Intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis: A case report

ObjectiveWe describe a case of intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis (RA).Case PresentationA 29-year-old man with a medical history of RA since 18 years of age was admitted to our hospital for vomiting, dysarthria, and conscious disturbance. At 23, he underwent ligation of the left internal carotid artery (ICA) with superficial temporal artery to middle cerebral artery anastomosis because of acute infarct of the left hemisphere caused by arterial dissection of the left ICA. During the current admission, computed tomography (CT) revealed subarachnoid hemorrhage, and digital subtraction angiography (DSA) demonstrated dissecting aneurysms of the left intracranial vertebral artery (VA) and right extracranial VA. We diagnosed him with a ruptured dissecting aneurysm of the left intracranial VA and performed endovascular parent artery occlusion on the left VA. For the right unruptured VA aneurysm, we performed coil embolization simultaneously. At 2 weeks after the endovascular treatment, follow-up DSA revealed that multiple de novo dissecting aneurysms developed on the origin of the left VA and left and right internal thoracic arteries. Those aneurysms were treated with coil embolization. Other remaining aneurysms on the left thyrocervical trunk, right transverse cervical artery, and both common iliac arteries were treated by conservative therapy. While continuing medical treatment for RA, the patient recovered and was discharged to a rehabilitation hospital.ConclusionConsidering that RA-induced vasculitis can be a potential risk of vascular complications including multiple arterial dissections, physicians should carefully perform endovascular interventional procedures for patients with long-term RA.     

Comparing outcomes of nonoperative treatment for adhesive small bowel obstruction with and without antibiotics

IntroductionSome clinicians administer antibiotics in adhesive SBO treatment to prevent bacterial translocation without evidence confirming reduced sepsis and mortality. We aimed to evaluate the effectiveness of preventive antibiotic administration in nonoperative treatment of adhesive small bowel obstruction (SBO) in a retrospective study.MethodsUsing a Japanese national inpatient database, we identified 114,786 eligible patients with adhesive SBO and divided patients into a group who did not receive intravenous antibiotics in the initial 2 consecutive days after admission (control group, n = 71,666) and a group who received intravenous antibiotics ≥2 days after admission (antibiotic group, n = 43,120). To compare the in-hospital mortality, occurrence of sepsis, septic shock, Clostridioides difficile colitis, length of stay, and total costs between the two groups, we performed instrumental variable analyses to adjust for measured and unmeasured confounding factors.ResultsOverall, in-hospital mortality was 2.2%, and the occurrence of sepsis was 0.8%. In the instrumental variable analyses, no significant differences were found for in-hospital mortality, occurrence of sepsis, septic shock, Clostridioides difficile colitis, or total hospitalization costs. The antibiotic group showed a longer length of stay than the control group (coefficient, 1.9 days; 95% confidence interval, 0.6–3.2).ConclusionsIn this large nationwide cohort of patients with adhesive SBO, we found no benefit regarding preventive antibiotic administration in nonoperative treatment; however, antibiotic administration was associated with a longer hospital stay. These results did not support routine administration of antibiotics at admission to prevent bacterial translocation.     

Low contrast dose protocol involving a 100 kVp tube voltage for hypervascular hepatocellular carcinoma in patients with renal dysfunction

Purpose

To evaluate the feasibility of a 20 % reduced contrast dose hepatic arterial phase (HAP) CT for hypervascular hepatocellular carcinoma (HCC) with 100 kVp.

Materials and methods

The study included 97 patients with hypervascular HCC who underwent dynamic CT, including HAP scanning. The 54 patients had an estimated glomerular filtration rate (eGFR) of ≥60 were scanned with our conventional 120 kVp protocol. The other 43 patients (eGFR < 60) underwent scans using a tube voltage of 100 kVp and a 20 % reduced contrast dose. We compared the estimated effective dose, image noise, tumor-liver contrast (TLC), and contrast-to-noise ratio (CNR) in the hepatic arterial phase between the two groups using the Student’s t test.

Results

Estimated effective dose and image noise were not significantly different between these groups (p = 0.67 and p = 0.20, respectively). The TLC and CNR were significantly higher for the 100 kVp protocol than for the 120 kVp protocol (52.2 HU ± 17.4 vs 40.8 HU ± 18.6, p < 0.01 and 6.8 ± 2.6 vs 5.5 ± 2.4, p = 0.01, respectively).

Conclusion

For hepatic arterial phase CT of hypervascular HCC, 100 kVp scan allows a 20 % reduction in the contrast dose without reduction in image quality compared with a standard 120 kVp CT protocol.

     

Crystal structures of two tropinone reductases: Different reaction stereospecificities in the same protein fold

A pair of tropinone reductases (TRs) share 64% of the same amino acid residues and belong to the short-chain dehydrogenase/reductase family. In the synthesis of tropane alkaloids in several medicinal plants, the TRs reduce a carbonyl group of an alkaloid intermediate, tropinone, to hydroxy groups with different diastereomeric configurations. To clarify the structural basis for their different reaction stereospecificities, we determined the crystal structures of the two enzymes at 2.4- and 2.3-Å resolutions. The overall folding of the two enzymes was almost identical. The conservation was not confined within the core domains that are conserved within the protein family but extended outside the core domain where each family member has its characteristic structure. The binding sites for the cofactor and the positions of the active site residues were well conserved between the two TRs. The substrate binding site was composed mostly of hydrophobic amino acids in both TRs, but the presence of different charged residues conferred different electrostatic environments on the two enzymes. A modeling study indicated that these charged residues play a major role in controlling the binding orientation of tropinone within the substrate binding site, thereby determining the stereospecificity of the reaction product. The results obtained herein raise the possibility that in certain cases different stereospecificities can be acquired in enzymes by changing a few amino acid residues within substrate binding sites.     

Cold pain prolongs gastric emptying of liquid but not solid meal: an electrical impedance tomography (EIT) study

Stressful stimuli are reported to affect gastric emptying. However, methods for measuring gastric emptying are, in themselves, stressful. Electrical impedance tomography (EIT) is a method for measuring gastric emptying noninvasively. We used EIT to measure gastric emptying of liquid and solid meals to determine the effect of cold pain stress on gastric emptying. EIT (DAS-01P APT system; University of Sheffield, UK) was carried out in six healthy women (age, 21.6 ± 0.4 [mean ± SD] years) who had ingested a liquid (potage, 263 g; 139 kcal) or solid (beef patty, 205 g; 435 kcal) test meal. Cold pain stimuli consisted of repeated immersions of the subject's non-dominant hand into ice water (4°C) for 1 min, with a 15-s recovery period between immersions, for a total of 20 min. For the control stimulus, water at 37°C was used. The cold pain stimulus was applied immediately after the ingestion of a test meal. All studies were carried out randomly in each subject at intervals of more than 1 week. With cold pain, the half emptying time of the liquid meal was significantly greater than that with the control stimulus (47.6 ± 26.1 min vs 28.1 ± 10.8 min, P < 0.05). For the solid meal, the half emptying time did not differ between stimuli (101.9 ± 44.8 min with cold pain vs 92.6 ± 30.5 min with control stimulus). There were no significant differences in lag time between the liquid and solid meals. Cold pain stress delayed gastric emptying of liquid but not solid meals. Received: September 28, 1999 / Accepted: February 25, 2000