Clinical utility of treatment method conversion during single-session endoscopic ultrasound-guided biliary drainage

BACKGROUND Although several techniques for endoscopic ultrasound-guided biliary drainage(EUS-BD)are available at present,an optimal treatment algorithm of EUS-BD has not yet been established.AIM To evaluate the clinical utility of treatment method conversion during single endoscopic sessions for difficult cases in initially planned EUS-BD.METHODS This was a single-center retrospective analysis using a prospectively accumulated database.Patients with biliary obstruction undergoing EUS-BD between May 2008 and April 2016 were included.The primary outcome was to evaluate the improvement in EUS-BD success rates by converting the treatment methods during a single endoscopic session.Secondary outcomes were clarification of the factors leading to the conversion from the initial EUS-BD and the assessment of efficacy and safety of the conversion as judged by technical success,clinical success,and adverse events(AEs).RESULTS A total of 208 patients underwent EUS-BD during the study period.For 18.8%(39/208)of the patients,the treatment methods were converted to another EUSBD technique from the initial plan.Biliary obstruction was caused by pancreatobiliary malignancies,other malignant lesions,biliary stones,and other benign lesions in 22,11,4,and 2 patients,respectively.The reasons for the difficulty with the initial EUS-BD were classified into the following 3 procedures:Target puncture(n=13),guidewire manipulation(n=18),and puncture tract dilation(n=8).Technical success was achieved in 97.4%(38/39)of the cases and clinical success was achieved in 89.5%of patients(34/38).AEs occurred in 10.3%of patients,including bile leakage(n=2),bleeding(n=1),and cholecystitis(n=1).The puncture target and drainage technique were altered in subsequent EUSBD procedures in 25 and 14 patients,respectively.The final technical success rate with 95%CI for all 208 cases was 97.1%(95%CI:93.8%-98.9%),while that of the initially planned EUS-BD was 78.8%(95%CI:72.6%-84.2%).CONCLUSION Among multi-step procedures in EUS-BD,guidewire manipulation appeared to be the most technically challenging.When initially planned EUS-BD is technically difficult,treatment method conversion in a single endoscopic session may result in successful EUS-BD without leading to severe AEs.     

Influence of Dialysis Duration on the Outcome of Living Kidney Transplantation

Previous studies have reported negative impacts of long‐term dialysis on kidney transplantation (KTx) outcomes. However, advances in surgical techniques, immunosuppressive therapies, and post‐transplant monitoring have led to an impressive increase in patient and allograft survival. Thus, the number of KTx among patients on long‐term dialysis is increasing. We evaluated the influence of dialysis duration on the outcome of living donor KTx. Between January 2000 and October 2011, we performed 1098 first KTx from living donors in adults (>18 years). We divided the patients into six groups, A group: pre‐emptive kidney transplantation, B group: <24 months duration of dialysis, C group: 25–60 months duration, D group: 61–120 months duration, E group: 121–240 months duration, and F group: ≥241 months duration. The 5‐year patient survival rates were 95.7, 98.8, 99.0, 99.0, 97.3, and 100% in groups A–F, respectively. The 5‐year graft survival rates were 91.3, 95.6, 94.2, 96.3, 90.7, and 100% in groups A–F, respectively. No significant differences were observed in patient or graft survival among the six groups. Longer dialysis duration was correlated with lower rates of preoperative hypertension and diabetes mellitus. Survivors of long‐term dialysis tended to be in good compliance with self‐management. If recipients of living KTx have few complications, good prognoses are expectable even if dialysis periods are very long.     

SCAPHOLUNATE DISSOCIATION CAUSED BY GOUTY ARTHRITIS OF THE WRIST: Case report

Gouty arthritis of the wrist is rare, and may be associated with scapholunate dissociation. To our knowledge, only two cases have been reported so far. In this report, we describe a 40-year-old patient with scapholunate dissociation caused by acute gouty arthritis of the wrist. His clinical findings and radiographs mimicked infectious arthritis or osteomyelitis of the carpal bones.     

Formaldehyde concentrations in the breathing zone of medical students during gross anatomy laboratory in Toho University

Cadavers for gross anatomy laboratories are conventionally embalmed by formaldehyde (FA) solution in most medical schools. Thus, medical students and instructors are exposed to FA vapors emitted from cadavers during dissection. As a basic survey for the improvement of the dissection environment, we examined FA concentration in the gross anatomy laboratory during the 2006 academic year at the Faculty of Medicine of Toho University. Air samples were taken from 20 cm above a cadaver as breathing zone, and above a desk between cadavers as indoor FA concentration. FA concentrations in the breathing zone were ranged from 0.24 to 3.04 (mean 1.71) ppm during systematic anatomy, and from 0.72 to 1.60 (mean 1.16) ppm during neuroanatomy, and indoor FA concentration ranged from 048 to 1.11 (mean 0.76) ppm and from 0.21 to 0.23 (mean 0.22) ppm, respectively. These results showed that medical students and instructors are exposed to higher concentrations of FA than allowed by the guidelines of the Japan Ministry of Health, Labor and Welfare, and suggested the need to reduce FA levels in the gross anatomy laboratory.     

Cytochemical analysis of storage materials in cultured skin fibroblasts from patients with I-cell disease

BACKGROUND: In cultured fibroblasts from I-cell disease patients the transport of many lysosomal enzymes is defective, and affected cells contain inclusion bodies filled with undegraded substrates. However, the contents of these inclusion bodies have not been well characterized yet. We attempted to identify accumulated substances in cultured I-cell disease fibroblasts cytochemically. METHODS: Cultured fibroblasts from I-cell disease patients were double-stained with a monoclonal antibody to lysosome-associated membrane protein-1 (LAMP-1) and that to GM2 ganglioside, or a series of lectins that specifically bind to sugar moieties. RESULTS: The patients' cells were granularly stained with the antibody to GM2 ganglioside and the lectins including Maakia amurensis, Datura stramonium, and concanavalin A. Their localization was coincident with that of LAMP-1. CONCLUSIONS: GM2 ganglioside and various kinds of glycoconjugates having sialic acidalpha2-3galactose, galactosebeta1-4N-acetylglucosamine and mannose residues accumulate in enlarged lysosomes in I-cell disease fibroblasts.     

Comprehensive assessment of amino acid substitutions in the trimeric RNA polymerase complex of influenza A virus detected in clinical trials of baloxavir marboxil

BackgroundBaloxavir marboxil (BXM) is an approved drug that selectively targets cap‐dependent endonuclease on PA subunit in the RNA polymerase complex of influenza A and B viruses. Amino acid substitutions at position 38 in the PA subunit were identified as a major pathway for reduced susceptibility to baloxavir acid (BXA), the active form of BXM. Additionally, substitutions found at positions E23, A37, and E199 in the PA subunit impact BXA susceptibility by less than 10‐fold.MethodsWe comprehensively evaluated the impact of novel amino acid substitutions identified in PA, PB1, and PB2 subunits in BXM clinical trials and influenza sequence databases by means of drug susceptibility and replicative capacity.ResultsPA/I38N in A(H1N1)pdm09 and PA/I38R in A(H3N2) were newly identified as treatment‐emergent substitutions in the CAPSTONE‐2 study. The I38N substitution conferred reduced susceptibility by 24‐fold, whereas replicative capacity of the I38N‐substituted virus was impaired compared with the wild‐type. The I38R‐substituted virus was not viable in cell culture. All other mutations assessed in this extensive study did not significantly affect BXA susceptibility (< 2.4‐fold change).ConclusionThese results provide additional information on the impact of amino acid substitutions in the trimeric viral polymerase complex to BXA susceptibility and will further support influenza surveillance.     

Downhill azygos vein secondary to occlusion of the superior vena cava in Beh?et's disease

A patient with downhill azygos venous flow is reported. This reverse flow was due to an obstruction in the superior vena cava and the azygos entry due to Beh?et's disease. Color flow mapping of the azygos vein, using transesophageal real-time two-dimensional Doppler echography, was used for both anatomic and hemodynamic analysis.     

Diagnosis of gallstone ileus by serial computed tomography

An unusual case of choledocholithiasis followed by gallstone ileus documented by serial computed tomography is reported. A 91-year-old woman underwent gastrostomy because she repeatedly developed aspiration pneumonia, and a common bile duct stone was detected. She and her family refused surgery once symptoms resolved. One year later, she presented with increasing, intermittent abdominal pain and nausea. Abdominal computed tomography revealed a common bile duct stone with inflammatory changes, but the patient still refused surgery. Three months later, she was admitted with abdominal pain and vomiting. On admission, plain abdominal radiographs demonstrated proximal small bowel obstruction. A long ileus tube was inserted through the gastric fistula. Two days after admission, gallstone ileus was diagnosed on abdominal computed tomography based on the presence of pneumobilia, disappearance of the common bile duct stone, fluid-filled bowel loops, and the discovery of an impacted stone in the small bowel. Ten and 15 days after admission, repeated computed tomography demonstrated the impacted stone in the terminal ileum. Seventeen days after admission, a laparotomy was performed, and a 5x3-cm gallstone was removed through an ileotomy.