precipitating factors include emotionally or physically stressful events and exogenous and endogenous adrenaline. In this report, we describe a case of atypical TTS in a 73-year-old woman who reported no dental fear and required acute cardiac care in an outpatient setting. She underwent routine extraction of an upper left premolar under local anesthesia. She reported heart palpitations after the injection, and the procedure was completed in 15 min. After presenting symptoms of sweating, pale skin, vomiting, low blood pressure, and ST-segment elevation, cardiologists ordered echocardiography, coronary angiography, and ventriculography. Upon receiving a TTS diagnosis, the patient was hospitalized and administered an intra-aortic balloon pump and beta-blocker. Her symptoms resolved, and she was discharged with no sequelae. We found no precipitating factors in the progression of TTS in this case, which suggests that TTS can develop in the absence of precipitating factors. All general dentists and oral surgeons should recognize the possible risk of TTS, even during minimally invasive dental procedures, such as routine extractions in patients without dental phobia.     

Endoscopic screening for early esophageal cancer by iodine staining in patients with other current or prior primary cancers

BACKGROUND: Although early diagnosis of esophageal carcinoma is an important determinant of outcome, early stage carcinomas are rarely detected on routine endoscopic examination. Iodine staining may be useful in the detection of early stage esophageal carcinoma, especially in high-risk populations. In a prior study, 29.2% (68/233) patients with superficial esophageal carcinoma (SEC) undergoing resection at our hospital had other nonesophageal primary carcinomas, suggesting that patients with nonesophageal primary cancers are at increased risk for the development of esophageal cancer. The aim of the current study was to determine whether endoscopic screening with iodine staining is useful for the detection of SEC in patients with a history of non-esophageal cancers. PATIENTS AND METHODS: In a prospective study, 331 patients with nonesophageal primary cancers were screened for esophageal cancer by endoscopic examination with iodine staining. All patients were men 55 years of age or older. RESULTS: Nine patients (2.7%) with SEC were identified. Among these patients, 7 with mucosal cancer were treated by endoscopic mucosal resection, and 2 with submucosal cancer were treated by surgical resection or radiation therapy. Five patients (1.5%) were found to have cancer confined to the epithelium or the lamina propria. These lesions were difficult to detect by conventional endoscopic screening and were cured by endoscopic mucosal resection. After exclusion of 51 patients with head and neck cancer, the incidence of SEC was still 2.1% (6/280), higher than reported in prior screening studies. CONCLUSIONS: All men with a history of nonesophageal primary cancers should undergo endoscopic screening for esophageal cancer. Endoscopic iodine staining in such patients may be useful in screening for early stage esophageal carcinoma.     

Pivotal role of Notch signaling in regulation of erythroid maturation and proliferation

Notch signaling plays an important role in cell fate decisions in developmental systems. To clarify its role in committed hematopoietic progenitor cells, we investigated the effects of Notch signaling in erythroid colony forming cells (ECFCs) generated from peripheral blood. ECFCs express Notch receptors, Notch1 and Notch2, and Notch ligands Delta1, Delta4, and Jagged1. When we assayed the effects of Notch ligands on erythroid maturation by flow cytometry, we found that immobilized Delta1 and immobilized Delta4 in particular inhibited maturation, whereas Jagged1 had no effect. In addition, Delta4 inhibited proliferation without reducing cell viability. Increases in expression levels of the Notch target gene hairy enhancer of split (HES) -1 were evident by real-time PCR after stimulation with immobilized Delta4. The effect of soluble Delta4 on expression of HES-1 was less pronounced than that seen with the immobilized form, indicating that all surface-bound ligands are important for effective signal transduction. When ECFCs were cultured in the presence of soluble Delta4 at a low cell concentration, erythroid maturation was slightly inhibited, but at a high concentration, maturation was promoted via competition of soluble Delta4 with endogenous ligands. These results indicate a pivotal role of Notch signaling in regulating erythroid maturation and proliferation, and further suggest that cell-cell interactions modulate growth of erythroid progenitor cells via Notch system.     

Does off-pump coronary artery bypass grafting really preserve renal function?

It is well known that the use of cardiopulmonary bypass (CPB) influences renal function and occasionally results in renal failure following cardiac surgery. Coronary artery bypass grafting (CABG) without CPB may avoid this and preserve the perioperative renal function. The present study enrolled 52 patients undergoing CABG without CPB (OPCAB group) and matched them for renal function and prognostic variables with 53 patients undergoing conventional CABG (CABG group). Perioperative renal function and early clinical results were assessed. The OPCAB group had significantly less increase in creatinine levels (0.16 +/- 0.05 vs 0.45 +/- 0.06 mg/dl; p = 0.01) and greater creatinine clearance (81.6 +/- 7.3 vs 56.3 +/- 4.8ml/min; p = 0.01) postoperatively. Postoperative recovery of free water clearance was more prompt in the OPCAB group. The duration of intubation and intensive care unit stay was significantly shorter, and the creatine kinase-MB release and blood transfusion requirements were significantly less in the OPCAB group. The OPCAB technique preserved glomerular filtration rate and prevented the increase in creatinine levels. The results suggest that the technique enables earlier patient recovery and gives superior renal protection compared with conventional CABG.     

Significant liver injury with dual positive IgM antibody to Epstein-Barr virus and cytomegalovirus as a puzzling initial manifestation of infectious mononucleosis

A 35-year-old man was admitted because of significant hepatic dysfunction with mild splenomegaly and intra-abdominal lymphadenopathy of unknown cause. Infectious mononucleosis was suggested by subsequently detected high fever, pharyngotonsillitis and cervical lymphadenopathy, but IgM to Epstein-Barr virus (EBV) and cytomegalovirus (CMV) showed dual positivity. A definite diagnosis of EBV-induced infectious mononucleosis was established 3 months later on the basis of seroconversion to Epstein-Barr nuclear antigen (EBNA)-IgG positivity and reduced CMV-IgM titer with persistently negative CMV-IgG. This case highlights the initial diagnostic difficulties of EBV-induced infectious mononucleosis particularly in older patients, due to concomitant abnormal humoral immunity and unusual initial manifestations such as significant liver injury and extensive intra-abdominal lymphadenopathy.