Hepatocellular Carcinoma with Invasion of the Right Intrahepatic Bile Duct Observed by Peroral Cholangioscopy: a Case Report

A 48-year-old chronic alcoholic with previous hepatitis B virus infection presented with recurrent episodes of obstructive jaundice secondary to hepatocellular carcinoma. The obstructive nature of the jaundice was confirmed by the peroral cholangioscopic findings of a friable nodular mass partially obstructing the right hepatic duct, and by relief of obstructive signs and symptoms after endoscopic sphincterotomy freed the common bile duct of “dark greenish formed materials”.     

A Xanthanolide with Potent Antibacterial Activity against Methicillin-resistant Staphylococcus aureus

This study was conducted to find constituents of an annual herb, Xanthium sibiricum Patr er Widd, with effective antibacterial activity against methicillin-resistant Staphylococcus aureus (MRSA). By monitoring antibacterial activity against MRSA strains, it was shown that a sesquiterpene lactone, identified as [3aR-(3aα,7β,8aβ)]-3,3a,4,7,8,8a-hexahydro-7-methyl-3-methylene-6-(3-oxo-1-butenyl)-2H-cyclohepta[b]furan-2-one, or xanthatin, isolated from leaves of the herb, had outstandingly potent activity against S. aureus species, including MRSA; its activity against MRSA and MSSA strains was similar. Other bacteria, e.g. Staphylococcus epidermidis, Klebsiella pneumoniae, Bacillus cereus, Pseudomonas aeruginosa and Salmonella typhi, were also susceptible at the concentrations tested but the compound had no inhibitory effect on some other bacteria, including Escherichia coli. The results show that xanthatin has outstandingly potent activity against strains of S. aureus but that the activity of the compound is highly species-specific.     

Evaluation of residual neuromuscular blockade using modified double burst stimulation

Background: To assess the degree of residual neuromuscular blockade, double burst stimulation (DBS) is commonly applied in the clinical setting. However, fades in response to DBS_3,3 can rarely be identified manually when train-of-four (TOF) ratios are ≧0.70, and, in contrast, fades in response to DBS_3,2 are felt manually in an undesirably high proportion of cases, even at TOF ratios greater than 0.7. We investigated whether a new monitoring method, modified DBS, would be useful to determine an adequate degree of recovery from neuromuscular blockade. For modified DBS, two burst stimuli were applied at an interval of 750 ms. The first stimulation in the modified DBS consisted of two stimuli of 0.3 ms duration at 50 Hz and the second of two stimuli of 0.2 ms duration at 50 Hz. Methods: Forty-five adult patients undergoing elective nitrous oxide-oxygen-isoflurane anesthesia were randomly divided into one of three groups: DBS_3,3 group (n=15), DBS_3,2 group (n=15), or modified DBS group (n=15). During recovery from vecuroni-um-induced neuromuscular blockade, on both forearms, DBS_{3, 3}, DBS_{3, 2}, and modified DBS were delivered in the DBS_{3, 3} group, DBS_{3, 2} group, and modified DBS group, respectively. One hand and forearm (fixed arm) were immobilized to quantify the degree of neuromuscular blockade mechanically, and the contralateral arm (free arm) was unrestrained. An observer deter-mined tactilely on the free arm the presence or absence of fade in response to the three DBS patterns. Results: Probabilities of detection of fade in response to the DBS_{3, 3} were 67% (TOF ratio of 0.51–0.60), 40% (0.61–0.70), 19% (0.71–4).80), 5% (0.81–0.90), and 0% (0.91–1.00). Those to the DBS₃, ₂ were 95% (0.51–0.60), 93% (0.61–0.70), 83% (0.71–0.80), 65% (0.81–0.90), and 38% (0.91–1.00). Those to modified DBS were 90% (0.51–0.60), 86% (0.61–0.70), 65% (0.71–0.80), 25% (0.81–0.90), and 3% (0.91–1.00). The modified DBS was more sensitive in diagnosing residual neuromuscular blockade than DBS_{3, 3} at the TOF ratio of 0.51–0.90, but was less sensitive than DBS_{3, 2} at the TOF ratio of 0.81–1.00 (P < 0.05). Conclusion: Our results indicate that the modified DBS may be a useful stimulation pattern to diagnose the adequacy of recovery from neuromuscular blockade.     

Minimum alveolar concentration of sevoflurane for tracheal extubation in children

Background: One advantage of tracheal extubation during deep anaesthesia is that respiratory complications are reduced. Sevoflurane is a suitable anaesthetic agent for children. This study was conducted to determine the minimum alveolar concentration of sevoflurane required to prevent cough or movement during and after tracheal extubation (MAC_extubation).
Methods: We studied 30 nonpremedicated children, aged 2–10 yr, undergoing plastic surgery. They were allocated randomly to five groups (end-tidal sevoflurane concentrations: 2.0, 2.5, 3.0, 3.5, 4.0%). After surgery, 60% nitrous oxide was discontinued and the target concentration of sevoflurane was maintained for at least 10 min in 100% oxygen, then the trachea was extubated to determine MAC_extubation. Logistic regression was used to estimate MAC_extubation. of sevoflurane.
Results: MAC_extubation. was 2.3 (0.2; standard error)% (95% confidence limits: 1.2% and 2.7%).
Conclusions: Tracheal extubation in 50% of anaesthetized children age 2–10 yr may be accomplished without coughing or moving at 2.3% end-tidal concentration of sevoflurane.     

Heart Rate Variability in Patients with Familial Amyloid Polyneuropathy

The purpose of this study was to evaluate heart rate variability (HRV) in patients with familial amyloid polyneuropathy (FAP) using the time- and frequency-domain analysis. The study population consisted of 19 patients with FAP, and 19 age and sex matched normal volunteers. The 24-hour Holter recordings of all subjects in sinus rhythm and off medication were analyzed. Five time-domain indices of HRV were computed. The frequency component of HRV was calculated by fast Fourier transform analysis of the RR intervals. The power spectrum of the low frequency (LF) between 0.04–0.15 Hz and high frequency (HF) between 0.15–0.40 Hz and the LF/HF ratio was calculated. Global measures of HRV including the standard deviation of the mean of RR intervals (SDNN) and the standard deviation of 5-minute mean RR intervals (SDANN) were decreased in patients with FAP. Specific vagal influences on HRV including the proportion of RR intervals more than 50 milliseconds different (pNN50) and the HF power on spectral analysis were less in patients with FAP. LF power and LF/HF ratio were more decreased in patients with FAP at the advanced stage than at the early stage. In conclusion, HRV was significantly decreased in patients with FAP at the early stage, and sympathetic activity was more decreased in patients at the advanced stage. These findings suggest that the decrease of the HRV is an indicator of this disease and the power spectral analysis of the HRV is beneficial in assessing the severity of the autonomic dysfunction.     

Hepatic HCV-RNA as a predictor of outcome after interferon therapy in patients with chronic hepatitis C

Measurement of serum HCV-RNA is a useful index for evaluating the antiviral effect of interferon therapy in chronic hepatitis C. In the present study, we investigated whether the detection of hepatic HCV-RNA after interferon treatment, using a polymerase chain reaction assay, predicted long-term response to therapy in patients with chronic hepatitis C. Thirty-three patients underwent liver biopsies before and after interferon therapy. Histology and clinical courses were compared after treatment. Before therapy, serum and hepatic HCV-RNA was detected in specimens from 32 (97%) and 33 (100%) patients, respectively. Serum HCV-RNA became undetectable in samples from 22 (67%) patients; however, in 10 of these patients (45%), serum HCV-RNA levels relapsed after therapy. Hepatic HCV-RNA became undetectable in 14 patients after therapy and the serum aminotransferase concentration remained within normal limits during and following (24–92 weeks) therapy in 12 of these patients (86%). All 11 patients with detectable hepatic HCV-RNA also had serum HCV-RNA and elevated aminotransferase concentrations refractory to therapy. The absence of hepatic HCV-RNA at the end of interferon treatment thus predicted a long-term complete response to therapy with a sensitivity of 100%, a specificity of 90% and an accuracy of 94%. We conclude that hepatic rather than serum HCV-RNA is a more useful index for the prediction of the long-term efficacy of interferon therapy.     

Stromal Cell‐Derived Factor 1α Induces Accumulation of Intraveneously Administered Marrow‐Derived Stromal Cells in the Partially Obstructed Rat Bladder

Objectives: We investigated the time course of the stromal cell‐derived factor 1α (SDF1α) expression and behavior of intravenously administered bone marrow‐derived stromal (BMS) cells in the urinary bladder of partial bladder outlet obstruction (PBOO) rats. Methods: Study 1: Recombinant SDF1α or saline was directly injected into the bladder wall of female rats followed by intravenous administration of BMS cells isolated from green fluorescent protein (GFP) transgenic rats. The bladder was examined with immunohistochemistry to determine whether SDF1α would enhance migration of BMS cells to the bladder. Study 2: Following surgery of PBOO or sham in female rats, bladders were removed on days 1–14, and expression of hypoxia inducible factor 1α (HIF1α) and SDF1α were examined with real‐time polymerase chain reaction (PCR) to determine if PBOO preferentially increased their expression. Study 3: Female rats underwent PBOO or sham surgery followed by intravenous administration of GFP‐positive BMS cells. Bladders were examined with immunohistochemistry on days 1–14 to determine whether BMS cells preferentially accumulated in the bladder. Results: BMS cells were accumulated in the injection site of SDF1α but not saline in the bladder. SDF1α and HIF1α increased at day 1 after PBOO compared to sham. More BMS cells accumulated in the bladder of PBOO on day 1, and some BMS cells expressed smooth muscle phenotypes by day 14. Conclusion: SDF1α induced with ischemia/hypoxia due to PBOO is implicated in the accumulation of BMS cells in the bladder and regeneration of the bladder for PBOO.