Massive Ascites Caused by Primary Diffuse Large B-cell Lymphoma of the Jejunum: A Case of a Rare Initial Symptom

A 74-year-old man presented with abdominal swelling. Computed tomography revealed massive ascites and localized thickening of the small intestinal wall. Enteroscopy showed ulcerative lesions along the circumference of the jejunum. Histological examination showed dense proliferation of large lymphoid atypical cells, and immunohistochemistry showed CD20 and CD10 positivity, CD3 negativity, and Ki67 labeling index >80%. Cytology of the ascitic fluid revealed large lymphoid cells. These findings suggest that small intestine primary diffuse large B-cell lymphoma (DLBCL) caused the ascites. Massive ascites as an initial symptom of primary DLBCL of the jejunum is rare. Herein, we describe this unusual presentation.     

Analysis of Protein Removal Properties During Cryofiltration Apheresis Using the Evaflux‐5A Plasma Fractionator in a Patient With Hepatitis C Virus‐Associated Cryoglobulinemic Glomerulonephritis

Cryofiltration (CF) is a technique in which separated plasma is chilled before being subjected to a plasma fractionator (PF), leading to cryoglobulin precipitation or cryogel formation. In CF using the Evaflux‐5A as the PF, there is no consensus on the necessity of albumin supplementation, and when or how often the PF column should be washed. We analyzed the sieving effects of various solutes (albumin, IgG, IgM, LDL, HCV‐RNA, and cryoglobulin) depending on transmembrane pressure (TMP_PF) during CF using the Evaflux‐5A in a patient with hepatitis C virus‐associated cryoglobulinemic glomerulonephritis. Five CF treatments were initially performed and a sixth one later, at disease recurrence. Quantitative detection of cryoglobulin and a marked rise in TMP_PF to 400 mm Hg were observed only at the first and sixth treatment, and albumin losses during these treatments were very high, at 16.8 g, and 14.6 g, respectively, while those of others (from the second to fifth) were 6.7 g, 6.4 g, 5.9 g, and 7.0 g, respectively. The sieving coefficients (SCs) of both albumin and IgG were stable (0.8–1.0) at TMP_PF < 200 mm Hg, but significantly decreased at TMP_PF ≥ 200 mm Hg (P < 0.01). The SC of IgM tended to decrease at TMP_PF ≥ 200 mm Hg, but not significantly, while that of LDL was zero regardless of the TMP_PF. Albumin loss per treatment likely depends on degree of TMP_PF rise, which is mainly affected by the patient's cryoglobulinemic status. In CF using Evaflux‐5A, washing the PF column to keep TMP_PF < 200 mm Hg during treatment may be a recommended for selective removal and albumin salvage.     

The posterior thigh flap revisited: clinical use in oncology patients

Purpose

The posterior thigh flap is a reliable flap owing to the dependability of the inferior gluteal artery. Its utility for the reconstruction of sacral, perineal, ischial, pelvic, trochanteric and vulvar defects is well established. We herein describe the use of the flap for a variety of indications, and discuss the results with respect to postoperative complications in oncology patients.

Methods

We reviewed nine oncology patients who were treated with pedicled posterior thigh flaps. We assessed the use of this treatment by recording the site of the defect, the type of flap used, and the presence or absence of previous surgical procedures, radiation therapy and postoperative complications.

Results

Defects after resection of soft tissue sarcomas were the most common condition (n = 4), followed by skin cancers (n = 2), gastrointestinal cancers (n = 2) and radiation osteomyelitis (n = 1). Six patients (66 %) developed complications; three (33 %) were major and three (33 %) were minor. There was one case of total necrosis of the flap and two cases of partial necrosis.

Conclusions

In oncology patients, the posterior thigh flap is an excellent choice for the reconstruction of sacral, ischial, pelvic or buttock defects, since it does not cause any donor site morbidity.     

Imidazole antifungals, but not triazole antifungals, increase membrane Zn2+ permeability in rat thymocytes Possible contribution to their cytotoxicity

The use of zinc as a nutritional supplement has become common in many countries. Since zinc has diverse actions, it may be difficult to predict its synergistic and/or antagonistic action in simultaneous presence of drug(s). The combination of imidazole antifungals, but not triazole antifungals, with 3-30 microM ZnCl2 significantly increased the lethality of rat thymocytes. Since intracellular Zn2+ exerts various actions on the process of cell death, there is a possibility that imidazole antifungals, but not triazole antifungals, increases concentration of intracellular Zn2+ ([Zn2+]i). To test the possibility, we examined the effects of imidazole and triazole antifungals on [Zn2+]i of rat thymocytes in absence and presence of extracellular Zn2+ by the use of FluoZin-3, a fluorescent Zn2+ indicator. Imidazole antifungals (clotrimazole, econazole, and oxiconazole) increased the [Zn2+]i in the presence of extracellular Zn2+ while it was not the case for triazole antifungals (itraconazole and fluoconazole). Thus, it is suggested that imidazole antifungals increase the membrane permeability of Zn2+. The potency order in the augmentation of FluoZin-3 fluorescence by imidazole antifungals in the presence of extracellular Zn2+ was the same as that in their cytotoxic action. Therefore, the cytotoxic action of imidazole antifungals may be related to their action on membrane Zn2+ permeability.     

Postoperative evaluation of surgically treated cases with temporary silicone implant in temporomandibular joint

We have carried out temporary silicone implants after diskectomies or arthroplasties in temporomandibular joint surgeries to avoid postoperative adhesion and to maintain articular space. We evaluated 19 joints in 15 patients who had received dacron-reinforced silicone implant after silicone sheet removal through follow-up for at least 6 months. The cases included temporomandibular joint disorder (10 joints in 9 patients), psoriatic arthritis (2 joints in 1 patient), ankylosis (4 joints in 3 patients) and synovial chondromatosis (2 joints in 2 patients). On the basis of the criteria of temporomandibular dysfunction for the results, they were classified as bad (4 patients). It is thought that factors other than the implant are related to the bad results in the postoperative evaluation. In this study, lymphadenopathy induced by exfoliated silicone debris could not be confirmed. The temporary silicone implant in the temporomandibular joint was thought to be useful.     

Blockade of ATP-sensitive potassium channels by 5-hydroxydecanoate suppresses monophasic action potential shortening during regional myocardial ischemia

Summary We tested 5-hydroxydecanoate (5-HD), a specific blocker of ATP-sensitive potassium channels (IK.ATP), to determine if it mitigates electrophysiologic changes produced by regional myocardial ischemiain vivo. A sequence of 5-minute occlusion of the distal LAD and 30-minute reperfusion was repeated while recording the monophasic action potential (MAP) and bipolar electrogram (EG) from the epicardial center of the ischemic myocardium in anesthetized dogs. 5-HD (30 mg/kg, IV) or glibenclamide (0.15 or 0.3 mg/kg, IV) was administered before the third occlusion, and the data were compared to the second occlusion data. 5-HD did not affect baseline MAP duration at 90% and 50% repolarization (APD90, APD50) before LAD occlusion but suppressed occlusion-induced shortening of APD90 (16 ± 2% during the second occlusion vs. 5 ± 3% during the third occlusion, n=8, p<0.01) and APD50 (16 ± 3% vs. 10 ± 3%, n=8, p<0.05). Pretreatment with glibenclamide also suppressed occlusion-induced MAP shortening and eliminated an additional effect of 5-HD (n = 3). 5-HD did not affect the occlusion-induced increase in duration and activation time of EG. 5-HD, as well as glibenclamide, suppressed regional ischemia-induced MAP shortening, probably by blocking activation of IK.ATP, without affecting conduction delay. These differential effects of 5-HD on repolarization and conduction during the early phase of regional ischemia might have the potential to suppress reentrant ventricular arrhythmias.This study was supported in part by Mitsukoshi Prize of Medicine 1993 (Satoshi Ogawa, Toshihisa Miyazaki).     

Prognostic significance of late gadolinium enhancement quantification in cardiac magnetic resonance imaging of hypertrophic cardiomyopathy with systolic dysfunction

Hypertrophic cardiomyopathy (HCM) with systolic dysfunction carries a poor prognosis. Although late gadolinium enhancement (LGE) on cardiac magnetic resonance is associated with adverse cardiac events in HCM and is inversely related to left ventricular ejection fraction (LVEF), it is unknown whether LGE or LVEF more accurately predicts adverse cardiac events in HCM with systolic dysfunction. We retrospectively assessed the extent of LGE with a threshold of 6 standard deviations in 46 consecutive HCM patients with systolic dysfunction defined as LVEF <50 % (average 35 ± 12 %) who underwent cardiac magnetic resonance (35 males, mean age 59 ± 14 years). They were followed up over 1755 ± 594 days. The composite adverse cardiac events end point included cardiovascular death, lethal arrhythmia, cardioembolic stroke, and unplanned heart failure hospitalization. LGE was detected in all patients, and the mean extent was 30 ± 15 %. Twenty-nine patients developed adverse cardiac events. Multivariate Cox proportional hazard analysis revealed the extent of LGE as a good independent predictor of adverse cardiac events. Risk increased with the extent of LGE (hazard ratio = 1.62/10 % increase in LGE, 95 % confidence interval = 1.23–2.15, p < 0.001). LVEF was inversely related to the extent of LGE (r = ?0.44; p = 0.002) and was also an independent predictor of adverse cardiac events. Risk decreased with LVEF (hazard ratio = 0.68/10 % increase in LVEF, 95 % confidence interval = 0.51–0.91, p = 0.010). The Akaike information criterion evaluating the fit of a model demonstrated that the extent of LGE was a better independent predictor of MACE than LVEF (Akaike information criterion = 172.20 and 178.09, respectively).The extent of LGE was a good independent predictor of adverse cardiac events and reflected mortality and morbidity more precisely than LVEF in HCM with systolic dysfunction.     

Role of galectin-3 in human pulmonary fibrosis.

BACKGROUND: Galectin-3 is a beta-galactoside-binding protein which is implicated in diverse physiological and pathological processes including human liver cirrhosis and a mouse lung fibrosis model. The aim of this study is to determine whether galectin-3 is involved in human lung fibrosis. METHODS: We measured galectin-3 concentration in bronchoalveolar lavage fluid (BALF) and examined its expression in alveolar macrophages from patients with interstitial lung disorders using ELISA and immunohistochemical staining, respectively. Using monocyte/macrophage cell lines in vitro, we examined the effect of cytokines on galectin-3 expression, and the opposite similarly by RT-PCR and Western blotting. Finally, we performed Micro Boyden chamber assay and Sircoll assay to determine whether galectin-3 induces migration and collagen synthesis, respectively, in fibroblasts. RESULTS: Galectin-3 was specifically increased in BALF from patients with idiopathic pulmonary fibrosis (IPF) and interstitial pneumonia associated with collagen vascular disease (CVD-IP). Galectin-3 levels in BALF seemed to be lower in IPF and CVD-IP patients receiving corticosteroid therapy. Alveolar macrophages from IPF patients expressed more galectin-3 compared with those from control. Galectin-3 expression was induced by tumor necrosis factor-alpha (TNF-alpha) and interferon (IFN)-gamma in a monocytic cell line U937. Galectin-3 also induced mRNA expression and protein production of TNF-alpha and interleukin (IL)-8 in a macrophage cell line THP-1. This lectin stimulated NIH-3T3 fibroblast to induce migration and collagen synthesis in vitro. CONCLUSIONS: These results suggest that galectin-3 is involved in the pathogenesis of human IPF and CVD-IP by activating macrophages and fibroblasts.     

Improved safety of biologic therapy for rheumatoid arthritis over the 8-year period since implementation in Japan: long-term results from a multicenter observational cohort study

This study aimed to compare the long-term safety of biologics by initiation year of treatment in patients with rheumatoid arthritis (RA) in Japan. RA patients who started their first biologics including infliximab, etanercept, adalimumab, and tocilizumab between 2003 and 2008 were identified in the Tsurumai Biologics Communication Registry (TBCR), multicenter observational cohort, and followed for 2 years or until discontinuation of the drugs. We identified baseline predictors for adverse events (AEs) resulting in discontinuation of the first TNFI using Cox proportional hazards regression analysis. A total of 874 cases (1,340 person-years) were observed. During the observation period, 96 AEs (4.7 events/100 person-years) occurred. From 2003 to 2008, there were significant changes in disease duration, Steinbrocker stage, and disease activity in those aged ≤64 years with no increase of incidence of AEs, whereas those aged >64 years had no significant changes in these variables. In the later initiation year of treatment with biologics, the fewer AEs were observed (log-rank, p?=?0.017, 2008 vs. 2003–2005). Multivariate analysis showed that the initiation year significantly impacted the incidence of AEs 6 months into the observation period [initiation at 2008 (vs. 2003–2005): OR: 0.30, 95 % CI: (0.14–0.68)] after adjusting for variables at baseline. The decrease of AEs in the later initiation year was evident in those aged >64 years. The safety of biologic therapy improved over the course of the 8 years from its implementation in Japan.