A case of left ventricular free wall rupture after insertion of an IMPELLA® left ventricular assist device diagnosed by transesophageal echocardiography

[Background]The IMPELLA® is a minimally invasive left ventricular assist device. We report a case in which transesophageal echocardiography (TEE) was useful in diagnosis of left ventricular rupture after IMPELLA® insertion. [Case presentation]A 75-year-old man presented to the emergency room with chest pain and underwent percutaneous coronary intervention for 100% stenosis of the left anterior descending branch #7. An IMPELLA® was inserted to stabilize the circulation, but hypotension persisted. Transthoracic echocardiography revealed increased pericardial effusion and suspicion of free wall left ventricular rupture, leading to emergency surgery. TEE revealed the IMPELLA® straying into the left ventricle apical wall and cardiac tamponade. Hemorrhage was observed from the thinning free wall and the tip of the IMPELLA® was palpable. The IMPELLA® was removed and the left ventricular wall was repaired. [Conclusions]The IMPELLA® requires implantation of the tip in the left ventricle, but it should be noted that a fragile ventricular wall can be easily perforated

Agreement between continuous cardiac output measured by the fourth-generation FloTrac/Vigileo system and a pulmonary artery catheter in adult liver transplantation

In liver transplantation for end-stage liver failure, monitoring of continuous cardiac output (CCO) is used for circulatory management due to hemodynamic instability. CCO is often measured using the minimally invasive FloTrac/Vigileo system (FVS-CCO), instead of a highly invasive pulmonary artery catheter (PAC-CCO). The FVS has improved accuracy due to an updated cardiac output algorithm, but the effect of this change on the accuracy of FVS-CCO in liver transplantation is unclear. In this study, we assessed agreement between fourth-generation FVS-CCO and PAC-CCO in 20 patients aged ≥ 20 years who underwent scheduled or emergency liver transplantation at Kyoto University Hospital from September 2019 to June 2021. Consent was obtained before surgery and data were recorded throughout the surgical period. Pearson correlation coefficient (r), Bland–Altman and 4-quadrant plot analyses were performed on the extracted data. A total of 1517 PAC-CCO vs. FVS-CCO data pairs were obtained. The mean PAC-CCO was 8.73 L/min and the mean systemic vascular resistance was 617.5 dyne·s·cm⁻⁵, r was 0.48, bias was 1.62 L/min, the 95% limits of agreement were − 3.04 to 6.27, and the percentage error was 54.36%. These results show that agreement and trending between fourth-generation FVS-CCO and PAC-CCO are low in adult liver transplant recipients

Evaluation of Patient Positioning during Digital Tomosynthesis and Reconstruction Algorithms for Ilizarov Frames: A Phantom Study

Aim: Metallic components from circular external fixators, including the Ilizarov frame, cause artefacts on X-rays and obstruct clear visualisation of bone detail. We evaluated the ability of tomosynthesis to reduce interference on radiographs caused by metal artefacts and developed an optimal image acquisition method for such cases. Materials and methods: An Ilizarov frame phantom was constructed using rods placed on the bone for the purpose to evaluate the benefits of tomosynthesis. Distances between the rod and bone and the angle between the rod and X-ray tube orbit were set at three different levels. Filtered backprojection images were reconstructed using two different features of the reconstruction function: THICKNESS−− (CONTRAST4) and THICKNESS++ (METAL4); the first is suitable for improving contrast and the second is suitable for metal artefacts. The peak signal-to-noise ratio (PSNR) was used during image evaluation to determine the influence of the metallic rod on bone structure visibility. Results: The PSNR increased as the angle between the metal rod and the X-ray tube orbit and the distance between the metallic rod and bone increased. The PSNR was larger when using THICKNESS−− (CONTRAST4) than when using THICKNESS++ (METAL4). Conclusion: The optimal reconstruction function and image acquisition determined using the metallic rod in this study suggest that quality equal to that without the metallic rod can be obtained. Clinical significance: We describe an optimised method for image acquisition without unnecessary acquisition repetition and unreasonable posture changes when the bone cannot be adequately visualised

トランスフェリンを介する鉄の細胞内取り込み機序 ―特に肝細胞への取り込みにおける内皮細胞の関与について―

Transferrin (Tf) is thought to play a pivotal role in iron metabolism of various kinds of cells. Tf has specific receptors on the surface of the cells that require iron. Tf-receptor binding is followed by internalization through a system of coated pits and vesicles. The rapid decline of pH of these vesicles leads to the release and sequestration of iron by the cell. Apotransferrin-receptor complex returns to the cell surface, where under neutral pH conditions, apotransferrin is dissociated from the receptor. Recent advances in cellular and molecular biology, gene cloning and monoclonal antibody technique have elucidated many features of these processes at a molecular level. These advances are briefly reviewed, and particularly, our own observations concerning endothelial mediation of uptake of Tf by hepatocytes are discussed.トランスフェリン（Tf）は鉄代謝において重要な役割を担っている。鉄を必要とする細胞の表面には，Tfの特異的受容体が存在し，Ffは受容体との結合に引き続いて，coated　pitsとcoated　vesiclesを介して細胞内に取り込まれる（internalization）。Vesicle内での急速なpHの低下にともない，鉄はTfから分離し，細胞内で分画される。一方，鉄を失ったTf（アポTf）は受容体と結合したまま細胞表面にもどり，中性のpHのもとで受容体から解離する。最近の細胞・分子生物学の進歩，遺伝子クローニング，ならびにモノクローナル抗体の開発により，分子レベルで鉄代謝経路が解明されつつある。今回，これまでの主要な知見をまとめ，特に，最近筆者らの研究により明らかとなった，肝の鉄代謝における内皮細胞の役割について考察した

Total synthesis of TMG-chitotriomycin based on an automated electrochemical assembly of a disaccharide building block

The total synthesis of TMG-chitotriomycin using an automated electrochemical synthesizer for the assembly of carbohydrate building blocks is demonstrated. We have successfully prepared a precursor of TMG-chitotriomycin, which is a structurally-pure tetrasaccharide with typical protecting groups, through the methodology of automated electrochemical solution-phase synthesis developed by us. The synthesis of structurally well-defined TMG-chitotriomycin has been accomplished in 10-steps from a disaccharide building block

Early diagnosis of pancreatic cancertrial of a mass screening test for detecting early pancreatic cancer

膵癌を治癒に導くためには早期診断，早期切除以外に方法はない。そこで，無症状者のなかから早期膵癌を発見するためのスクリーニング法を検討するためProspective studyを実施した。人間ドック目的の来院患者を主とする三朝分院外来患者776名を対象とし，一次スクリーニング検査として，血清アミラーゼ，エラスターゼⅠ，CA19－9，アルカリフォスファターゼ，γ-GTP，血糖値の測定および腹部超音波検査を施行し，異常者に対して二次スクリーニングとして腹部超音波検査の再精査およびERCPを施行した。その結果，早期膵癌1例および進行膵癌2例を検出し，膵癌発見率は0.39％　と満足のいく結果が得られた。しかし一次スクリーニング検査の要精検率は46％　と高値を示したこと，一次スクリーニング検査の費用は胃集検の約3.3倍，二次スクリーニング検査の費用は胃精査の約2.6倍かかることからcost-benifitの面で問題となった。また見逃し症例の有無をモニターするためfollow upも今後の問題として残った。There is no other way of curing pancreatic cancer than early diagnosis and resection. However, an effective protocol has not been established for detecting early pancreatic cancer among asymptomatic populations by means　of a mass screening test. Therefore, a prospective study was attempted on 776 patients who came to Medical Clinic of Misasa Branch Hospital, Okayama University Medical School mostly for a routine annual check-up. The following tentative protocol was proposed, based on the retrospective analyses of our 13 patients with early pancreatic cancer: (1) a first step test includes serum amylase, elastase Ⅰ, alkaline phosphatase, r-GTP, carcinoembryonic antigen, fasting blood sugar and routine abdominal ultrasonography (US); (2) a second step test includes thorough abdominal US with various kinds of probes and patients' positioning which was performed on individuals with abnormal findings on the first step test, (3) a third step test includes ERCP which was performed on individuals with abnormal or questionable findings on the second step test. Further detail examinations were performed when ERCP was abnormal or questionable. Consequently 357 patients (46% of the total 776 patients) underwent thorough US and 45 patients (5.8%) underwent ERCP. ERCP findings included pancreatic cancer in two patients, suspect of pancreatic cancer in three, advanced chronic pancreatitis in two, equivocal as for chronic pancreatitis (according to the Cambridge classification) in nine, and normal in 29. Final diagnosis was early pancreatic cancer in one patient, advanced pancreatic cancer in two, and calcified chronic pancreatitis in two; detection rate of pancreatic cancer (0.39%) in this series was slightly higher than that usually reported with a mass screening test for stomach cancer. From a cost-benefit point of view, however, examinations for the pancreas cost 2.6 times as much as those for the stomach. Further studies are needed (1) to refine the protocol, (2) to improve cost-benefit efficiency, (3) and also to confirm by follow-up that no cases of pancreatic cancer have passed through the test undetected

Clinical evaluation of endoscopic ultrasonography (EUS) in the diagnosis of gastric disease.

ラジアルセクタ式超音波内視鏡（EUS）を，15例の胃疾患患者に用い，その有用性を検討した。胃癌の深達度診断は併存潰瘍を有するm癌の1例をsm癌とした以外は，いずれも正診であり，胃癌の深達度診断にEUSが有用であることが示唆された。その他，胃粘膜下腫瘍の占拠部位や発育様式の診断や壁外性圧排との鑑別など胃疾患の診断にEUSの有用性が示唆され，文献的考察を加えて報告した。We performed EUS in seven cases with gastric cancer, one with gastric malignant lymphoma, two with submucosal tumor of the stomach (SMT), two with tumourous compression by extra-gastric organs and three with others. Except one case with early gastric cancer, the depth of cancerous lnvasion was correct1y diagnosed by EUS. It was posible to detect which layer had SMT in the 5 layer strcture of the gastric wall by EUS and it was helpful in determination of histological origin of SMT. Furthermore EUS was able to make the differential diagnosis between SMT and tumourous compression by extra gastric organ. Our result showed that EUS was a useful procedure in the diagnosis of gastric diseases