Endoscopic sphincterotomy for common bile duct stones: Impact of recent technical advances

Technical improvements, such as mechanical lithotripsy, stenting or nasobiliary drainage, and wire-guided cannulation, have reduced the risk of complications in endoscopic sphincterotomy. To determine the extent of this reduction in risk, we assessed the medical records of 1352 patients with common bile duct stones in whom the procedure was conducted. Complications examined were: acute cholangitis and pancreatitis. Stone clearance was achieved in 1256 patients (92.8%), with an overall morbidity rate of 7.7% and a mortality rate of 0.15%. One hundred and forty-two patients had stones with a diameter greater than 20mm; 97 of these patients did not undergo lithotripsy. Cholangitis occurred in 10 of these 97 patients (10.3%), whereas, in the 45 patients who underwent lithotripsy, there were no cases of cholangitis (P=0.02). Stone removal was not immediately accomplished or attempted in 396 patients. In 82 of these patients in whom a stent or a nasobiliary drain was placed in the common bile duct, the incidence of cholangitis was 1.2%, significantly less (P=0.045) than the incidence of 6.4% in the other 314 patients given no stenting or nasobiliary drain. To overcome difficult cannulation, precut sphincterotomy was conducted in 134 patients and wireguided sphincterotomy, a recently introduced procedure, was conducted in 55 patients. When the precutting technique was used, the incidence of acute pancreatitis was significantly higher (8/134; 6.0%) than that in the patients in whom the standard procedure was conducted, i.e., neither the precut technique nor wire-guided ES was used (23/1218; 1.9%) (P=0.008). There were no cases of pancreatitis in the 55 patients in whom wire-guided sphincterotomy was performed, although the difference was not statistically significant because of the small number of patients (P=0.06). Based on these findings, we conclude that improved technologies have led to a significant reduction of complications in endoscopic sphincterotomy.     

A review of Disrupted-In-Schizophrenia-1 (DISC1): neurodevelopment, cognition, and mental conditions.

Disrupted-In-Schizophrenia-1 (DISC1) is a promising candidate gene for schizophrenia (SZ) and bipolar disorder (BP), but its basic biology remains to be elucidated. Accumulating genetic evidence supports that DISC1 is associated with some aspects of cognitive functions relevant to SZ and BP. Here, we provide a summary of the current updates in biological studies of DISC1. Disrupted-In-Schizophrenia-1, preferentially expressed in the forebrain, has multiple isoforms with potential posttranslational modifications. Disrupted-In-Schizophrenia-1 protein occurs in multiple subcellular compartments, which include the centrosome, microtubule fractions, postsynaptic densities, actin cytoskeletal fractions, the mitochondria, and the nucleus. Recent studies have clarified that DISC1 mediates at least centrosome-dynein cascade and cyclic adenosine monophosphate (cAMP) signaling. Furthermore, both cytogenetic and cell biological studies consistently suggest that an overall loss of DISC1 function (either haploinsufficiency or dominant-negative, or both) may be associated with SZ and BP. On the basis of these findings, production of DISC1 genetically engineered mice is proposed as a promising animal model for SZ and BP. Several groups are currently generating DISC1 mice and starting to characterize them. In this review, the advantages and disadvantages of each animal model are discussed.     

Vav3 modulates B cell receptor responses by regulating phosphoinositide 3-kinase activation.

To elucidate the mechanism(s) by which Vav3, a new member of the Vav family proteins, participates in B cell antigen receptor (BCR) signaling, we have generated a B cell line deficient in Vav3. Here we report that Vav3 influences phosphoinositide 3-kinase (PI3K) function through Rac1 in that phosphatidylinositol-3,4,5-trisphosphate (PIP3) generation was attenuated by loss of Vav3 or by expression of a dominant negative form of Rac1. The functional interaction between PI3K and Rac1 was also demonstrated by increased PI3K activity in the presence of GTP-bound Rac1. In addition, we show that defects of calcium mobilization and c-Jun NH2-terminal kinase (JNK) activation in Vav3-deficient cells are relieved by deletion of a PIP3 hydrolyzing enzyme, SH2 domain-containing inositol polyphosphate 5'-phosphatase (SHIP). Hence, our results suggest a role for Vav3 in regulating the B cell responses by promoting the sustained production of PIP3 and thereby calcium flux.     

Usefulness of two-dimensional time-of-flight MR angiography combined with surface anatomy scanning for convexity lesions

Thirty-eight patients with convexity lesions were studied prospectively with the two-dimensional time-of-flight (2D-TOF) magnetic resonance angiography (MRA) method. Of these 21 cases had additional surface anatomy scanning (SAS) and 7 cases had three-dimensional phase contrast (3D-PC) MRA. The findings were compared during surgery, and the predictability of 2D-TOF evaluated. 2D-TOF was obtained with 2 mm slice thickness after the administration of contrast media for routine magnetic resonance imaging (MRI). Cortical veins were visualized with a good resolution with a scan time of only 5 minutes. The tumor was also visible in the background, due to enhancement, and thus the tumor-vessels relation was shown. Slow-flow vessels were also adequately seen. SAS was done at the same sitting with fast spin echo (FSE) with a scan time of 3 minutes. Once both images were incorporated, information on gyri and their relation to the lesions and vasculature could be obtained from a single image. We found 2D-TOF alone, or at times in combination with SAS, useful for planning of operation for convexity lesions.     

Toluene in blood as a marker of choice for low-level exposure to toluene

The validity of two new biological exposure markers of toluene in blood (TOL-B) and toluene in urine (TOL-U) was examined in comparison with that of the traditional marker of hippuric acid in urine (HA-U) in 294 male workers exposed to toluene in workroom air (TOL-A), mostly at low levels. The exposure was such that the geometric mean for toluene was 2.3 ppm with a maximum of 132 ppm; the workers were also exposed to other solvents such as hexane, ethyl acetate, styrene, and methanol, but at lower levels. The chance of cutaneous absorption was remote. Higher correlation with TOL-A and better sensitivity in separating the exposed workers from the nonexposed subjects were taken as selection criteria. When workers exposed to TOL-A at lower concentrations (< 50 ppm, < 10 ppm, < 2 ppm, etc.) were selected and correlation with TOL-A was examined, TOL-B showed the largest correlation coefficient which was significant even at TOL-A of < 1 ppm, whereas correlation of HA-U was no longer significant when TOL-A was < 10 ppm. TOL-U was between the two extremes. The sensitivities of TOL-B and TOL-U were comparable; HA-U showed the lowest sensitivity. Thus, it was concluded that TOL-B is the indicator of choice for detecting toluene exposure at low levels.     

Rupture of an isolated internal iliac artery aneurysm into the rectum: Report of a case

Aneurysmal rupture into the intestinal tract is a rare but disastrous complication of an internal iliac artery aneurysm. We report herein the successful surgical repair of a fistula between a huge aneurysm of the right internal iliac artery and the rectum in an 81-year-old man. After a femoro-femoral cross-over bypass had been performed, the aneurysm was opened and its patent arterial branches were ligated with sutures. The fistula was then intra-aneurysmally sutured and covered with an omental flap. The diagnostic and therapeutic approaches to this severe complication are discussed with a review of the literature following the presentation of this case.     

Effect of clot removal on cerebral vasospasm

The effect of clot removal on cerebral vasospasm was studied in 104 patients with aneurysmal subarachnoid hemorrhage (SAH). The series included patients who fulfilled all of the following criteria: operation was performed by Day 3 after the ictus; the patient's preoperative clinical grade was between Grades I and IV; there was no rebleeding; computerized tomography (CT) showed only SAH; and carotid angiograms were performed by Day 2 and repeated between Days 7 and 9. Both the degree of SAH on CT and angiographic vasospasm were graded from 0 to III. The relationship of the SAH grade in the basal frontal interhemispheric fissure (IHF) to the presence of vasospasm at the A2 segments of the anterior cerebral artery and the relationship of the SAH grade in the sylvian stems to the presence of vasospasm at the M1 segments of the middle cerebral artery were analyzed. Correlation of preoperative and postoperative SAH grades with the angiographic vasospasm grades, with the incidence of symptomatic vasospasm, and with the low-density area on CT could be found in the A2 and M1 territories. Decrease of cisternal blood measured by CT after the operation did not relate directly to the reduction of vasospasm. When the SAH was Grade II or III in the basal frontal IHF, the angiographic vasospasm grades at the A2 were significantly lower in patients with surgery via the interhemispheric approach than in those with surgery via the pterional approach. Symptomatic vasospasm occurred in two of the eight cases operated on by the interhemispheric approach compared with 11 of the 22 cases approached via the pterional route. In patients with a pterional approach, there was no significant difference in severity of vasospasm in the M1 territory between the side of approach and the opposite side. No consistent relationship could be found between the time interval from SAH to operation and the severity of vasospasm. While clot removal may ameliorate cerebral vasospasm, its effect per se does not seem to be significant.     

A Case of a Patient with a Rectal Ulcer Who Had an Unusual Defecation Habit

Abstract: This case report describes a patient with a rectal ulcer who had an unusual defecation habit. Complete healing was recognized colonoscopically after the patient was instructed to break this habit. A polyp of the ascending colon was detected by a barium enema in a 37-year-old man complaining of anal bleeding. He was admitted to our division to undergo a polypectomy. At the time of the polypectomy, a round ulcer, measuring 1 cm in diameter, was detected on the right wall of the rectum 3 cm from the anal verge. A diagnosis of mucosal prolapse syndrome of the rectum could not be made because the patient did not exhibit the characteristic habit of excessive “straining” mentioned by patients with this syndrome, and no characteristic finding of fibromuscular obliteration was found on histological examination of biopsied specimens taken endoscopically from the lesion. Repeated history taking, however, revealed that the patient had the unusual habit of inserting his finger into his rectum after defecation. He broke this habit following instruction to do so. As a result, on colonoscopic examination 15 month later, the ulcer was found to have become a scar:     

Moment analysis of drug disposition in kidney. II: Urine pH-dependent tubular secretion of tetraethylammonium in the isolated perfused rat kidney

Effects of urine pH on the renal tubular secretion of an organic cation (tetraethylammonium, TEA) and an organic anion (p-aminohippurate, PAH) were investigated using the isolated erythrocyte-perfused rat kidney. The method was based on a multiple indicator dilution experiment and noncompartmental moment analysis. Treatment with sodium bicarbonate and sodium dihydrogen phosphate increased and decreased urine pH, respectively, but affected neither the condition of the perfused kidney nor the renal handling of albumin and inulin. In TEA studies, the increase of urine pH prolonged the mean residence time in renal epithelial cells (T cell) and reduced the apparent secretion intrinsic clearance, but did not influence the volume of distribution in the kidney (Vd drug). The decrease of urine pH did not affect these kinetic parameters. By contrast, PAH secretion was constant against the change of urine pH. Since any change in the basolateral membrane transport is reflected in Vd drug, the net transport from blood to cells can be regarded as similar under these treatments. On the other hand, the prolonged T cell of TEA with the increased urine pH suggested a slow transport from cells to lumen across the brush-border membranes. The present results coincide with the hypothetical mechanism that organic cations are secreted via an active transport system, coupled to the countertransport of H+ into cells. In conclusion, the present method is useful to separately evaluate the transmembrane transport across both sides of the renal epithelial cells in a morphologically intact kidney.