Difficulty in diagnosing autoimmune pancreatitis by imaging findings

BACKGROUND: Autoimmune pancreatitis (AIP) presents as diffuse enlargement of the pancreas and as diffuse irregular narrowing of the main pancreatic duct. However, some AIP cases are difficult to diagnose because of atypical imaging findings. OBJECTIVE: To clarify a variety of imaging findings of AIP and the reason for its misdiagnosis. DESIGN: We examined the imaging findings of 37 AIP cases and also examined misdiagnosed cases of AIP to determine their reasons for misdiagnosis. PATIENTS: A total of 37 patients with AIP who reported to our hospital or its affiliate over a 17-year period (1989 to May 2005). RESULTS: Patients in 15 AIP cases showed segmental narrowing of the main pancreatic duct. There were 6 patients with focal enlargement of the pancreas, whereas 3 patients showed no enlargement. There were 3 cases of calcification of the pancreas. Pancreatic cysts were detected in 2 patients. Abdominal US showed multiple low-echoic masses in 1 case and a single mass in 3 cases. Sixteen patients had stenosis of the bile duct at the hilar hepatic lesion and/or the intrahepatic duct. Only 7 patients had typical AIP findings. Six patients were misdiagnosed with pancreatic cancer and 2 with bile-duct cancer. Seven cases were surgically treated. Five cases were misdiagnosed because of the nonexistence of, or the unfamiliarity with, the concept of AIP and sclerosing cholangitis with AIP. Another 3 cases were diagnosed with pancreatic cancer because of segmental stenosis of the main pancreatic duct and no or focal enlargement of the pancreas. CONCLUSIONS: The results of this study suggest that AIP presents a variety of imaging findings. The most important diagnostic factor is clinician awareness of the concept of AIP and the diverse nature of imaging findings.     

A novel endoscopic suturing technique using a specially designed so-called "8-ring" in combination with resolution clips (with videos)

BACKGROUND: Although EMR has been proven to be a safe procedure, the risk of hemorrhage and perforation increases with the size of the resected lesion. To overcome such complications, we previously reported a technique using an endoloop and metal clips to close large mucosal defects after EMR. This procedure, however, requires a 2-channel colonoscope, which is not always available. OBJECTIVES: Our purpose was to demonstrate the feasibility of mucosal defect closure by using a conventional single-channel colonoscope, a specially designed figure-of-8-shaped stainless steel ring (8-ring) and resolution clips. DESIGN: Pilot study. SETTING: Private outpatient clinic. PATIENTS: A total of 10 patients with 10 lesions underwent this procedure for closure after EMR. INTERVENTION: After EMR, a Resolution clip (Boston Scientific, Natick, Mass) was placed through 1 hole of the 8-ring and then attached to normal mucosa near 1 side of the resection site. Another resolution clip was inserted through the remaining hole of the device and clipped in the normal mucosa on the other side, thus providing complete closure. To strengthen the closure, conventional endoclips were also placed. MAIN OUTCOME MEASUREMENTS: Technical feasibility of endoscopic closure of the mucosal defect after EMR and complications associated with endoscopic procedures. RESULTS: Mean size of resected lesion was 16.3 mm. All the defects were successfully closed without any complication such as delayed bleeding or perforation. LIMITATIONS: Further study is needed to examine the maximum size of defects that can be closed with this method. CONCLUSIONS: Defects after EMR can be treated successfully with this simple technique.     

Three Na+/Ca2+ exchanger (NCX) variants are expressed in mouse osteoclasts and mediate calcium transport during bone resorption

The plasma membrane Na(+)/Ca(2+) exchanger (NCX) is a bidirectional transporter that mediates the exchange of Na(+) for Ca(2+) depending on the electrochemical gradients. Mammalian NCXs form a multigene family comprising NCX1, NCX2, and NCX3 isoforms. Although it has been known that NCX1 in rat osteoclasts is coupled with the Na(+)/ H(+) exchanger for regulation of intracellular Ca(2+) concentration ([Ca(2+)](i)), it is unclear what kind of NCX1 variants are expressed and whether the other two NCX isoforms are also present in mouse osteoclasts. To clarify the role of NCXs during bone resorption, we investigated the expression of NCXs, the ion transport via NCXs, and the effects of NCX inhibitors on bone-resorbing activity in mouse osteoclasts. Using RT-PCR, immunocytochemical, and Western blot methods, we detected three splice variants of NCX1 and NCX3, namely NCX1.3, NCX1.41, and NCX3.2. Of these, NCX1.41 is a newly identified splice variant. Low extracellular sodium ([Na(+)](o)) solution increases the intracellular Ca(2+) concentration via NCX transporter in fura-2-loaded osteoclasts. The [Na(+)](o)-free solution-induced [Ca(2+)](i) increase was suppressed by benzyloxyphenyl NCX inhibitors. Bidirectional NCX currents in mouse osteoclasts were recorded using the patch clamp method and could be suppressed with NCX inhibitors. NCX inhibitors also decreased the resorption pit area surrounding osteoclasts in a dose-dependent manner. Furthermore, small interference RNAs targeted against NCX1.3, NCX1.41, and NCX3.2 expressed in mouse osteoclasts suppressed osteoclastic pit formation. These results show that three NCX variants are expressed in mouse osteoclasts and play an important role for Ca(2+) transport and regulation during osteoclastic bone resorption.     

Risk evaluation and midterm outcome of cardiac surgery in patients on dialysis

The medical charts of 54 patients on maintenance dialysis who underwent cardiovascular surgery (37 elective and 17 urgent/emergency) from 1994 to 2004 were retrospectively analyzed. Thirty patients had coronary artery bypass grafting (17 elective and 13 urgent/emergency), 18 had valve replacement (16 elective and 2 urgent/emergency), and 6 underwent aortic surgery (4 elective and 2 urgent/emergency). The overall early mortality rate was 11.1%, comprising 2 patients (5.4%) who had elective operations and 4 (23.5%) who had urgent or emergency operations ( p = 0.049). The overall 5-year survival rate was 48.4%. The 5-year survival rate was 67.2% for elective surgery and 10.5% for urgent/emergency surgery ( p = 0.0001). The midterm clinical results after elective cardiovascular surgery were acceptable, whereas the results after urgent/emergency surgery were poor. For elective surgery, sufficient and detailed preoperative examinations might have contributed to the better operative outcome. Early diagnosis and consultation to avoid urgent/emergency operations in dialysis patients is recommended.     

Chimeric DNA-RNA hammerhead ribozyme targeting transforming growth factor-beta1 mRNA ameliorates renal injury in hypertensive rats

OBJECTIVE: Transforming growth factor (TGF)-beta is a critical factor in the progression of renal injury, regardless of the primary etiology. Such injury is characterized by glomerular sclerosis and tubulointerstitial fibrosis. To develop a ribozyme-based therapy for progressive renal diseases, we examined the effects of chimeric DNA-RNA hammerhead ribozyme targeting TGF-beta1 mRNA on glomerulosclerosis in salt-loaded, stroke-prone spontaneously hypertensive rats (SHR-SP) and salt-sensitive Dahl (Dahl-S) rats. METHODS: The chimeric DNA-RNA ribozyme to TGF-beta1 was delivered by polyethylenimine to cultured mesangial cells from SHR-SP in vitro and to glomeruli in SHR-SP in vivo. The chimeric ribozyme reduced expression of TGF-beta1 mRNA and protein, which was accompanied by inhibition of expression of extracellular matrix molecules such as fibronectin and collagen type I in mesangial cells from SHR-SP in vitro. RESULTS: One intraperitoneal injection of 200 microg of chimeric DNA-RNA ribozyme to TGF-beta1 in vivo markedly ameliorated thickening of capillary artery walls and glomerulosclerosis in salt-loaded SHR-SP and Dahl-S rats without a reduction in blood pressure. The chimeric ribozyme reduced expression of TGF-beta1 and connective tissue growth factor (CTGF) mRNAs in renal cortex in salt-loaded Dahl-S rats. Chimeric ribozyme to TGF-beta1 significantly reduced levels of protein in urine in the Dahl-S rats. CONCLUSION: These results suggest that chimeric DNA-RNA ribozyme to TGF-beta1 may be useful as a gene therapy for progressive tissue injury in a wide variety of renal diseases, including hypertensive nephrosclerosis.     

Predictors of houseboundedness among elderly persons living autonomously in a rural community

AIM: The housebound state is a risk factor for disability. This prospective study aimed to determine factors predictive of houseboundedness in the elderly, with an ultimate goal of preventing this condition. METHODS: A self-report questionnaire pertaining to mental, physical and social status was administered to 732 community-dwelling elderly persons (313 men, 419 women; age range, 65-85 years) in October 2000. All subjects independently performed both basic and instrumental activities of daily living, went out alone for long distances, and did not use long-term care insurance. They were followed up until March 2003. "Housebound" was defined as leaving the house once a week or less. A stepwise multiple logistic regression model, adjusted for age, was used to identity factors predictive of houseboundedness. Data were analyzed on the basis of gender. RESULTS: By the end of the follow-up period, 14.4% of men and 26.0% of women had become housebound. Stepwise multiple logistic regression analysis showed that predictive factors for men were lack of frequent contact with friends, neighbors and relatives; symptoms of lower limb pain; and self-assessed weight or muscle loss; and predictive factors for women were lack of frequent contact with friends, neighbors and relatives; lower limb pain; and self-assessed deterioration in health. Limited social contact and the presence of lower limb pain were common predictive factors for houseboundedness in both men and women. CONCLUSION: The findings from this study show that, among autonomous elderly persons, those who are socially isolated or who have physical pain are more likely to become housebound.     

The unification of hematopoietic stem cell transplantation registry in Japan and establishment of the TRUMP system

There are four registries of hematopoietic cell transplant in Japan; the Japan Society for Hematopoietic Cell Transplantation (JSHCT), Japanese Society of Pediatric Hematology, Japan Marrow Donor Program and Japan Cord Blood Bank Network, each playing an important role in society by reporting the number and outcomes of transplantations and contributing new findings obtained from studies on individual topics. However, there have been a number of difficulties with analyzing data in overlapping registries and multiple databases at centers affiliated with each of the four registry organizations. JSHCT was pivotal in orchestrating the computerization and unification of hematopoietic stem cell transplant registries for the purpose of resolving these issues and providing a more accurate awareness of hematopoietic stem cell transplantations performed in Japan. JSHCT played a central role in developing the "Transplant Registry Unified Management Program (TRUMP)" to enable transplant institutes to manage patient information with emphasis on convenience to institutes, safety of patient information, and quality of data management. While enhancing domestic registries, the program seeks to coordinate with other hematopoietic cell transplant registries around the world to contribute to the development of registries throughout Asia.