Increased risk of cholelithiasis after esophagectomy

Background/Purpose Truncal vagotomy enhances gallstone formation. As esophagectomy involves truncal vagotomy, it was hypothesized that esophagectomy would increase the risk of cholelithiasis. This study was intended to test this hypothesis and to elucidate factors influencing the incidence of cholelithiasis after esophagectomy.Methods The study was a retrospective analysis of 136 patients with esophageal carcinoma who had survived for 5 years or longer after esophagectomy. Eight patients (5.9%) had cholelithiasis before esophagectomy. Of the remaining 128 patients, 113 underwent abdominal ultrasonographic examination for cholelithiasis twice a year after esophagectomy; the median follow-up time was 89.5 months (range, 60–117 months).Results Gallstones developed in 26 (23%) of the 113 patients undergoing regular ultrasonographic examination. The cumulative incidence of cholelithiasis reached a plateau of 34% at 10 years after esophagectomy. Reduction of body mass index after esophagectomy was the strongest independent predictor of gallstone formation after esophagectomy (P = 0.0001, log-rank test; P = 0.0003, Coxs proportional hazards model). The prevalence of cholelithiasis at 5 years after esophagectomy (18/113; 16%) was significantly higher than that before esophagectomy (8/136; 5.9%; P = 0.012, Fishers exact test).Conclusions Esophagectomy yields an increased risk of the development of cholelithiasis. Truncal vagotomy and postsurgical malnutrition may contribute to this increased gallstone formation after esophagectomy.     

The management of possible fishbone ingestion

OBJECTIVE: We assessed the usefulness of computed tomography (CT) in cases of suspected impaction of fish bones in the esophagus. The findings of this study were also compared with those of studies in which surgery was used to remove or confirm the presence of fish bones. We accordingly propose a management protocol to ensure optimum outcome for patients with a history of fish bone ingestion. METHODS: X-ray and CT imaging were performed in 76 patients in whom esophageal impaction of fish bones was suspected. RESULTS: Plain X-ray revealed impacted fish bones in 17 patients (22%), soft-tissue swelling but no evidence of foreign body in 5 (7%), and no abnormal findings in 54 (71%). These findings were apparent on CT scans in 31 (41%), 8 (10%), and 37 (49%), respectively. Of the 31 patients in whom CT revealed a fishbone, 17 (55%) also exhibited X-ray evidence of foreign body. Of the remainder, X-ray revealed only soft-tissue swelling in 3 (10%), and was unremarkable in 11 (35%). Among the 5 patients in whom X-ray demonstrated only soft-tissue swelling, CT was positive for foreign body in 3 (60%). Of the 54 patients in whom X-ray appearances were normal, CT revealed foreign bodies in 11 (20%) and other abnormalities in 6 (11%). CONCLUSION: In the present study, sensitivity and specificity of plain X-ray was 54.8% (17 of 31) and 100% (45 of 45), respectively. However, for CT, both sensitivity and specificity were 100%. CT was determined to be very useful in the diagnosis of impacted fish bones in the esophagus.     

Reversal of antigen-dependent signaling by two mutations in antibody/receptor chimera: implication of inverse agonism in cytokine receptor superfamily

Understanding the receptor activation mechanism is essential for the rational design of pharmacologically active ligand molecules. However, the activation mechanism of most cytokine receptors remains still unclear, and while agonism and antagonism have been described for ligand-mimetic peptides, there has been no report of inverse agonism that has been characterized for G protein-coupled receptors (GPCRs). To explore the activation mechanism of cytokine receptors, here we tried to investigate how agonism and antagonism could be altered by randomizing antibody variable region of an antibody/cytokine receptor chimera recognizing hen egg lysozyme (HEL) as an agonist. Based on our previous finding that the co-expression of V(H)-gp130 and V(L)-erythropoietin receptor (EpoR) chimeras transduced strict and efficient HEL-dependent cell growth signal, a V(H)-gp130 library encoding four randomized CDR2 residues was retrovirally infected to IL-3-dependent Ba/F3 cells already transfected with V(L)-EpoR. The selection without IL-3 resulted in a clonal expansion of the transduced cells, and interestingly some of which showed HEL dose-dependent growth suppression. Our results clearly indicate that agonism and antagonism of the antibody/cytokine receptor chimera can be readily switched by a subtle modification of the ligand binding domain as well as that of GPCRs, also implying the existence of inverse agonism in cytokine receptor superfamily.     

An optimized homogeneous noncompetitive immunoassay based on the antigen-driven enzymatic complementation

We describe an optimized noncompetitive and homogeneous immunoassay based on the antigen-dependent reassociation of antibody variable domains and beta-galactosidase (beta-gal) complementation (open sandwich enzymatic complementation immunoassay, OS-ECIA). The reassociation of two fusion proteins, an antibody heavy chain variable region fragment tethered to an N-terminal deletion mutant of beta-gal, V(H)Deltaalpha, and the light chain variable region fragment tethered to a C-terminal deletion mutant of beta-gal, V(L)Deltaomega, was monitored by the enzymatic complementation between the two. With the use of anti-hen egg lysozyme (HEL) antibody HyHEL10, an antigen-dependent enhancement in the enzymatic activity was clearly observed. To optimize the assay, the lengths of the linkers connecting the two domains of each fusion protein were varied, and the optimal pair V(H)(G(4)S)(2)Deltaalpha/V(L)(G(4)S)Deltaomega showed much improved antigen-responsive beta-gal activity. After various optimizations, almost 1000-fold improvement in sensitivity compared with that of our corresponding homogeneous open sandwich (OS) assays based on the energy transfer was observed, possibly due to lower V(H)/V(L) concentration and background heterodimer association.     

Nursing discharge summaries of deceased patients with respiratory diseases

To explore how nurses feel about deceased patients and end-of-life care, the nursing discharge summaries of 115 sequential patients who died in the respiratory division of a Japanese university hospital were reviewed. When compared to discharge summaries of patients with non-malignant illness, a significantly higher percentage of discharge summaries of those with malignant illnesses documented support from family members (P = 0.0166), patient's hope for cure (P = 0.0206), and patient anxiety (P = 0.0258). As difficult situations stay with nurses as memories, it is important for both new graduates and skilled nurses to document their feelings in difficult clinical situations.     

Embolization for spontaneous retroperitoneal hemorrhage from adrenal myelolipoma

Adrenal myelolipoma is a benign tumor composed of fat and bone marrow tissues and is usually found incidentally. Spontaneous retroperitoneal hemorrhage from this tumor is rare. To our knowledge, there have been only 11 reported cases of ruptured adrenal myelolipoma in the literature. We report a 37-year-old female patient who underwent transcatheter arterial embolization using gelatin sponge particles for retroperitoneal hemorrhage from adrenal myelolipoma, 8x6x6 cm in size. This case, which is the second in the literature, illustrates the usefulness of embolization to achieve hemostasis prior to subsequent tumor resection.     

Different characteristics of carcinoma in the gastric remnant: histochemical and immunohistochemical studies

Seventy cases of cancer of the gastric remnant were divided into three groups: 33 cases following surgery for benign disease (group A), and 15 cases occurring more than 10 years and 22 cases occurring within 10 years after the first gastrectomy for malignant disease (groups B and C, respectively). Then mucin histochemical and immunohistochemical studies were undertaken. Billroth-II procedure for anastomosis was most frequently performed in group A. Intestinal metaplasia within the mucosa surrounding the carcinomas was more frequently present in groups A and C with a diffuse distribution. Intestinal-type surrounding mucosa was significantly more frequent in group C. The immunohistochemical expression of p53 protein was most frequently expressed in group B. We conclude that a different mechanism of carcinogenesis exists in these three groups; i) group A: the reflux of duodenal juice especially following B-II procedures leads to progression of the carcinoma. ii) group B: some genetic factor such as p53 may be related to the metachronous multiple carcinogenesis. iii) group C: metachronous multiple carcinogenesis within the short interval may be closely associated with diffuse intestinal metaplasia in the surrounding mucosa.     

Bleeding Meckel's diverticulum in an adult

Bleeding Meckel's diverticulum tends to be a complication of ectopic gastric mucosa. It has been known that the gastric acid and digestive fluid produced from the ectopic gastric mucosa cause peptic ulcer, which leads to bleeding. When the ectopic gastric mucosa is entirely formed by the pyloric gland, however, ulcer formation may result from factors other than gastric acid and digestive fluid. This is a report of an adult case of bleeding Meckel's diverticulum with ectopic gastric mucosa in whom mechanical stimulation was suggested as a cause of the erosion and ulceration, resulting in bleeding.     

Manserin as a novel histochemical neuroendocrine marker in prostate cancer

ObjectivesTo investigate the presence of manserin in human prostate cancers and to correlate manserin expression with pathologic outcomes and progression-free survival.MethodsEighty-seven patients with recent prostate cancer were classified into 4 groups based on Gleason score, and manserin immunohistochemistry was correlated with Gleason sum grade. To investigate the validity of manserin as a prognostic factor, the Cox proportional hazards regression model was performed on 48 patients in our cohort with T3 or T4 prostate cancer who were initially treated with androgen deprivation therapy.ResultsThe manserin-positive rates of patients with Gleason sums of 6, 7, 8, and ≥9 were 0%, 20.0%, 35.0%, and 48.1%, respectively. Manserin-positive rates were positively correlated with Gleason sums (P = 0.0001). Median times to cancer progression in groups with (n = 8) and without (n = 40) manserin expression were 8 months and 28 months, respectively (P = 0.01). Univariate Cox analysis revealed that manserin expression, clinical stage T4, and high Gleason sum were significantly associated with progression. Multivariate analysis revealed that only 2 factors, manserin expression (hazard ratio (HR) 4.99, P = 0.01) and clinical stage T4 (HR 4.77, P = 0.03), were independent risk factors for progression.ConclusionsThis is the first report of manserin expression in human prostate cancers. Manserin may serve as a marker of prostate cancer progression.