Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Phosphorylation of extracellular signal‐regulated kinase 1/2, p38 mitogen‐activated protein kinase and nuclear translocation of nuclear factor‐κB are involved in upregulation of matrix metalloproteinase‐9 by tumour necrosis factor‐α

Background: Upregulation of matrix metalloproteinase‐9 (MMP‐9) induced by tumour necrosis factor‐α (TNF‐α) is reportedly involved in a variety of non‐neoplastic and neoplastic diseases. In this study, we examined which signalling pathways are involved in TNF‐α‐induced MMP‐9 upregulation in cholangiocarcinoma (CC). Methods: We used two CC cell lines: HuCCT‐1 and CCKS‐1. Results: In an ex vivo study using HuCCT‐1 and CCKS‐1 cells, TNF‐α treatment induced MMP‐9 production and activation via interaction with TNF receptor‐1 (TNF‐R1) but not with TNF receptor‐2 (TNF‐R2), shown by zymography, and increased MMP‐9 promoter activity (luciferase assay). As for the signalling pathway, TNF‐α stimulation led to the phosphorylation of extracellular signal‐regulated kinase 1/2 (Erk1/2) and p38 mitogen‐activated protein kinase (p38MAPK) and translocation of nuclear factor κB (NF‐κB) (p65) into the nuclei. Inhibition studies using SB203580 (inhibitor of p38MAPK), U0126 (inhibitor of mitogen‐activated or extracellular signal‐regulated protein kinase 1/2) and MG132 (inhibitor of NF‐κB) showed that the phosphorylation of Erk1/2 and p38MAPK with activation of NF‐κB was closely related to MMP‐9 upregulation in both cell lines. Conclusion: These data suggest that TNF‐α/TNF‐R1 interaction leads to the phosphorylation of Erk1/2 and p38MAPK and nuclear translocation of NF‐κB, which is closely associated with the production and activation of MMP‐9 in cultured CC cells of HuCTT‐1 and CCKS‐1. Upregulation of MMP‐9 with NF‐κB activation may be involved in the tumour invasion of CC.     

Peut-on individualiser la prise en charge de la douleur ?

While most cesareans are conducted without any particular problem, in nearly 20% of cases, women may present severe postoperative pain, despite adequately managed multimodal analgesia. In terms of pain, there is significant variability because of the numerous factors involved, including physiological, cognitive, cultural, social, emotional and genetic ones.Different approaches have been proposed to identify women at risk of developing significant postoperative pain, including nociceptive tests and/or psychosocial questionnaires associated or not to genetic analyses.Although some results remain controversial, these approaches now identify a population at risk in the presence of preoperative features such as: anxiety, catastrophism, low nociceptive threshold, hyperalgesia or certain genetic polymorphisms involved in nociception or effectiveness of analgesic drugs.If nociceptive tests and especially genetic tests are currently difficult to implement, assessment of psychosocial factors using questionnaires, more or less complex, seems like a more appropriate routine approach.     

Coupled 182W-142Nd constraint for early Earth differentiation

Recent high precision ¹⁴²Nd isotope measurements showed that global silicate differentiation may have occurred as early as 30–75 Myr after the Solar System formation [Bennett V, et al. (2007) Science 318:1907–1910]. This time scale is almost contemporaneous with Earth’s core formation at ∼30 Myr [Yin Q, et al. (2002) Nature 418:949–952]. The ¹⁸²Hf-¹⁸²W system provides a powerful complement to the ¹⁴²Nd results for early silicate differentiation, because both core formation and silicate differentiation fractionate Hf from W. Here we show that eleven terrestrial samples from diverse tectonic settings, including five early Archean samples from Isua, Greenland, of which three have been previously shown with ¹⁴²Nd anomalies, all have a homogeneous W isotopic composition, which is ∼2ε-unit more radiogenic than the chondritic value. By using a 3-stage model calculation that describes the isotopic evolution in chondritic reservoir and core segregation, as well as silicate differentiation, we show that the W isotopic composition of terrestrial samples provides the most stringent time constraint for early core formation (27.5–38 Myr) followed by early terrestrial silicate differentiation (38–75 Myr) that is consistent with the terrestrial ¹⁴²Nd anomalies.     

Pharmacokinetics of ivermectin applied topically by whole‐body bathing method in healthy volunteers

As a novel administration method of ivermectin (IVM) for scabies treatment, we proposed a “whole‐body bathing method (WBBM)”. In this method, the patients would bathe themselves in a bathing fluid containing IVM at an effective concentration. Previously, we demonstrated that WBBM could deliver IVM to the skin but not to the plasma in rats. In the present study, to assess the clinical validity of the method an arm bathing examination (first trial) and a whole‐body bathing examination (second trial) were conducted in healthy volunteers. In both the first and second trials, after bathing in fluid containing IVM, the exposure in the stratum corneum was higher compared with that after taking IVM p.o. as reported previously. IVM was not detected in plasma at any sampling point after the whole‐body bathing in the second trial. Furthermore no serious adverse events were found. These results in both trials suggest that WBBM can deliver IVM to the human stratum corneum without systemic exposure or serious adverse effects in healthy volunteers, and at concentrations that would be adequate for scabies treatment.     

Target range of PTH in ESRD patients

The normal bone turnover is important for ESRD patients in not only skeletal problem but also patients QOL and survival. The abnormal bone turnover often induces the renal osteodystrophy and ectopic calcification. The major regulative factor on bone turnover is PTH. We propose here the target zone of PTH in ESRD patients with skeletal resistance for PTH. We recommended the intact-PTH 100 - 150 pg/mL for normal Ca/Pi/bone metabolism. This range of intact-PTH is equivalent to C-PTH 4.0 - 6.2 ng/mL, HS-PTH 10.0 - 16.0 ng/mL, and whole-PTH 80 - 110 pg/mL. The maintenance of normacalcemia and normophosphatemia are important for the arrival into the target zone of PTH using active vitamin D.     

Endovascular treatment for poorest-grade subarachnoid hemorrhage in the acute stage: has the outcome been improved?

OBJECTIVE: Patients with poor-grade subarachnoid hemorrhage (SAH) have been considered good candidates for endovascular treatment. The results of treatment of Grade V SAH, the poorest grade, however, have not been fully elucidated. METHODS: The clinical characteristics and outcome parameters of 22 World Federation of Neurosurgical Societies Grade V SAH patients treated endovascularly in the acute stage between 1998 and 2000 are summarized and compared with those of 18 Grade V SAH patients treated conservatively between 1995 and 1997. RESULTS: Among the 22 patients treated endovascularly, 8 patients (36.4%) survived. The rate was significantly higher than that of the 18 patients treated conservatively (5.6%), only one of whom survived. The favorable outcome rate, however, was not significantly different between the two groups (4.5% versus 6.0%). Subdivision of both treatment groups according to Glasgow Coma Scale (GCS) score showed that the improved survival among those treated endovascularly was attributable to the improved survival in those with a preprocedural GCS score of 6 but not of 4 or 5. CONCLUSION: Endovascular treatment of the 22 World Federation of Neurosurgical Societies Grade V SAH patients improved their survival rate but not their favorable outcome rate in comparison with conservative treatment. Further accumulation of clinical data is essential to determine whether endovascular treatment can improve the functional outcome of those with GCS scores of 6 and whether there is no role for endovascular treatment in those with GCS scores of 4 or 5.     

Preoperative and intraoperative evaluation of diameter-reflux relationship of calf perforating veins in patients with primary varicose vein

OBJECTIVE: Interruption of incompetent perforating veins (PVs) is important for varicose vein surgery. The purpose of this study was to evaluate the preoperative and intraoperative diameter-reflux relationship of PVs and to evaluate the accuracy of preoperative duplex scanning in patients with varicose vein. METHODS: Patients with primary varicose veins were retrospectively investigated. Diameters and reflux of PVs were evaluated before surgery with color flow duplex ultrasound scan (US). During operation, the incompetent PVs were defined as those that showed an outward spurt of blood flow from the stump of the PVs. The sensitivity and specificity of US in the detection of reflux of PVs were calculated. Competent versus incompetent vein diameters were compared with the Student t test and one-way analysis of variance. RESULTS: Three hundred twenty-four calf PVs were detected in 304 legs of 175 patients with varicose vein. Diameters of competent and incompetent PVs confirmed with intraoperative finding averaged 2.67 +/- 1.10 mm (n = 28) and 3.28 +/- 1.01 mm (n = 58), respectively, at the upper calf (P =.012), 2.85 +/- 0.85 mm (n = 53) and 3.68 +/- 0.94 mm (n = 137), respectively, at the lower calf (p <.001), and 2.67 +/- 0.99 mm (n = 14) and 3.27 +/- 0.66 mm (n = 22), respectively, at the posterior calf (P =.036). The overall sensitivity of detection of reflux with US was 87.7%, and the specificity was 75.3%. Diameters of true-incompetent PVs and false-incompetent PVs were 3.59 +/- 0.94 mm (n = 199) and 3.31 +/- 0.84 mm (n = 24), respectively (P =.157). Diameters of true-competent PVs and false-competent PVs were 2.61 +/- 0.91 mm (n = 73) and 2.89 +/- 0.82 mm (n = 28), respectively (P =.158). CONCLUSION: Although the diameter of incompetent PVs was larger than that of competent PVs in both US and intraoperative findings, diameter measurement alone can not completely distinguish competent and incompetent PVs. The sensitivity and specificity of reflux obtained with US showed that the accuracy of preoperative duplex scanning to evaluate PV competency was not sufficient.     

The sleep of Africans and Europeans in the Ivory Coast: questionnaire study

Sleep behaviour has been extensively studied with questionnaires in industrialised countries to investigate the epidemiology of sleep-wake disorders. However, only few attempts have yet been made to examine sleep behaviour of people living in Africa. Although, a large number of studies in hot or cold environments have used short-term exposures, reporting disrupted sleep for most of them, long-term exposures to stressful thermal environments are rare in the literature. Prior to the present investigation, we used questionnaires to analyse the effects of seasonal heat increase on perceived sleep behaviour and sleep quality in young native African students in Niger [7], even though these methods of investigation are by no means as accurate as polysomnographic recordings. The hypothesis was that sleep behaviour may be influenced by climatic variations in a hot dry tropical climate. Such climatic variations have been shown to induce seasonal heat acclimatisation marked by changes in body temperature rhythms in the hot versus the cool season [13]. Sleep behaviour was examined during two 7-day periods in January ("cool-dry" season, 88 subjects) and May ("hot-dry" season, 53 subjects). The questionnaire was completed after night sleep and/or naps. The subjects slept an average of 7 1/2 hours a day, most of them having afternoon naps. They experienced no major seasonal variation in their sleep behaviour, but for an increased number of awakenings during the hot season. Restorative quality of sleep scored lower after a nap than after nocturnal sleep. Therefore, general sleep characteristics were not modified by seasonal temperature variations in African native students, perhaps because of the limited changes in daylight under the low latitude of Niamey. Another investigation was carried out using the same 12-item questionnaire in Abidjan on 78 medical students who did not have a nap [9]. Contrary to the Niamey students, the Abidjan subjects adopted short duration sleep schedules, without any effect on the subjective quality of the restorative properties of their sleep.