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.     

Significance of chymase-dependent angiotensin II formation in the progression of human liver fibrosis

Aim: Angiotensin II may contribute to liver fibrogenesis. In addition to angiotensin-converting enzyme (ACE), chymase, which is expressed by mast cells, is also known to be an angiotensin II-forming enzyme. However, it is unclear which of these two angiotensin II-forming enzymes plays a more important role in liver cirrhosis progression. In the present study, the role of angiotensin II-forming enzymes in the progression of liver cirrhosis was clarified. Methods: A total of 77 patients (16 in F0 stage, 10 in F1 stage, 22 in F2 stage, 12 in F3 stage, and 17 in F4 stage) were classified according to the new Inuyama classification into a non-cirrhosis (F0) group, an early cirrhosis (F1 + F2) group, and a chronic cirrhosis (F3 + F4) group. Results: Both chymase and total angiotensin II-forming activities were significantly higher in chronic cirrhosis patients than in the other two groups. However, there was nodifference among the three groups in ACE activity. On immunohistology, the number of chymase- and angiotensin II-positive cells was significantly higher in the chronic cirrhosis group than in the non-cirrhosis and early cirrhosis groups. There were significant correlations between the number of chymase-positive cells and the number of angiotensin II-positive cells, between the number of chymase-positive cells and the degree of fibrosis, and between the number of angiotensin II-positive cells and the degree of fibrosis. Conclusion: These results suggest that chymase-dependent angiotensin II formation may play an important role in hepatic fibrosis of patients with cirrhosis.     

The latest wire technique for chronic total occlusion.

If patency is restored after chronic total occlusion (CTO), it can be maintained over the long term by implanting drug-eluting stents. The cause of unsuccessful percutaneous coronary intervention is usually failure of the wire to cross the site of CTO. The objective of this article is to describe the latest wire techniques for CTO. As for wire selection, CTO should generally be treated with hard-tipped spring wires, preferably Conquest Pro series (Asahi Intec). According to the penetrating strategy, the course of a blood vessel with CTO is established preoperatively and the wire is advanced based on the imaging data with minimum rotation (a torque of +/- 90 degrees or less). If the operator encounters divergence between the preoperative CTO image and the actual course of the coronary artery, the parallel wire technique should be used. With this method, a wire which enters the subintimal space is left there, and a second wire is inserted along it to find a new channel. When this technique is successful, the following findings are often noted: 1) the second wire crosses over the first one in the CTO; 2) the second wire shows more acute curve than the first wire; 3) the second wire penetrates the lesion from the outer curvature of the coronary artery and then is advanced along the same curvature of the vessel. Indeed, the second wire should be operated intentionally to achieve these findings so that the probability of success increases and the duration of the procedure is shortened.     

Molecular phylogeny of a newfound hantavirus in the Japanese shrew mole (Urotrichus talpoides)

Recent molecular evidence of genetically distinct hantaviruses in shrews, captured in widely separated geographical regions, corroborates decades-old reports of hantavirus antigens in shrew tissues. Apart from challenging the conventional view that rodents are the principal reservoir hosts, the recently identified soricid-borne hantaviruses raise the possibility that other soricomorphs, notably talpids, similarly harbor hantaviruses. In analyzing RNA extracts from lung tissues of the Japanese shrew mole (Urotrichus talpoides), captured in Japan between February and April 2008, a hantavirus genome, designated Asama virus (ASAV), was detected by RT-PCR. Pairwise alignment and comparison of the S-, M-, and L-segment nucleotide and amino acid sequences indicated that ASAV was genetically more similar to hantaviruses harbored by shrews than by rodents. However, the predicted secondary structure of the ASAV nucleocapsid protein was similar to that of rodent- and shrew-borne hantaviruses, exhibiting the same coiled-coil helix at the amino terminus. Phylogenetic analyses, using the maximum-likelihood method and other algorithms, consistently placed ASAV with recently identified soricine shrew-borne hantaviruses, suggesting a possible host-switching event in the distant past. The discovery of a mole-borne hantavirus enlarges our concepts about the complex evolutionary history of hantaviruses.     

Phase transformation of a new generation yttria-stabilized zirconia femoral head after total hip arthroplasty

We examined a new-generation yttria-stabilized zirconia head manufactured by NGK 1 year after total hip arthroplasty. Monoclinic content of the retrieved head was twice that of the unused head at the pole and equator. A fourfold increase in monoclinic content was observed at 5 mm below the equator. Transformation from the tetragonal phase to the monoclinic phase occurred in the new generation zirconia with alumina doping within a relatively short period in vivo.     

Comorbid irritable bowel syndrome symptoms and headache have greater association with anxiety than depression: Annual health check-up survey results

High rates of co-existing irritable bowel syndrome (IBS) and headache have been reported in western countries. We investigated that comorbidity in individuals in Japan, along with anxiety and depression in subjects with and without IBS symptoms and/or headache.This cross-sectional study was performed from April 2012 to January 2013 at the Matsue Seikyo General Hospital Health Check Center. Questionnaires concerning symptoms related to IBS (Rome III) and headache, as well as anxiety/depression score were sent to individuals scheduled to undergo an annual health check-up, then returned during the visit and analyzed in a blinded manner.A total of 2885 individuals returned completed questionnaires and were enrolled, of whom 218 (7.6%) met the IBS criteria. The rates of co-existing headache in subjects with and without IBS symptoms were 44.0% (96/218) and 22.9% (611/2667), respectively, indicating a significantly higher rate of co-existing headache in subjects with as compared to without IBS (odds ratio [OR] 2.65, P < .001). Furthermore, the percentage of subjects with anxiety along with comorbid IBS symptoms and headache was significantly greater as compared to those with IBS (OR 3.01, P = .001) or headache (OR 2.41, P < .001) alone. Unlike anxiety, the percentage of subjects with depression was not significantly different among the IBS/non-headache, non-IBS/headache, and IBS/headache groups.Subjects with IBS symptoms had a higher rate of co-existing headache as compared to those without IBS. Furthermore, those with comorbid IBS symptoms and headache had a greater association with anxiety than with depression, as compared to those with only IBS or headache.     

Contrast echocardiography for the diagnosis of left ventricular thrombus in anterior myocardial infarction

Although detecting left ventricular thrombus in anterior myocardial infarction is important for the prevention of embolic events, imaging of apical thrombus is often difficult using conventional echocardiography. We examined whether contrast echocardiography improves sensitivity and specificity in detecting thrombus in the left ventricle in comparison with conventional echocardiography alone in patients with anterior myocardial infarction. Participants in this single-center prospective study comprised 392 patients with anterior myocardial infarction admitted between 2000 and 2006. After conventional echocardiography, all patients underwent contrast echocardiography (left ventricular opacification and myocardial contrast echocardiography) during intravenous drip infusion of contrast media at rest. Left ventricular thrombus was diagnosed based on left ventriculography or multidetector-row computed tomography (MDCT). Mural left ventricular thrombus was confirmed by left ventriculography and/or MDCT in 32 of 393 patients (8 %). Sensitivity and specificity of conventional echocardiography alone were 88 % and 96 %, respectively, compared with 100 % each with contrast echocardiography. Among the 32 patients with left ventricular thrombus, 25 patients (78 %) showed no perfusion in the anterior wall on myocardial contrast echocardiography, even with a four-beat interval. In conclusion, contrast echocardiography offers a clinically feasible and useful method for noninvasively evaluating left ventricular thrombus in anterior myocardial infarction.