Successful Treatment of Stricture of Duct-to-Duct Biliary Anastomosis After Living-Donor Liver Transplantation of the Left Lobe: A Case Report.

Biliary complications, such as stricture or obstruction, after living-donor liver transplantation (LDLT) remain major problems to be solved. Magnetic compression anastomosis (MCA) is a minimally invasive method of biliary anastomosis without surgery in patients with biliary stricture or obstruction. A 66-year-old woman had undergone LDLT for end-stage liver disease for primary biliary cholangitis 20 months previously at another hospital. Computerized tomography showed dilation of the intrahepatic bile duct (B2). Because B2 was invisible with the use of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of cholangitis. The rendezvous technique failed because a guidewire could not pass through the biliary stricture. Therefore, we decided to perform MCA. A parent magnet was endoscopically placed distally in the common bile duct of the stricture, and a daughter magnet attached to a guidewire was inserted proximally through the fistula tract of the PTBD. Both magnets were positioned across the stricture, and the 2 magnets were pulled to each other by magnetic power, to sandwich the stricture. By 14 days after MCA, a fistula between B2 and the common bile duct was created. At 28 days after MCA, the magnets were removed distally and a 16-French tube was placed across the fistula. At 7 months after MCA, that tube was removed. In conclusion, when a conventional endoscopic or percutaneous approach including the rendezvous technique fails, MCA is a good technique for biliary stricture after LDLT.

Neonatal dural arteriovenous fistula at the confluence presenting with paralysis of the orbicularis oris muscle.

A male neonate presented a dural arteriovenous fistula (DAVF) at the confluence with paralysis of the orbicularis oris muscle. The interesting features in our case were the clinical symptoms (orbicularis oris muscle paralysis at birth), angioarchitecture (high-flow arteriovenous shunts at the confluence) and the size and hemodynamic flow (mid-sized venous pouch) of the fistula. Additionally, the embolization technique (i.e., occipital artery approach, closing shunts with pure glue) automatically resulted in the immediate and complete closure of accessory feeders without any additional treatment, and the midterm clinical outcome was good. We succeeded improving the symptoms of a neonate with a congenital high-flow DAVF by closing a fistula using a small amount of glue.

Relationship between two different functions derived from diffusion-based decompression theory.

Hempleman's diffusion-based decompression theory yields two different functions; one is expressed by a simple root function and the other by a complex series function. Although both functions predict the same rate of gas uptake for relatively short exposure times, no clear mathematical explanation has been published that describes the relationship between the two functions. We clarified that (1) the root function is the solution of the one-dimensional diffusion equation for a semi-infinite slab, (2) the series function is an applicable solution for a finite slab thickness, (3) the parameter values of the root function can be used to determine the parameter values of the series function, and (4) the predictions of gas kinetics from both functions agree until an adequate amount of diffusing inert gas reaches the boundary at the opposite end of the finite slab. The last point allows the use of the simpler root function for predicting short no-stop decompression limits. Experience dictates that the inert gas accumulation for a 22 min at 100 feet of seawater (fsw) dive is considered safe for no-stop decompression. Although the constraint, Depth square root of Bottom Time = 100 square root of 22, has been applied as an index to determine either the safe depth or bottom time (given the other) for no-stop decompression, it should not be applied more broadly to dives requiring decompression stops.

Intention myoclonus in paediatric patients following severe cardiopulmonary failure: a report of three cases.

We describe the development of intention myoclonus following severe cardiopulmonary failure in three paediatric patients. Symptoms occurred during the withdrawal of midazolam and fentanyl, which were used for prolonged sedation, and resolved spontaneously. Because the three patients had concomitant brain injury secondary to cardiopulmonary failure.related hypoxia, we propose that the combination of hypoxic brain injury and sedative withdrawal may predispose to intention myoclonus.

Decreased expression of Bcl-x protein during hepatocarcinogenesis induced exogenously and endogenously in rats.

Dysregulations of apoptosis have been widely recognized as important events in multi-stage carcinogenesis. Bcl-x, a member of the Bcl-2 family, is known to act as a regulator of apoptosis. The present study was conducted to assess the role of altered Bcl-x protein expression in exogenous and endogenous hepatocarcinogenesis in rats. In the short-term exogenous models, male Fischer 344 rats, 6 weeks old, were given a single intraperitoneal injection of diethylnitrosamine (DEN) at a dose of 200 mg / kg body weight, partially hepatectomized at the end of week 3, administered phenobarbital at a concentration of 0.05% from the end of week 2 for 6 weeks, and sacrificed. In the livers, glutathione S-transferase (GST-P)-positive, putative preneoplastic lesions were induced, and Bcl-x protein expression was decreased in 24.7% of such lesions. The incidence of GST-P-positive lesions with decreased Bcl-x increased depending on the size of the lesions; 18.9%, 32.4% and 86.5% in the lesions smaller than 0.03, between 0.03 and 0.3, and larger than 0.3 mm(2), respectively. In GST-P-positive lesions larger than 0.3 mm(2), both apoptosis induction and cell proliferation activity were enhanced when Bcl-x protein expression was decreased. In the long-term exogenous models, rats were given 10 mg / kg of DEN, partially hepatectomized 4 h after treatment, administered 0.5 mg / kg of colchicine at the end of days 1 and 3, subjected to a selection procedure, and sacrificed at the end of week 45. Hepatocellular carcinomas were induced with the decreased Bcl-x protein expression. In the endogenous model, rats were fed a choline-deficient, L-amino acid-defined diet for 16 or 80 weeks and sacrificed. Bcl-x protein expression was decreased both in GST-P-positive lesions and hepatocellular carcinoma. These results suggest that this decrease of Bcl-x protein might serve as an indicator of the advanced form of preneoplastic lesions, and that this decrease could also be associated with a potential to progress into carcinoma in both exogenous and endogenous hepatocarcinogenesis of rats.

[Anesthesia for a patient with alcoholic heart disease and transient complete heart block].

A 70-year-old man who had been drinking a bottle of whisky each day was scheduled for laser resection of a tongue tumor. His electrocardiogram showed sinus bradycardia (heart rate was 35-40 bpm), and transient complete heart block was observed. Echocardiography showed hypertrophic cardiomyopathy. After a temporary transvenous pacemaker had been inserted, anesthesia was induced with thiopental and vecuronium bromide, and maintained with sevoflurane and fentanyl. Heart rate was 45.min-1 before the induction of anesthesia, and after the induction increased to 70-80.min-1. Analysis of heart rate variability suggested that the increase in heart rate was due to augmentation of sympathetic nervous activity after intubation and operation stress. After the operation his bradycardia improved gradually, and after 3 months heart rate settled at about 55.min-1. Cadiomyopathy is known to be one of the complications of alcoholism. It was reported that alcoholic heart disease was improved promptly by abstinence from alcohol. During his long hospitalization, abstinence might have improved his severe bradycardia. Thiopental is useful for induction of anesthesia in a patient with severe bradycardia from alcoholic cadiomyopathy.

The heterocyclic amine, 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole induces apoptosis in cocultures of rat parenchymal and nonparenchymal liver cells.

In this study, we investigated the mechanism of apoptosis by 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1) in cocultures of parenchymal and nonparenchymal liver cells, since the liver consists of various cell types and they cooperatively respond to chemicals. It was found that cocultures were more susceptible to cell death by Trp-P-1 than culture of each cell type alone. In cocultures, Trp-P-1 induced DNA fragmentation accompanied by the activation of 18-kDa endonuclease. Trp-P-1 (30 microM) caused a rapid increase in Bid protein level in mitochondria and the leakage of cytochrome c from mitochondria into the cytosol 15 min after treatment. On the other hand, an increase in Bax protein and a decrease in Bcl-2 protein were detected in the mitochondrial fraction 2 h after treatment following the increases in p53 protein level and DNA binding activity of NF-kappa B. Caspase-8 was activated within 30 min followed by the activation of downstream caspases as measured using the corresponding peptide substrates. The activation of caspases was also confirmed by cleavage of caspase-3, poly(ADP-ribose)polymerase, and protein kinase C-delta as analyzed by Western blotting. A peptide inhibitor of caspase-8 diminished DNA ladder formation and the activation of downstream caspases, but a caspase-9 inhibitor and pyrrolidinedithiocarbamate as an inhibitor of NF-kappa B showed only partial inhibition, suggesting that caspase-8 is the apical caspase in the cascade. These results led to the conclusion that Trp-P-1 mainly drives the caspase-8-mediated pathway that involves Bid, accompanied by a delay in the p53/NF-kappa B-mediated side pathway that involves Bax, Bcl-2, and caspase-9.

Arterial ketone body ratio for the assessment of the severity of illness in pediatric patients following cardiac surgery.

PURPOSE: The purpose of this study was to assess whether the arterial ketone body ratio (AKBR) can be effectively used to evaluate the severity of illness in children following cardiac surgery. MATERIALS AND METHODS: AKBR was measured in 157 consecutive pediatric patients following heart surgery on the odd numbers of postoperative days. The relationship between AKBR and patient outcome was analyzed using the data of 141 patients with cardiopulmonary bypass. RESULTS: Initial AKBR was frequently lower than 1.0, and this was associated with the increases in total ketone body counts. Insufficient glucose metabolism appeared to contribute to the low initial AKBR. As a result, the specificity of initial AKBR as a mortality predictor was lower than that of initial blood lactate. In the sequential analysis of AKBR for the 48 patients with PICU stay longer than 5 days, patients showing a sustained lower level <1.0 had significantly higher development of organ dysfunction (liver, heart) and greater mortality (56%). CONCLUSIONS: Sustained postoperative decrease in AKBR <1.0 represents lethal outcome. The analysis of AKBR trend in combination with a measurement of blood lactate level in early postoperative period appears to be useful for the assessment of the severity of illness in pediatric patients following heart surgery.

Inefficient visual search for second-order motion.

Visual search rate was used to assess attentional resources required for detection of opposing motions defined either by luminance or by modulations of texture contrast, flicker, or size. Though luminance-based targets were detected quickly, search through second-order motion was slow. Control experiments ruled out stimuli visibility, complexity, eccentricity sensitivity, and attributes of the carrier as possible accounts. Results suggest separate processing of the two types of stimuli: Luminance-based motion is detected by spatiotemporal filters, whereas second-order motion is likely processed by a capacity-limited, later stage. Rate-reducing effects of increased contrast and speed mirrored previous research suggesting that effortful feature tracking may be the mechanism.

Telepsychiatry: assessment of televideo psychiatric interview reliability with present- and next-generation internet infrastructures.

OBJECTIVE: We assessed the reliability of remote video psychiatric interviews conducted via the internet using narrow and broad bandwidths. METHOD: Televideo psychiatric interviews conducted with 42 in-patients with chronic schizophrenia using two bandwidths (narrow, 128 kilobits/s; broad, 2 megabits/s) were assessed in terms of agreement with face-to-face interviews in a test-retest fashion. As a control, agreement was assessed between face-to-face interviews. Psychiatric symptoms were rated using the Oxford version of the Brief Psychiatric Rating Scale (BPRS), and agreement between interviews was estimated as the intraclass correlation coefficient (ICC). RESULTS: The ICC was significantly lower in the narrow bandwidth than in the broad bandwidth and the control for both positive symptoms score and total score. CONCLUSION: While reliability of televideo psychiatric interviews is insufficient using the present narrow-band internet infrastructure, the next generation of infrastructure (broad-band) may permit reliable diagnostic interviews.

[Perioperative assessment of blood lactate levels in pediatric heart surgery].

Measuring arterial lactate concentration is a prompt, easy and relatively non-invasive way to estimate tissue oxygen metabolism. We evaluated whether perioperative levels of the arterial lactate concentrations can reflect the general severity of a pediatric patient's condition. A consecutive series of 112 patients, aged 5 days to 17 years (median age: 12 months), admitted to our pediatric intensive care unit (PICU) following cardiac surgery under cardiopulmonary bypass were studied. Arterial blood lactate concentration was measured preoperatively, immediately upon termination of the cardiopulmonary bypass (postCPB), immediately following the operation, and 16th hours postoperatively (D1). Trends within arterial lactate concentrations were examined in relation to mortality rates, the duration of PICU stays and the patient's ages. The studied population had a mortality rate of 5.7% (6 patients). Lactate levels increased significantly and exceeded 4.0 mmol.l-1 during postCPB measurements in a majority of the patients. The increases in lactate levels are affected by the changes in interorgan blood flow, blood glucose levels and/or blood pH in addition to the effects of the CPB-priming lactated Ringer's solution. Thus, higher cut off values have to be determined, and lower probabilities assigned, when using postCPB lactate levels to predict the severity of an outcome. Significantly and sustained increases in D1 lactate levels were noted in neonates, patients with longer PICU stays (> 15 days) and those died later. Hyperlactemia greater than 2.2 mmol.l-1 at D1 predicted death with a sensitivity of 82% and a specificity of 72%. The measurement of early postoperative lactate levels, reflecting postoperative ability to eliminate intraoperative hyperlactemia, is a better way of assessing the severity of a pediatric patient's condition following cardiac surgery. The ideal time to measure early postoperative lactate levels should be determined by further research.

Application of modified sequential organ failure assessment score in children after cardiac surgery.

OBJECTIVE: To evaluate the usefulness of the modified sequential organ failure assessment (m/SOFA) score for assessing morbidity and mortality in pediatric patients after cardiac surgery. DESIGN: Analysis of a prospectively collected database. SETTING: Pediatric intensive care unit of a university-affiliated hospital. PARTICIPANTS: Consecutive pediatric patients (n = 142) undergoing cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The m/SOFA score, consisting of 5 organ scores (maximum score of 20 points), was calculated on admission (initial) and at 12 and 36 hours postoperatively. An initial score of >5 points with an unchanged or upward postoperative trend predicted a higher postoperative mortality and a greater need for intensive care intervention. In neonates, sustained higher score >10 points predicted an outcome of death with a sensitivity of 100% and a specificity of 87%. Given the higher mortality related to immature organ function and a greater complexity of heart defects, the application of the m/SOFA score, a less invasive and simple way to assess organ damage, is especially suitable in neonates. The m/SOFA score would be more appropriately assessed according to the congenital heart defect or surgical procedure because the types of cardiac defect after the surgical repair affect each organ score measurement. CONCLUSION: Application of the m/SOFA score in the early postoperative period, which reflects cumulative perioperative organ damage, would provide some direction to eventual outcomes of morbidity and mortality in patients with congenital heart defects undergoing surgery.

Analysis of postoperative pancreatitis in DSRS with SPD.

BACKGROUND/AIMS: Distal splenorenal shunt with splenopancreatic disconnection (DSRS + SPD) evolved to prevent the development of a pancreatic siphon, to improve maintenance as well as quality of portal perfusion and to achieve better long-term survival. We report several cases of postoperative pancreatitis in DSRS + SPD. Recently, oxygen-derived free radicals have been reported to play an important role in pathogenesis of acute pancreatitis. METHODOLOGY: In this study, ten cases of DSRS + SPD were examined intraoperatively. The local changes in oxygen-derived free radicals were obtained by measuring lipid peroxide and an endogenous scavenger (SOD) in the development of DSRS + SPD-induced pancreatitis. RESULTS: Lipid peroxide activity as the offense system was not changed before or after SPD. However, SOD activity as a defense system was significantly lowered after SPD compared to before SPD. CONCLUSIONS: These results indicate that an imbalance of both systems might be the cause of postoperative pancreatitis.

3-Amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1) induces caspase-dependent apoptosis in mononuclear cells.

3-Amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1), one of the tryptophan pyrolysates, is a dietary carcinogen and is formed in cooked meat and fish in our daily diet. Trp-P-1 will affect the cells in the blood circulation system before it causes carcinogenicity in target organs such as the liver. In this study, the cytotoxicity of Trp-P-1 was investigated in mononuclear cells (MNCs) from blood. Trp-P-1 (10-15 microM) decreased cell viability and induced apoptosis characterized both by morphological changes and by DNA fragmentation 4 h after treatment. DNA fragmentation was also observed following treatment at 1 nM after 24 h in culture. This result suggested that apoptosis would occur in the body following unexpected intake of foods containing Trp-P-1. To determine the mechanism of apoptosis, we investigated the activation of the caspase cascade in MNCs. Trp-P-1 (10-15 microM) activated the caspase cascade, i.e. the activity of caspase-3, -6, -7, -8 and -9 increased dose-dependently using peptide substrates, the active forms of caspase-3, -8 and -9 were detected by immunoblotting, and cleavage of poly(ADP-ribose) polymerase and protein kinase C-delta as the intracellular substrates for caspases was observed. A peptide inhibitor of caspase-8 completely suppressed activation of all other caspases, while an inhibitor of caspase-9 did not. These results indicated that caspase-8 may act as an apical caspase in the Trp-P-1-activated cascade.

Somatosensory evoked potential recovery in myotonic dystrophy.

OBJECTIVE: To evaluate recovery functions of the sensory cortex using somatosensory evoked potentials (SEPs) elicited by paired stimuli of the median nerve in patients with myotonic dystrophy (MD). SUBJECTS/METHODS: Twelve MD patients were enrolled in the present investigation. Five patients with facioscapulohumeral muscular dystrophy (FSH) and 12 healthy volunteers were studied as control groups. SEP was recorded from the hand sensory area contralateral to the median nerve stimulated at the wrist. Single pulse or paired-pulse stimuli at various interstimulus intervals (ISIs) (10, 20, 40, 60, 80, 100, 150, 200 and 300 ms) were given. Recovery functions of N9, N20onset-N20peak, N20-P25 and P25-N33 components were studied. RESULTS: Conventional SEPs to a single stimulus were normal in the latency and amplitude in all the patients. Recovery functions of both N9 and N20o-N20p components were normal in the patients. In contrast, in MD patients, disinhibited or hyperexcitable recovery pattern was observed in recovery curves of the N20-P25 or P25-N33 components, whereas those were normal in FSH patients. CONCLUSIONS: Disinhibited cortical excitability (or hyperexcitability) is present in the sensory cortex in patients with myotonic dystrophy. This may reflect cortical pathology or functional alteration of the sensory cortex in MD.

A novel endo-beta-galactosidase from Clostridium perfringens that liberates the disaccharide GlcNAcalpha 1-->Gal from glycans specifically expressed in the gastric gland mucous cell-type mucin.

We found that commercially available sialidases prepared from Clostridium perfringens ATCC10543 were contaminated with an endoglycosidase capable of releasing the disaccharide GlcNAcalpha1-->4Gal from glycans expressed in the gastric gland mucous cell-type mucin. We have isolated this enzyme in electrophoretically homogeneous form from the culture supernatant of this organism by ammonium sulfate precipitation followed by affinity chromatography using a Sephacryl S-200 HR column. The enzyme was specifically retained by and eluted from the column with methyl-alpha-Glc. By NMR spectroscopy, the structure of the disaccharide released from porcine gastric mucin by this enzyme was established to be GlcNAcalpha1-->4Gal. The specificity of this enzyme as an endo-beta-galactosidase was established by analyzing the liberation of GlcNAcalpha1-->4Gal from GlcNAcalpha1-->4Galbeta1-->4GlcNAcbeta1-->6(GlcNAcalpha1--> 4Galbeta1-->3)GalNAc-ol by mass spectrometry. Because this novel endo-beta-galactosidase specifically releases the GlcNAcalpha1-->4Gal moiety from porcine gastric mucin, we propose to call this enzyme a GlcNAcalpha1-->4Gal-releasing endo-beta-galactosidase (Endo-beta-Gal(GnGa)). Endo-beta-Gal(GnGa) was found to remove the GlcNAcalpha1-->4Gal epitope expressed in gastric adenocarcinoma AGS cells transfected with alpha1,4-N-acetylglucosaminyltransferase cDNA. Endo-beta-Gal(GnGa) should become useful for studying the structure and function of glycoconjugates containing the terminal GlcNAcalpha1-->4Gal epitope.

Evidence for dissociation between the perceptual and visuomotor systems in humans.

When a visual stimulus is continuously moved behind a small stationary window, the window appears displaced in the direction of motion of the stimulus. In this study we showed that the magnitude of this illusion is dependent on (i) whether a perceptual or visuomotor task is used for judging the location of the window (ii) the directional signature of the stimulus, and (iii) whether or not there is a significant delay between the end of the visual presentation and the initiation of the localization measure. Our stimulus was a drifting sinusoidal grating windowed in space by a stationary, two-dimensional, Gaussian envelope (sigma=1 cycle of sinusoid). Localization measures were made following either a short (200 ms) or long (4.2 s) post-stimulus delay. The visuomotor localization error was up to three times greater than the perceptual error for a short delay. However, the visuomotor and perceptual localization measures were similar for a long delay. Our results provide evidence in support of the hypothesis that separate cortical pathways exist for visual perception and visually guided action and that delayed actions rely on stored perceptual information.

DNA-damaging carcinogen 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole (Trp-P-1) induces apoptosis via caspase-9 in primary cultured rat hepatocytes.

The mechanism of cytotoxicity induced by the DNA-damaging carcinogen 3-amino-1,4-dimethyl-5H-pyrido[4,3-b] indole (Trp-P-1) was investigated in primary cultured rat hepatocytes. Cytotoxicity was caused by intact Trp-P-1 and not by metabolically activated derivatives prepared using a recombinant yeast strain AH22/pAMR2 expressing rat cytochrome P450 1A1, and not by metabolically activated derivatives. We also found internucleosomal DNA fragmentation 6 h after treatment with 30 microM Trp-P-1, indicating that the cytotoxicity was due to the induction of apoptosis. After treatment with Trp-P-1, c-Myc protein level increased in a time-dependent manner and p53 protein also increased transiently with a subsequent increase in Bax protein level. This apoptotic pathway required the activation of caspase-9 as an initiator after leakage of cytochrome c into the cytosol from mitochondria and the activation of caspase-3 and -7 as executioners, but not caspase-1, -6 or -8 as measured using the corresponding peptide inhibitors and substrates or western blotting. The activated caspases in turn cleaved poly(ADP-ribose) polymerase as an intracellular substrate. Furthermore, we detected NUC18-like endonuclease activity during apoptosis induced by Trp-P-1. These findings suggest that this apoptosis may have a role against heterocyclic amine-type carcinogens in normal cells.

Enzymatic syntheses of T antigen-containing glycolipid mimicry using the transglycosylation activity of endo-alpha-N-acetylgalactosaminidase.

Thomsen-Friedenreich antigen (T antigen) disaccharide, beta-D-galactose-(1-->3)-alpha-N-acetyl-D-galactosamine (beta-D-Gal-(1-->3)-alpha-D-GalNAc), containing glycolipid mimicry was synthesized using the transglycosylation activity of endo-alpha-N-acetylgalactosaminidase from Bacillus sp. This enzyme could transfer the disaccharide from a p-nitrophenyl substrate to water-soluble 1-alkanols and other alcohols at a transfer ratio of 70% or more. Although the transfer ratios were lower for water-insoluble than water-soluble alcohols, they were shown to increase by adding sodium cholate to the reaction mixtures. The enzyme also transferred the disaccharide directly from asialofetuin to 1-alkanols. The anomeric bond between the disaccharide and 1-alkanols of the transglycosylation product is in the alpha configuration as determined by sequential digestion of jack bean beta-galactosidase and Acremonium alpha-N-acetylgalactosaminidase. Since the transglycosylation product, beta-D-Gal-(1-->3)-alpha-D-GalNAc-(1-->O)-hexyl, efficiently inhibits the binding of anti-T antigen monoclonal antibody to asialofetuin, it has potential as an agent for blocking T antigen-mediated cancer metastasis.