Use of carbon monoxide in minimizing ischemia/reperfusion injury in transplantation

Although carbon monoxide (CO) is known to be toxic because of its ability to interfere with oxygen delivery at high concentrations, mammalian cells endogenously generate CO primarily via the catalysis of heme by heme oxygenases. Recent findings have indicated that heme oxygenases and generation of CO serve as a key mechanism to maintain the integrity of the physiological function of organs and supported the development of a new paradigm that CO, at low concentrations, functions as a signaling molecule in the body and exerts significant cytoprotection. Consequently, exogenously delivered CO has been shown to mediate potent protection in various injury models through its anti-inflammatory, vasodilating, and antiapoptotic functions. Ischemia/reperfusion (I/R) injury associated with organ transplantation is one of the major deleterious factors limiting the success of transplantation. Ischemia/reperfusion injury is a complex cascade of interconnected events involving cell damage, apoptosis, vigorous inflammatory responses, microcirculation disturbance, and thrombogenesis. Carbon monoxide has a great potential in minimizing I/R injury. This review will provide an overview of the basic physiology of CO, preclinical studies examining efficacy of CO in I/R injury models, and possible protective mechanisms. Carbon monoxide could be developed to be a valuable therapeutic molecule in minimizing I/R injury in transplantation.     

Cost disparity between open repair and endovascular aneurysm repair for abdominal aortic aneurysm: a single-institute experience in Japan

Purpose

We conducted this study to compare the cost of open surgical repair (OR) with that of endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA).

Methods

Between January 2007 and November 2008, 70 patients underwent open repair and 57 patients underwent EVAR. We evaluated the total cost, including that of the Diagnosis Procedure Combination (DPC), that of the surgical procedure, that of materials such as grafts and guide wires, and that of the anesthesia.

Results

The mean costs for OR versus EVAR were as follows: DPC, ??632370 versus ??490050, respectively, which was significant; anesthesia, ??123540 versus ??86220, respectively (P?Conclusions New technologies should not only be clinically effective, but also cost effective. EVAR is less invasive clinically, but the cost of endovascular prostheses and other materials remains high.     

Predictive validity of weekly monitoring of wound status using DESIGN‐R score change for pressure ulcer healing: A multicenter prospective cohort study

There are few studies on predictive validity of methods to monitor the healing process of pressure ulcers. We evaluated whether the change of DESIGN‐R (rating) score could predict subsequent healing, and determined the optimal cutoff points. In a multicenter prospective cohort study, patients were followed until wound healing or censoring. Wound severity was evaluated by the DESIGN‐R tool every week, and the score change was calculated over 1–4 weeks (n = 411, 286, 224, and 170, respectively). In the multivariate analyses stratified by depth, a one‐point improvement in DESIGN‐R score over any period was positively associated with healing within the next 30 days independent of initial wound severity (hazard ratios over each 1–4 weeks ranging from 1.16 to 1.33 for superficial ulcers and from 1.21 to 1.27 for deep ulcers; all p < 0.05). The optimal cutoff points over 1–4 weeks were set as negative change for superficial ulcers and as positive change of ≥two points for deep ulcers. Nonhealing rate was higher for ulcers with DESIGN‐R score change below the cutoff points than that aforementioned for both depths. Weekly monitoring by the DESIGN‐R tool will be advantageous for evaluating prognosis of pressure ulcers independent of initial wound severity and depth.     

Transcatheter renal artery embolization improves lung function in patients with autosomal dominant polycystic kidney disease on hemodialysis

Background

Since 1996, transcatheter renal artery embolization (renal TAE) has been performed to reduce the volume of the kidneys in patients with autosomal dominant polycystic kidney disease (ADPKD) and complications of nephromegaly at our hospital. Respiratory dysfunction is often a serious problem in these patients before TAE.

Patients and methods

Between January 2006 and October 2008, renal TAE was performed and lung function testing [percent vital capacity (%VC) and percent forced expiratory volume in 1?s (%FEV_1.0)] was done by spirometry in 28 patients on maintenance hemodialysis who had respiratory symptoms.

Results

Renal volume was 6,330.5?±?3,126.5?cm³ (range 1,771–12,761?cm³) before TAE, and decreased significantly to 2,892.2?±?1,841.7?cm³ (range 622–6,961?cm³) by 12?months after TAE (p?=?0.0001). The percent decrease of renal volume at 12?months after TAE versus baseline was 45.6?±?14.6% (range 6.6–67.3%). %VC showed a significant increase from 95.9?±?14.8% (range 63–127%) before renal TAE to 100.1?±?11.7% (range 78–120%) at 12?months after TAE (p?<?0.01). %FEV_1.0 was also significantly increased from 87.9?±?15.0% (range 55–110%) before renal TAE to 92.5?±?14.4% (range 58.0–115.0%) at 12?months after TAE (p?<?0.01). The changes of VC (ΔVC%) and FEV_1.0 (ΔFEV_1.0%) both showed a significant positive correlation with the reduction of renal volume (Δ renal volume) (p?=?0.001 and p?=?0.004, respectively).

Conclusion

Since TAE not only led to a significant decrease of renal volume in ADPKD patients with nephromegaly, but also improved lung function (both %VC and %FEV_1.0), pulmonary dysfunction should be recognized as one of the extrarenal complications of ADPKD.     

The impact of ferritin fluctuations on stable hemoglobin levels in hemodialysis patients

Background

Hemoglobin (Hb) cycling in patients with renal anemia might be associated with a higher mortality rate. We investigated the association of factors relating serum ferritin and dose of erythropoiesis-stimulating agents (ESAs) with Hb levels.

Methods

We measured Hb and ferritin levels every month in 266 hemodialysis (HD) patients for 12?months.

Results

The standard deviation (SD) and residual SD (RSD) (liner regression of Hb or ferritin SD values) values of Hb were significantly correlated with ferritin SD or RSD values, respectively. The percentage achievement of target Hb in the target-ferritin group was significantly higher than in the high-amplitude fluctuation ferritin group. Ferritin SD and RSD values in patients with oral or no iron supplementation were significantly lower than those who received intravenous iron.

Conclusion

Iron storage varies over a relatively wide range in HD patients, and this variation is closely associated with Hb cycling. The stability of iron storage and ESA dosage is important for maintaining stable Hb levels.     

Psoriatic arthritis in two patients with an inadequate response to treatment with tocilizumab

Psoriatic arthritis (PsA) is considered as one of the seronegative spondylarthropathies. Like rheumatoid arthritis (RA), the increased production of interleukin (IL)-6 suggests a pathogenic role of IL-6 in PsA. However, whether humanized anti-IL-6 receptor antibody such as tocilizumab (TCZ) might be effective for PsA as well as RA has yet to be determined. We report herein two cases of PsA treated using TCZ. Although, TCZ treatment resulted in disappearance of serum CRP in both patients, arthritis and skin lesions were not improved despite 6-month administration of TCZ. In contrast, tumor necrosis factor (TNF) inhibitor proved effective against arthritis and skin lesions in these patients. Collectively, these findings not only indicate that IL-6 has distinct pathological roles in RA and PsA, but also suggest that TNF inhibitor therapy (but not TCZ) is effective for arthritis and skin lesions of PsA.     

Autoimmune pancreatitis that developed over a 3-month observation period for IgG4-related dacryoadenitis and sialadenitis

Autoimmune pancreatitis (AIP) that developed in a short period in a patient with IgG4-related dacryoadenitis and sialadenitis is reported. A 67-year-old man was diagnosed as having IgG4-related dacryoadenitis and sialadenitis histologically, serologically, and radiologically. At that time, the pancreas was normal on computed tomographic scanning, magnetic resonance imaging, and 18F-fluorodeoxyglucose positron emission tomography. However, AIP occurred in the pancreatic body and tail during the 3-month period of observation of the initial diseases. All IgG4-related lesions improved promptly after steroid therapy. This report emphasizes that, since IgG4-related disease can develop in other organs within a short period in a patient with IgG4-related disease, periodic imaging follow-up is necessary.     

Acute hemicerebellitis in a pediatric patient: a case report of a serial MR spectroscopy study

The changes in the signals for brain metabolites in the left cerebellum of a 14-year-old boy with acute hemicerebellitis were monitored using proton magnetic resonance spectroscopy (MRS). From the onset of disease treatment to long-term follow-up, MRS data were serially acquired from the left and right cerebella, basal ganglia (BG), and centrum semiovale (CS). Large fluctuations in his MRS signals were observed in the left cerebellum. At onset (first day), his glutamate/glutamine complex signals were increased (>mean ± 2 standard deviations [SD] of the control), and those for N-acetylaspartate/N-acetylaspartylglutamate and myo-inositol were decreased (<2SD). By the 25th day, these signals had recovered to normal levels, while those for choline (Cho) were increased. In other locations, the signals for mIns in the BG and Cho in the CS were decreased on the seventh day. By the 201st day, the levels of all metabolites in all locations had recovered to within ± 2SD of the control levels. In vivo proton MRS monitoring demonstrated reversible metabolite changes associated with acute hemicerebellitis, which should contribute to its differential diagnosis from brain tumors.     

Multimodality evaluation of cardiac paraganglioma

We report 2 rare cases of primary cardiac paraganglioma demonstrated with multimodality imaging. Both a 46-year-old woman who presented with hypertension (case 1) and a 46-year-old woman without any symptoms (case 2) had mediastinal tumors depicted by CT and MRI. Both cases showed intense focal uptakes in the tumors with iodine-123-meta-iodobenzylguanidine SPECT. Case 2 also underwent 18F-FDG PET/CT and revealed a focal uptake. CT angiography detected the arterial feeder and venous drainages, information that was useful for the operation. After surgical removal, pathology confirmed primary cardiac paraganglioma in both cases. 18F-FDG PET/CT was also useful in ruling out residual or recurrent tumors.