Brain abscess following intracerebral haemorrhage

We report two cases of brain abscess, which developed at the site of an intracerebral haemorrhage (ICH) in a 75-year-old man and a 32-year-old-man. The patients recovered after surgical treatment and systemic antibiotic therapy. The route of infection could not be detected in either case. The literature contains only 13 reported cases of brain abscess as a complication of ICH. Although the interval from initial ICH to abscess formation ranged from 4 to 20 weeks, almost all patients had episodes of high fever, indicating the presence of systemic infection and bacterial seeding, 0-14 days after the onset of their ICH. Therefore, abscess formation appears to be caused by haematogenous seeding of infection in patients with ICH. Abscess formation should be considered when a patient deteriorates clinically with a febrile episode after an ICH.

A minimally invasive endoscopic transsphenoidal approach with an endonasal septal pushover technique by using a modified nasal speculum

Whereas the endoscopic endonasal transsphenoidal approach has been applied in patients with pituitary lesions as a potentially efficacious and less invasive surgical technique, the sinonasal step of a series of the surgical procedures is generally not well known to neurosurgeons. This is one of the reasons why the endoscopic technique has not been fully been adopted as a routine surgical procedure approaching towards the sella. The present paper describes the technical details of a purely endoscopic approach using an endonasal septal pushover technique. We also present a newly designed nasal speculum specialized for this endoscopic endonasal technique. As compared to the endoscopic endonasal approach previously reported, the surgical procedure required for sphenoidotomy with the aid of the modified speculum was simplified and thereby less time-consuming. This technique has been performed in 40 patients with several types of pituitary lesions. All patients recovered rapidly without significant rhinological complications. Despite a limited number of cases, our experience suggests that this simplified endoscopic technique could encourage a more routine use of endoscopes in the endonasal approach for pituitary lesions.

Myeloablative allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia in adults: significant roles of total body irradiation and chronic graft-versus-host disease

Disease-free survival in Philadelphia chromosome-positive ALL (Ph + ALL) is very poor, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently considered the only procedure with curative potential. To identify factors affecting transplant outcome, we analyzed the data from 197 Ph + ALL patients aged 16 years or older who had undergone allo-HSCT. The 5-year survival rates were 34% for patients in first complete remission (CR), 21% for those in second or subsequent CR, and 9% for those with active disease (P < 0.0001). Multivariate analysis showed four pre-transplant factors as significantly associated with better survival: younger age, CR at the time of transplantation, conditioning with total body irradiation, and HLA-identical sibling donor (P < 0.0001, P < 0.0001, P = 0.0301, P = 0.0412, respectively). Severe acute GVHD increased the risk of treatment-related mortality (TRM) without diminishing the risk of relapse, whereas chronic GVHD reduced the risk of relapse without increasing the risk of TRM. Thus, patients who developed extensive chronic GVHD had better survivals (P = 0.0217), and those who developed grade III-IV acute GVHD had worse survivals (P = 0.0023) than did the others.

Trial of Remote Telemedicine Support for Patients with Chronic Respiratory Failure at Home through a Multistation Communication System

To create and test a multistation telemedicine support system, three remote locations were connected: the homes of two patients with chronic respiratory failure, the hospital of the attending physician, and the hospital of the pulmonary specialist. Real-time connections were set up between the three locations. Medical history and biologic variables were noninvasively recorded, including blood pressure, arterial oxygen saturation, three-lead electrocardiogram, and end-tidal carbon dioxide. Both physicians shared in these data real-time. If necessary, the respiratory specialist could provide medical advice to the attending physician based on the patient's condition. The trial program resulted in the same information being exchanged remotely using the multi-station telemedicine system that would be exchanged in a direct, face-to-face encounter. This result, together with the improvement in quality of life and the establishment of appropriate treatment and cooperation between the respiratory specialist and attending physician, suggests our system can be considered useful and promising for further use.

IL-4-producing CD8+ T cells may be an immunological hallmark of chronic GVHD

Chronic graft-versus-host disease (cGVHD) occurs in approximately 60-80% of those who survive over 100 days after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the pathophysiology of cGVHD is poorly understood. To gain more insight into the immunological mechanism of cGVHD, we examine cytokine production of peripheral blood T cells from 19 patients in the chronic phase of allo-HSCT. The percentage of IFN-gamma-producing CD8(+) T cells among CD8(+) T cells was significantly higher in patients with or without cGVHD than in normal control subjects (P<0.001). On the other hand, the percentage of IL-4-producing CD8(+) T cells among CD8(+) T cells was significantly higher in patients with cGVHD (mean 3.3%; range 1.3-8.2%) than in patients without cGVHD (mean 1.2%; range 0.8-1.7%) and normal control subjects (mean 1.1%; range 0.1-1.6%) (both P<0.001). By contrast, the percentage of IL-4-producing CD4(+) T cells was not different among patients with and without cGVHD and normal controls. These findings suggest that IL-4-producing CD8(+) T cells may be an immunological marker of cGVHD.

Reduced-intensity stem-cell transplantation for adult acute lymphoblastic leukemia: a retrospective study of 33 patients

Efficacy of reduced-intensity stem-cell transplantation (RIST) for acute lymphoblastic leukemia (ALL) was investigated in 33 patients (median age, 55 years). RIST sources comprised 20 HLA-identical related donors, five HLA-mismatched related, and eight unrelated donors. Six patients had undergone previous transplantation. Disease status at RIST was first remission (n=13), second remission (n=6), and induction failure or relapse (n=14). All patients tolerated preparatory regimens and achieved neutrophil engraftment (median, day 12.5). Acute and chronic graft-versus-host disease (GVHD) developed in 45 and 64%, respectively. Six patients received donor lymphocyte infusion (DLI), for prophylaxis (n=1) or treatment of recurrent ALL (n=5). Nine patients died of transplant-related mortality, with six deaths due to GVHD. The median follow-up of surviving patients was 11.6 months (range, 3.5-37.3 months). The 1-year relapse-free and overall survival rates were 29.8 and 39.6%, respectively. Of the 14 patients transplanted in relapse, five remained relapse free for longer than 6 months. Cumulative rates of progression and progression-free mortality at 3 years were 50.9 and 30.4%, respectively. These findings suggest the presence of a graft-versus-leukemia effect for ALL. RIST for ALL is worth considering for further evaluation.

Combination of boron and gadolinium compounds for neutron capture therapy. An in vitro study

In neutron capture therapy, the therapeutic effect of the boron compound is based on alpha particles produced by the B(n, alpha) reaction while with the gadolinium compound the main radiation effect is from gamma rays derived from the Gd(n, gamma) reaction. The uptake and distribution within the tumor may be different among these compounds. Thus, the combination of the boron and gadolinium compounds may be beneficial for enhancing the radiation dose to the tumor. Chinese hamster fibroblast V79 cells were used. For the neutron targeting compounds, 10B (BSH) at 0, 5, 10, and 15 ppm, and 157Gd (Gd-BOPTA) at 0, 800, 1600, 2400, 3200, and 4800 ppm, were combined. The neutron irradiation was performed with thermal neutrons for 30 min. (neutron flux: 0.84 x 10(8) n/cm2/s in free air). The combination of the boron and gadolinium compounds showed an additive effect when the gadolinium concentration was lower than 1600 ppm. This additive effect decreased as a function of gadolinium concentration at 2400 ppm and resulted in no additive effect at more than 3200 ppm of gadolinium. In conclusion, the combination of the boron and gadolinium compounds can enhance the therapeutic effect with an optimum concentration ratio. When the gadolinium concentration is too high, it may weaken the boron neutron capture reaction due to the high cross-section of gadolinium compound against neutrons.

Value of chemotherapy before allogeneic hematopoietic stem cell transplantation from an HLA-identical sibling donor for myelodysplastic syndrome

Allogeneic hematopoietic stem cell transplantation (allo-SCT) is a curative treatment for myelodysplastic syndrome (MDS). The object of this study was to evaluate the impact of chemotherapy before allo-SCT. We analyzed the data of 283 patients who underwent allo-SCT from an HLA-identical sibling donor for MDS that were reported to the Japan Society for Hematopoietic Cell Transplantation. The cumulative incidence of grade II-IV acute GVHD was 33%. Overall survival (OS) at 5 and 10 years was 48.8 and 42.5%, respectively. Multivariate analyses identified karyotype, FAB classification, and the history of chemotherapy before allo-SCT as significant predictors for OS. OS at 5 years was 57% for patients who underwent allo-SCT as a primary treatment for refractory anemia with excess blasts in transformation (RAEB-t) or secondary acute myeloid leukemia (AML) and 54% for those who underwent allo-SCT in remission after induction chemotherapy (P=0.81). The proportion of patients with a poor karyotype was equivalent between the two groups (P=0.44). Although only a randomized controlled trial will be able to establish a definite conclusion, these results do not support the administration of induction chemotherapy for patients with RAEB-t or secondary AML before allo-SCT.

Bayesian joint prediction of associated transcription factors in Bacillus subtilis

Sigma factors, often in conjunction with other transcription factors, regulate gene expression in prokaryotes at the transcriptional level. Specific transcription factors tend to co-occur with specific sigma factors. To predict new members of the transcription factor regulon, we applied Bayes rule to combine the Bayesian probability of sigma factor prediction calculated from microarray data and the sigma factor binding sequence motif, the motif score of the transcription factor associated with the sigma factor, the empirically determined distance between the transcription start site to the cis-regulatory region, and the tendency for specific sigma factors and transcription factors to co-occur. By combining these information sources, we improve the accuracy of predicting regulation by transcription factors, and also confirm the sigma factor prediction. We applied our proposed method to all genes in Bacillus subtilis to find currently unknown gene regulations by transcription factors and sigma factors.

Feasibility of photocrosslinkable chitosan as an embolization material for aneurysms. Biological reaction after aneurysm embolization

SUMMARY

The purpose of this study was to evaluate the feasibility of photocrosslinkable chitosan as an embolization material for aneurysms. Three experimental aneurysms were created in three Japanese white rabbits. All of the aneurysms were packed with chitosan hydrogel. Histopathologic data were analyzed on two, seven, and 30 days after embolization. Unorganized clots and minimal inflammation around the applied chitosan hydrogel were observed two days after implantation. After seven days, the chitosan was reduced and inflammatory response appeared. At 30 days, most of the aneurysm lumen was replaced with inflammatory cells, and the remaining chitosan was not observed. Severe complications such as anaphylaxis did not occur after the embolization with the chitosan. These results suggest that photocrosslinkable chitosan might be a candidate for an embolization material for endovascular treatment of cerebral aneurysms.

Magnetic noise rejection in the MCG using independent component analysis

In magnetocardiogram (MCG) measurements, the magnetic noise from any magnetic wire, used to suture the sternum after heart surgery, becomes a problem. As one method of noise rejection, independent component analysis is seen here to be effective. In this study, MCG measurements were carried out under conditions where a wire was attached to a normal subject, also where no wire was attached. Signal processing by independent component analysis was carried out in order to reduce the effect of magnetic noise from the wire. From the comparison of the waveforms after this signal processing and the waveforms where the wire was not attached, it was apparent that the magnetic noise from the wire was reduced. Thus, we have shown that independent component analysis is effective for the reduction of magnetic noise from a magnetic wire, in MCG measurements.

Improvement of dose calculation accuracy for BNCT dosimetry by the multi-voxel method in JCDS

To carry out boron neutron capture therapy (BNCT) clinical trials based on accurate dosimetry of several dose components given to a patient, we had developed the JAERI computational dosimetry system (JCDS), which can determine the absorbed doses by numerical simulation. The verification results of initial version of JCDS indicated that JCDS causes characteristic discrepancy, when JCDS estimates a sharp change arising such as near the surface. The aim of this study is to improve the accuracy of the BNCT dosimetry efficiently. The multi-voxel calculation method that reconstructs the original voxel model by combining several voxel cell sizes such as 0.125, 1 and 8 cm(3) has been developed. To verify the accuracy of the method, the calculation results were compared with the phantom experimental data. Furthermore, to verify its practicality to BNCT, retrospective evaluation of an actual BNCT in JRR-4 was performed by the multi-voxel method. The results of the comparison with the phantom experiments demonstrated that the calculation accuracy for the distributions of the thermal neutron flux was improved by employing the multi-voxel method. The computing time using the multi-voxel method increased only approximately 33% compared to the conventional uniform 1cm(3) voxel method. These results proved that the multi-voxel calculation enables JCDS to more accurately estimate the absorbed doses to a patient by efficient calculations.

Current clinical results of the Tsukuba BNCT trial

Nine high grade gliomas (5 glioblastomas and 4 anaplastic astrocytomas) were treated with BSH-based intaoperative boron neutron capture therapy (IOBNCT). BSH (100 mg/kg body weight) was intravenously injected, followed by single fraction irradiation using the mixed thermal/epithermal beam of Japan Research Reactor 4. The blood boron level at the time of irradiation averaged 29.9 (18.8-39.5)microg/g. The peak thermal neutron flux as determined by post-irradiation measurements varied from 1.99 to 2.77x10(9) n cm(-2)s(-1). No serious BSH-related toxicity was observed in this series. The interim survival data in this study showed median survival times of 23.2 months for glioblastoma and 25.9 months for anaplastic astrocytoma, results which are consistent with the current conventional radiotherapy with/without boost radiation. Of the 4 residual tumors, 2 showed complete response (CR) and 2 showed partial response (PR) within 6 months following BNCT. No linear correlation was proved between the dose and the occurrence of early neurological events. The maximum boron dose of 11.7-12.2 Gy in the brain related to the occurrence of radiation necrosis. The clinical application of a mixed thermal/epithermal beam and JRR-4 facilities on BSH-based IOBNCT proved to be safe and effective in this series.

Atrophic dermatofibroma

Atrophic dermatofibroma, a newly proposed entity in recent times, is thought to be a specific variant of dermatofibroma. We report a typical case of atrophic dermatofibroma on the thigh of a 69-year-old female. The lesion consisted clinically of a light brown, intracutaneous nodule with a central crateriform depression, and histologically of fibrohistiocytic components in the thinning dermis. On elastica van Gieson stain, loss of elastic fibres and dense accumulation of elastic fibres around medium-sized vessels were observed in the lesion.

Predicting gene regulation by sigma factors in Bacillus subtilis from genome-wide data

MOTIVATION

Sigma factors regulate the expression of genes in Bacillus subtilis at the transcriptional level. We assess the accuracy of a fold-change analysis, Bayesian networks, dynamic models and supervised learning based on coregulation in predicting gene regulation by sigma factors from gene expression data. To improve the prediction accuracy, we combine sequence information with expression data by adding their log-likelihood scores and by using a logistic regression model. We use the resulting score function to discover currently unknown gene regulations by sigma factors.

RESULTS

The coregulation-based supervised learning method gave the most accurate prediction of sigma factors from expression data. We found that the logistic regression model effectively combines expression data with sequence information. In a genome-wide search, highly significant logistic regression scores were found for several genes whose transcriptional regulation is currently unknown. We provide the corresponding RNA polymerase binding sites to enable a straightforward experimental verification of these predictions.

Verification of the computational dosimetry system in JAERI (JCDS) for boron neutron capture therapy

Clinical trials for boron neutron capture therapy (BNCT) by using the medical irradiation facility installed in Japan Research Reactor No. 4 (JRR-4) at Japan Atomic Energy Research Institute (JAERI) have been performed since 1999. To carry out the BNCT procedure based on proper treatment planning and its precise implementation, the JAERI computational dosimetry system (JCDS) which is applicable to dose planning has been developed in JAERI. The aim of this study was to verify the performance of JCDS. The experimental data with a cylindrical water phantom were compared with the calculation results using JCDS. Data of measurements obtained from IOBNCT cases at JRR-4 were also compared with retrospective evaluation data with JCDS. In comparison with phantom experiments, the calculations and the measurements for thermal neutron flux and gamma-ray dose were in a good agreement, except at the surface of the phantom. Against the measurements of clinical cases, the discrepancy of JCDS's calculations was approximately 10%. These basic and clinical verifications demonstrated that JCDS has enough performance for the BNCT dosimetry. Further investigations are recommended for precise dose distribution and faster calculation environment.

Correlation between C677T MTHFR gene polymorphism, plasma homocysteine levels and the incidence of CAD

The lesions of coronary atherosclerosis represent the result of a complex, multicellular, inflammatory-healing response in the coronary arterial wall. In vivo and in vitro cellular and molecular studies have suggested a role for tissue homocysteine in endothelial cell injury and adverse extra-cellular matrix remodeling. Gene polymorphisms in relation with numerous risk factors might increase the incidence of coronary artery disease (CAD). In this review we have focused on the correlations between plasma homocysteine levels, the incidence of cardiovascular disease and the cytosine-to-thymidine substitution at nucleotide 677 (C677T) of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, coding for a key enzyme in methionine-homocysteine metabolism. The role of the C677T MTHFR gene polymorphism in the causation of CAD is controversial. We reviewed 12 recent case-control studies comprising 5370 genotyped patients with CAD and 4961 genotyped participants without CAD. There was no significant difference between those with and without CAD in the frequency of the C677T polymorphism (34.9 vs 33.6%). The frequency of homozygous C677T polymorphism in these groups was 10.9 versus 12.8%, respectively, although there were some ethnic differences in the C677T MTHFR polymorphism. In the analysis of the 12 studies, the odds ratio of CAD associated with the TT genotype (homozygous C677T polymorphism) was 1.18. Only slightly higher plasma homocysteine levels were observed in participants with the val/val (TT) genotype (14.4+/-2.9 micro mol/L in TT genotype vs 11.1+/-1.9 and 11.9+/-2 micro mol/L in CC and CT genotype, respectively). In addition, the relation between homocysteine increase after methionine loading and MTHFR genotypes is also controversial. However, hyperhomocysteinemia because of the C677T MTHFR allele may be corrected with oral folic acid therapy. Further investigations on the relationships between MTHFR genotypes and the incidence of CAD should be based on larger samples, paying attention to the differences between various ethnic populations. Individual therapeutic strategies based on single nucleotide polymorphism may become increasingly important for preventive treatment against polygenic CAD.

Intra-arterial steroid-injection therapy for steroid-refractory acute graft-versus-host disease with the evaluation of angiography

We treated three patients with steroid-refractory acute graft-versus-host disease (aGVHD) with intra-arterial steroid-injection therapy (IAST). Two patients with gut aGVHD received IAST into both superior and inferior mesenteric arteries, while one patient with liver aGVHD received IAST into the proper hepatic artery. The volume of stools and the bilirubin level improved soon after IAST. Angiography of the superior and inferior mesenteric arteries was performed in the two patients with steroid-refractory gut aGVHD, and identical abnormal findings were obtained. IAST might be an earlier option for steroid-refractory aGVHD.

Inhibition of nuclear factor kappa B activation and inducible nitric oxide synthase transcription by prolonged exposure to high glucose in the human keratinocyte cell line HaCaT

BACKGROUND

In human skin, inducible nitric oxide synthase (iNOS) appears to be a key enzyme during wound healing and has roles in protection from infection. We speculated that diabetic skin complications such as delayed wound healing and skin infection were due to iNOS activity altered by high glucose in skin keratinocytes.

OBJECTIVES

The purpose of this study was to see how high levels of glucose affect iNOS activity in the human keratinocyte cell line (HaCaT).

METHODS

HaCaT cells were exposed to high glucose for 1 day or 10 days. We measured nitric oxide (NO) end product nitrite in the culture medium using the Griess reagent, and intracellular tetrahydrobiopterin (BH(4), a cofactor of NOS) content by using high-performance liquid chromatography, analysed the expression level of iNOS mRNA by the reverse transcriptase-polymerase chain reaction method and evaluated the DNA binding activity of nuclear factor kappa B (NF-kappaB) by enzyme-immunoassay.

RESULTS

Short-term exposure (1 day) to a high level of glucose increased BH(4) and iNOS activity at the post-translational level. However, long-term exposure (10 days) to high glucose downregulates NF-kappaB binding activity and inhibits iNOS transcription and its activity.

CONCLUSIONS

Pretreatment with high glucose for 10 days down-regulated NF-kappaB activity and inhibited iNOS transcription and NO production, implying the involvement of a deficiency in NO synthesis in both skin infection and impaired wound healing in diabetic patients.

Computer simulation of flow dynamics in an intracranial aneurysm. Effects of vessel wall pulsation on a case of ophthalmic aneurysm

SUMMARY

Using a supercomputer, the authors studied the effect of vessel wall pulsation on flow dynamics with a three-dimensional model simulating both a rigid and pulsatile style. The design of the aneurysm models was set with a 5 mm dome diameter and a 1 or 3 mm orifice size to simulate a carotid-ophthalmic aneurysm. Flow dynamics were analyzed according to flow pattern, wall pressure and wall shear stress. The flow pattern in the aneurysm sac showed the great difference between rigid and pulsatile models particularly in the small-neck aneurysm model. The arterial wall tended to be exposed to a higher pressure peak in the pulsatile model than in the rigid one, especially at its bifurcation and curved regions. Sites of shear stress peak were found on the aneurysmal dome as well as at the distal end of the orifice in both rigid and pulsatile models. The effects of vessel-wall pulsation should be considered whenever evaluating conditions in and around an aneurysm.

Nagoya university training system for neuroendovascular therapists

SUMMARY

It is very important to train more neuroendovascular therapists (NETists) in response to Japan's growing social needs. Since the supply of qualified NETists is still insufficient to cover Japanese institutions, therefore some emergency cases with indications for endovascular therapy may be overlooked, untreated or treated by other methods resulting in unfavorable outcomes. Thus, neuroendovascular therapies are situated as one of the important tratment modalities for neurosurgical diseases (1,2). We studied our present states of the endovascular neurosurgery and introduce our training system.

Immune reconstitution following reduced-intensity transplantation with cladribine, busulfan, and antithymocyte globulin: serial comparison with conventional myeloablative transplantation

The primary object of the conditioning regimen for allogeneic reduced-intensity stem cell transplantation (RIST) is immunosuppression to achieve stable engraftment of donor cells, rather than bone marrow ablation. Therefore, immune reconstitution after RIST might be different from that after conventional stem cell transplantation (CST). In this study, 22 patients underwent RIST and 28 underwent CST. The RIST regimen consisted of cladribine (2-CdA; 0.11 mg/kg/day for 6 days), BU (4 mg/kg/day for 2 days), and rabbit anti-thymocyte globulin (ATG; 2.5 mg/kg/day for 2-4 days). The CST group received either the BU (4 mg/kg/day x 4 days)/CY (60 mg/kg/day x 2 days) (n=13) or CY (60 mg/kg/day x 2 days)/TBI (4 Gy/day x 3 days) regimen (n=15). All patients underwent transplantation with G-CSF-mobilized blood stem cells. Engraftment speed after RIST was fast and seven of 22 patients did not require platelet transfusion. We noted that the numbers of CD4+, CD4+CD45RA+, and CD4+CD45RO+ T cells after transplant in the RIST group were significantly lower than those in the CST group (P=0.0001 for both the comparisons). However, the reconstitution of CD20+ B cells was faster in the RIST group (P=0.0001). The response of T cells to PHA stimulation was lower in the RIST group (P=0.0001 on day 30 and P=0.02 on day 90). Nevertheless, there were no significant differences in the incidence of bacterial, fungal, or viral infections between the two groups. We concluded that our RIST regimen might delay laboratory-evaluated T-cell immune reconstitution compared to CST; however, the observed setbacks did not directly translate into clinically significant increases in infectious episodes.

Intrasplicing--analysis of long intron sequences

We propose a new model for the splicing of long introns, which we call intrasplicing. The basic idea of this model is that the splicing of long introns may be facilitated by the splicing of inner parts of the intron prior to the splicing of the long intron itself. Since long introns have up to about 100,000 bases, this model seems to be a likely explanation of their splicing. To investigate the possibility of this model, we develop a new computational method for the analysis of DNA sequences with respect to splicing. We analyze the genomic sequence of four species with our method and derive several results indicating that intrasplicing may be an appropriate model for the splicing of at least part of the long intron sequences.

High complete response rate after allogeneic hematopoietic stem cell transplantation with reduced-intensity conditioning regimens in advanced malignant lymphoma

The possible advantage of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a graft-versus-lymphoma effect. We explored the feasibility and efficacy of allo-HSCT with reduced-intensity (RI) regimens in advanced malignant lymphoma (ML). A total of 20 patients with indolent (n=9) or aggressive lymphoma (n=11) received allo-HSCT with an RI regimen (RIST). The preparative regimen consisted of a combination of purine analog and alkylating agent with or without antithymocyte globulin. A total of 11 patients had chemorefractory disease, seven had chemosensitive relapsed disease and two had residual disease. All of the patients received G-CSF-mobilized blood stem cells from HLA-matched siblings. Of the 20 patients, 19 achieved engraftment with acceptable regimen-related toxicities. Seven patients developed grade II-IV acute GVHD and 15 developed chronic GVHD. Of the 15 patients with evaluable disease, 12 achieved a complete response. One died of invasive fusariosis, four subsequently died of GVHD complicated with fungal infection and one died of progressive disease. With a median follow-up of 358 days, the Kaplan-Meier estimates for 1-year overall and progression-free survival were both 70%. The high response rate with low relapse observed in this study suggests that RIST may be an effective alternative curative treatment for patients with advanced ML.

Coil retrieval following embolization of cerebral aneurysms

SUMMARY

Failed coil embolization of cerebral aneurysms may be occasionally followed by direct surgical treatment. We had 5 patients who underwent coil retrieval and surgical clipping after coil embolization because of periprocedural complications. The patients, ranging in age from 40 to 71, had wide-neck aneurysms located at the anterior communicating artery (AcomA) in 3 patients, the middle cerebral artery (MCA) in 1, and the internal carotidophthalmic artery (IC-Ophthalmic) in 1. They were embolized with Guglielmi detachable coils (GDCs), which had to be retrieved within 8 days because of coil protrusion and migration in 3 patients, aneurysm rupture in 1, and increased mass effect due to coil compaction in 1. Coils were successfully removed with aneurysmotomy or arteriotomy under temporary trapping, aneurysms were then clipped or trapped. Three patients had a good outcome, but one suffered permanent visual disturbance and the other had a motor deficit. Our study revealed that a small AcomA aneurysm had a high risk of complication in a case of complex anatomy of the AcomA-A1-A2 complex with its difficult access. In addition, insufficient packing of the inflow zone in a large and symptomatic aneurysm may cause coil compaction and regrow with increasing mass effect. The indication and treatment strategy for these aneurysms should be carefully determined.

Updating of neuronavigation based on images intraoperatively acquired with a mobile computerized tomographic scanner: technical note

Image-guided surgery based on preoperatively obtained image data is susceptible to inaccuracy resulting from intraoperative brain shift and distortion. We report a technique of updating neuronavigational data with the aid of a mobile computerized tomographic (CT) scanner. A mobile CT which is readily available in an ordinary operating room was used to acquire intraoperative images. A total of 6 - 7 titanium screws placed on the skull were used as new reference points for updating navigation. Intraoperative CT scanning was performed with a 2 mm slice thickness. After the obtained image data were transferred as Dicom files to the computer workstation of the navigation system through an Ethernet connection, navigational data were updated to registering the new reference points. Under the guidance of the updated navigation, residual lesions were explored, and further resected. Our preliminary experience in 8 patients indicates that interactive image-guidance can stably be updated based on images intraoperatively acquired with a mobile CT scanner. Comparing to intraoperative magnetic resonance imaging, this technique can simply be done in an ordinary operating room without requiring special surgical instruments, thus making it possible to update interactive image guidance on demand during an operation.

Studies on the metabolic fate of M17055, a novel diuretic (6). Assessment for drug-drug interactions of M17055 in metabolism, distribution and excretion

1. The potential of M17055, a novel diuretic candidate, to affect the activities of human CYP enzymes, alter the plasma unbound fraction and compete with concomitant drugs in renal secretion as part of an assessment for drug-drug interactions in metabolism, distribution and excretion was investigated. 2. The effects of M17055 on the activities of human CYP1A2, CYP2E1, CYP2C9, CYP2C19, CYP2D6 and CYP3A4 were considered negligible at clinically relevant concentrations. 3. The majority of M17055 (99%) was bound to human plasma proteins, but it is unlikely to alter the binding of other clinically relevant drugs. 4. The renal clearance of M17055 (corrected for the plasma unbound fraction in male rats) substantially exceeded the glomerular filtration rate and was markedly reduced by treatment with probenecid, suggesting that the renal excretion of M17055 is controlled predominantly by an active secretion mechanism. 5. The results show that M17055 is unlikely to cause or undergo significant pharmacokinetic interactions with concomitant drugs in metabolism and distribution. However, when it is administered simultaneously with certain organic anions, drug-drug interactions during kidney excretion may be possible.

Primary cutaneous aspergillosis caused by Aspergillus ustus following reduced-intensity stem cell transplantation

A 19-year-old woman with myelodysplastic syndrome underwent reduced-intensity stem cell transplantation [RIST: (cladribine 0.11 mg/kg for 6 days, busulfan 4 mg/kg for 2 days, and rabbit antithymocyte globulin)] from her one HLA-mismatched mother. Prophylaxis against graft-versus-host disease (GVHD) was performed with cyclosporine A (CSA) alone. Severe acute GVHD in the skin, gut, and liver developed concurrently with stable engraftment, and methylprednisolone was administered (1-2 mg/kg per day, then pulse therapy with 1 g/day for 3 days) until day 40 of transplant, when a necrotic lesion of 10 mm in diameter appeared on the right cheek. The initial skin biopsy of the affected area showed a nonspecific inflammatory change. Routine X-ray and computed tomography examinations of the sinuses, chest, and abdomen disclosed no particular abnormalities. Despite intensive antibiotic therapy, the lesion rapidly extended to form an ulcer. A second biopsy specimen obtained from the lesion showed massive septa hyphae, suggesting mold infection. Although we immediately started amphotericin B, she died of multiorgan failure on day 68. Postmortem DNA sequence analysis of the specimen using the polymerase chain reaction identified Aspergillus ustus. Although this is an extremely rare complication after transplantation, this case highlights that we should pay more attention to primary cutaneous aspergillosis in severely immunosuppressed patients.

Histopathological grading does not affect survival after R0 surgery for gastric cancer

AIM

It is unclear whether Histopathological Grading (UICC, TNM Classification) affects survival after resection for gastric cancer.

METHODS

To investigate the prognostic significance of Histopathological Grading after gastrectomy, 1455 patients who underwent gastric resection for gastric adenocarcinoma were reviewed.

RESULTS

The R0 (UICC, R Classification) resection rate was inversely correlated with the grade (86.5% for Grade 1, 79.7% for Grade 2 and 69.2% for Grade 3) and the R1 and R2 resection rates increased with the grade. The Histopathological Grading did not influence survival in the 1119 patients who underwent R0 resection (71.0% for Grade 1, 65.7% for Grade 2 and 66.7% for Grade 3). When multivariate analysis was performed for the 1119 cases undergoing R0 resection, the Histopathological Grading was not a determinant prognostic factor.

CONCLUSION

We conclude that the UICC Histopathological Grading affects R0 resection rates, but does not affect survival independently.

Comparison of average and population bioequivalence approach

AIMS

We investigated the comparison of average bioequivalence approach and population approach using bioequivalence study data which have been reported.

MATERIALS

On MEDLINE, "bioequivalence" was entered as a key word to search in the 3 journals which were published between 1980 and 1989. Consequently, a total of 17 data sets on AUC and 12 data sets on Cmax were obtained and analyzed in this review.

METHOD

Assessment of average bioequivalence, assessment of population bioequivalence and assessment of inequality of variance (F-test) were conducted after all data were subjected to logarithmic conversion.

RESULTS

Of the data sets which were analyzed in this review, 11 data sets on AUC and 3 data sets on Cmax passed the average bioequivalence criterion, and 13 data sets on AUC and 8 data sets on Cmax passed the population bioequivalence criterion. Two data sets on AUC and 1 data set on Cmax passed the average bioequivalence criterion, but not the population bioequivalence criterion. Four data sets on AUC and 6 data sets on Cmax passed the population bioequivalence criterion, but not the average bioequivalence criterion. The correlation coefficient (r) for the population bioequivalence value and difference in the average bioavailability was 0.412, while the correlation coefficient for the population bioequivalence value and the difference in bioavailability variances was 0.708.

CONCLUSIONS

In this review using bioequivalence study papers which have been reported in references, the episodes to judge that the test formulation is bioequivalent to the reference formulation occurred more predominantly in the population bioequivalence approach than in the average bioequivalence approach, and population bioequivalence approach might be affected more extensively by the bioavailability variance rather than by the average bioavailability.

The skin fungus-induced Th1- and Th2-related cytokine, chemokine and prostaglandin E2 production in peripheral blood mononuclear cells from patients with atopic dermatitis and psoriasis vulgaris

BACKGROUND

It is suggested that skin fungi may be involved in the development of atopic dermatitis (AD) and psoriasis vulgaris (PV).

OBJECTIVE

We studied skin fungus-induced Th1- or Th2-related cytokine, chemokine and prostaglandin E2 (PGE2) secretion in peripheral blood mononuclear cells (PBMC) from patients with AD and PV and normal subjects.

METHODS

PBMC were cultured with the extracts of Malassezia furfur (MF), Candida albicans (CA) and Trichophyton rubrum (TR). The cytokine, chemokine and PGE2 amounts in the supernatants were measured by enzyme-linked immunosorbent assays.

RESULTS

MF induced IL-4 and macrophage-derived chemokine (MDC) secretion in AD patients, while induced IFN-gamma and interferon-inducible protein of 10 kDa (IP-10) secretion in PV patients, however, did not induce either secretion in normal subjects. CA induced IL-4, MDC, IFN-gamma and IP-10 secretion in AD and PV patients and normal subjects. In AD patients, the magnitude of IL-4 and MDC responses to CA was higher than that to MF. Compared with PV patients and normal subjects, the magnitude of IL-4 and MDC responses to CA was higher while that of IFN-gamma and IP-10 responses to CA was lower in AD patients. TR induced moderate IL-4 and MDC secretion only in AD patients. The three fungi induced higher levels of PGE2 secretion in AD patients than in PV patients and normal subjects. Cyclooxygenase-2 inhibitor NS-398 suppressed PGE2 responses to MF, CA and TR, and partially suppressed IL-4 and MDC responses to MF, CA and TR, while enhanced IFN-gamma and IP-10 responses to CA in AD patients, and these effects of NS-398 were reversed by cyclic AMP analogue.

CONCLUSION

AD patients manifest Th2-skewed responses to MF, CA and TR, which may be partially attributable to the enhanced PGE2 responses to these fungi. PV patients manifest Th1-skewed responses to MF.

Length of the antral segment in pylorus-preserving gastrectomy

BACKGROUND

Pylorus-preserving gastrectomy (PPG) has the advantages of preventing dumping syndrome and duodenogastric reflux. However, time was required to reduce symptoms of gastric fullness or to improve food intake after surgery. The aim of this study was to investigate whether the length of the retained antral segment influenced the postoperative symptoms in patients who underwent PPG.

METHODS

Thirty patients with early gastric cancer who underwent PPG were divided into two groups according to the length of the retained antrum. In group 1 (n = 20) the transection was 1.5 cm and in group 2 (n = 10) it was 2.5 cm proximal to the oral edge of the pyloric ring. The subjects were interviewed and examined periodically to assess symptoms, food intake, body-weight and serum nutritional variables. Endoscopy and a radioisotope gastric emptying test were performed 1 year after the operation.

RESULTS

In group 1 gastric fullness after meals was common, resulting in poor food intake and poor recovery of body-weight. A high incidence of food residue in the remnant stomach was found in group 1. With regard to gastric emptying, seven of 20 patients in group 1 and one of ten in group 2 had a delayed emptying curve 1 year after operation.

CONCLUSION

Group 2 was superior to group 1 in terms of postprandial symptoms, food intake, recovery of body-weight and gastric emptying. The length of the retained antrum may play an important role in the motility of the pyloric ring following PPG.

Length of the antral segment in pylorus-preserving gastrectomy

BACKGROUND

Pylorus-preserving gastrectomy (PPG) has the advantages of preventing dumping syndrome and duodenogastric reflux. However, time was required to reduce symptoms of gastric fullness or to improve food intake after surgery. The aim of this study was to investigate whether the length of the retained antral segment influenced the postoperative symptoms in patients who underwent PPG.

METHODS

Thirty patients with early gastric cancer who underwent PPG were divided into two groups according to the length of the retained antrum. In group 1 (n = 20) the transection was 1.5 cm and in group 2 (n = 10) it was 2.5 cm proximal to the oral edge of the pyloric ring. The subjects were interviewed and examined periodically to assess symptoms, food intake, body-weight and serum nutritional variables. Endoscopy and a radioisotope gastric emptying test were performed 1 year after the operation.

RESULTS

In group 1 gastric fullness after meals was common, resulting in poor food intake and poor recovery of body-weight. A high incidence of food residue in the remnant stomach was found in group 1. With regard to gastric emptying, seven of 20 patients in group 1 and one of ten in group 2 had a delayed emptying curve 1 year after operation.

CONCLUSION

Group 2 was superior to group 1 in terms of postprandial symptoms, food intake, recovery of body-weight and gastric emptying. The length of the retained antrum may play an important role in the motility of the pyloric ring following PPG.

Suspected delayed immune recovery against cytomegalovirus after reduced-intensity stem cell transplantation using anti-thymocyte globulin

A reduced-intensity hematopoietic stem cell transplantation (RIST) regimen was developed to induce immunosuppression to facilitate the engraftment of donor cells. However, there have been concerns that the incidence of opportunistic infection may increase after this procedure. To address this problem, we retrospectively analyzed the medical records of 24 RIST recipients who were treated over a recent 16-month period for comparison with 31 recipients of conventional allogeneic transplantation (CST). The RIST regimen consisted of cladribine (0.66 mg/kg), busulfan (8 mg/kg), and rabbit anti-thymocyte globulin (ATG; 5-10 mg/kg). All of the patients received allogeneic peripheral blood stem cells from an HLA-identical or one-locus mismatched related donor. Although the incidence of positive CMV antigenemia was comparable between the two groups (58% vs 68%), RIST patients developed positive antigenemia significantly sooner than did CST patients (P = 0.01) and showed higher initial and maximum antigenemia values (P = 0.026 and P = 0.003, respectively). These findings may suggest that immune recovery against CMV was delayed after our RIST procedure, but this did not directly translate into an increase in clinically significant CMV disease. Early therapeutic intervention with ganciclovir might play a role in preventing the progression of early CMV infection to CMV disease.

Combined surgery and endovascular stenting for basilar artery stenosis refractory to balloon angioplasty: technical case report

The authors report a case of symptomatic basilar artery stenosis treated by stenting via the surgically exposed C1 vertebral artery. This case was initially treated by percutaneous transluminal angioplasty via a transfemoral route but resulted in unsatisfactory dilatation. Stenting via a transfemoral route also resulted in failure because of the coiling of the proximal vertebral artery. Direct puncture of the vertebral artery beyond the coiling portion was tried but a stent could not be delivered beyond the C2 vertebrae. Finally, the vertebral artery was surgically exposed between C1 and the occipital bone and a stent was introduced into the lesion from this portion under fluoroscopic control. The basilar artery was fully opened by stenting without new neurological deficits. Stenting of the basilar artery via a transfemoral route is not always possible even with newer generation stents if the vertebral artery has elongated tortuous curves. Combined surgery and endovascular stenting is one of the alternatives in such cases including our case.

Does bilirubin play a role in the pathogenesis of both cholesterol and pigment gallstone formation? Direct and indirect influences of bilirubin on bile lithogenicity

Bilirubin is found in the center of cholesterol gallstones, but its pathogenic role in their formation is unknown. Bilirubin causes a disproportionate reduction of biliary lipid secretion without affecting bile salt secretion in association with a change of biliary lecithin species, which modulates the cholesterol crystallization process. Therefore, the present study investigated whether bilirubin can influence the cholesterol crystallization procedure, and the mechanism(s) of any such action. Supersaturated model bile was prepared (taurocholate/lecithin/cholesterol at 71:18:11, a total lipid concentration of 9.0 g/dl, and cholesterol saturation index of 1.8), and cholesterol crystallization was monitored over time using a spectrophotometer and video-enhanced differential contrast microscopy in the absence or presence of bilirubin (at a final concentration of 10 microM, 20 microM, 40 microM, and 100 microM). Bilirubin enhanced the onset of cholesterol crystallization by 50%, whereas the crystal growth rate and final crystal mass were reduced at a high concentration of bilirubin. Taken together, these results suggest that bilirubin influences the cholesterol crystallization process, by either a direct interaction with biliary lipids that alters metastability, an indirect alteration of the bile salt-micellar lipid holding capacity, or both. Thus, bilirubin may play a role in the pathogenesis of both cholesterol and pigment gallstones.

Association of BMI with the beta3-adrenergic receptor gene polymorphism in Japanese: meta-analysis

OBJECTIVE

To assess the effect of the Trp64Arg polymorphism in the beta3-adrenergic receptor gene (ADRB3) on body mass index (BMI) in the Japanese population.

RESEARCH METHODS AND PROCEDURES

We selected studies that evaluated the association between BMI and ADRB3 polymorphism among Japanese, using MEDLINE and PubMed. After data collection, an extension of ANOVA was performed to assess the differences according to the genotype.

RESULTS

In a total of 35 subgroups including 2316 subjects with the Trp64Arg variant and 4266 subjects without this variant, the weighted mean difference in BMI was 0.26 kg/m(2) (95% confidence interval: 0.18 to 0.42; p < 0.01), indicating that variant carriers exhibited higher BMI than did normal homozygous subjects.

DISCUSSION

Although it is known that the allele frequency of the ADRB3 polymorphism differs among races, this study focuses on the Japanese population, which has a high allele frequency of ADRB3 polymorphism. We assumed that statistical errors would be prevented due to the sufficient number of subjects. In conclusion, the results support the hypothesis that ADRB3 gene polymorphism is associated with BMI.

Phospholipid alterations in hepatocyte membranes and transporter protein changes in cholestatic rat model

Biliary components are transported by hepatic adenosine triphosphate-binding cassette (ABC) transporters that are located in canalicular membranes. Physiological transporter function is related to membrane fluidity, which is modulated by the phospholipid composition of the lipid bilayer. We hypothesized that cholestasis may alter transporter function by modifying phospholipid species to protect the cell from cholestatic damage. Therefore, we examined the expression of ABC transport proteins and their mRNA levels in canalicular membrane vesicles isolated from rat liver 6 hr or three days after bile duct ligation. Membrane lipid composition and membrane fluidity of both sinusoidal and canalicular membrane vesicles were also examined. By 6 hr after bile duct ligation, we found a clear increase of mdr2 and bsep mRNA. These changes were associated with an increase of mdr-Pgp and with a clear decrease of mrp2 protein, and small decrease of bsep protein. In addition, mdrlb mRNA showed a strong increase by three days after bile duct ligation. Canalicular membrane fluidity decreased in a marked time-dependent manner, whereas sinusoidal membranes showed biphasic changes: increased fluidity at 6 hr and a decrease at three days. These changes were closely related to the changes of membrane lipid constitution; the saturated/unsaturated fatty acid ratio increased for phosphatidylcholine in canalicular membrane and the reverse occurred in sinusoidal membrane, and those for sphingomyelin showed the opposite pattern. We conclude that cholestasis causes modulation of ABC transporters as well as that of the lipid constitution in lipid bilayer. These may confer cytoprotective resistance to hepatocytes against cholestatic stress.

Long-term low-dose acyclovir against varicella-zoster virus reactivation after allogeneic hematopoietic stem cell transplantation

To evaluate the efficacy of long-term administration of acyclovir as prophylaxis against varicella-zoster virus (VZV) reactivation, we analyzed the medical records of 86 consecutive adult patients who obtained engraftment after allogeneic hematopoietic stem cell transplantation from January 1996 to March 2000. We started long-term low-dose (400 mg/day) oral administration of acyclovir in June 1999, and this was continued until the end of immunosuppressive therapy after transplantation. There was no breakthrough reactivation of VZV in patients receiving acyclovir. Five patients who were receiving cyclosporine or prednisolone developed VZV reactivation after discontinuing acyclovir. With this prophylaxis, the cumulative incidence of VZV reactivation at 1 year after transplantation decreased from 33% to 10% (P = 0.025). On multivariate analysis, the use of long-term acyclovir was identified as a significant independent parameter for the development of VZV reactivation. These findings suggest the efficacy of long-term prophylaxis with low-dose acyclovir. Resumption of acyclovir upon restarting immunosuppressive therapy might be important for the further prevention of VZV reactivation. The benefit of long-term low-dose acyclovir should be confirmed prospectively.

Early full donor myeloid chimerism after reduced-intensity stem cell transplantation using a combination of fludarabine and busulfan

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate lineage-specific chimerism reconstitution after reduced-intensity allogeneic stem cell transplantation (RIST) using a combination of fludarabine (30 mg/m2 for 6 days) and busulfan (4 mg/kg for 2 days).

DESIGN AND METHODS

We prospectively enrolled 8 consecutive patients with hematologic malignancies who were not candidates for conventional transplantation because of either high age or organ dysfunction. Host-donor chimerism was evaluated using polymerase chain reaction-based amplification of a polymorphic short tandem repeat region.

RESULTS

All of our patients achieved engraftment within a median of 11 days after transplantation. On day 30, full donor myeloid cell chimerism (>90%) was achieved in 7 patients whereas full donor T-cell chimerism was achieved in only one patient. Thus, in contrast to other reported results, full donor chimerism was achieved earlier in the myeloid lineage than the T-cell lineage. On day 60, however, T-cell chimerism caught up with myeloid chimerism. Two patients developed grade II-IV acute graft-versus-host disease (GVHD) before the detection of full donor T-cell chimerism.

INTERPRETATION AND CONCLUSIONS

Our findings suggest that the kinetics of lineage-specific chimerism depend on the agents used in the conditioning regimen, and may provide insight into the chimerism kinetics and pathogenesis of GVHD. Thus, the strategy for controlling immunosuppression after RIST should be modified according to the type of conditioning regimen applied.

Supercharged gastric tube pull-up procedure for total esophageal reconstruction

Total esophageal reconstruction using a gastric tube is complicated because it sometimes causes postoperative complications such as anastomotic leakage, stenosis, or fistula formation resulting from insufficient blood flow at the distal end. To overcome this problem, during the past 5 years the authors performed seven additional microvascular anastomoses using the short gastric vessels of the gastric tube. No postoperative complications occurred except partial tracheal necrosis in 1 patient. Postoperative radiographic examination showed no reflux or stasis in all patients, and no evidence of necrosis at the anastomotic site of the pulled-up gastric tube was observed by postoperative endoscopy. This technique reduces risk and may contribute to the successful reconstruction of the digestive tract after total esophagectomy.

Differential display analysis of mutants for the transcription factor Pdr1p regulating multidrug resistance in the budding yeast

The transcription factor Pdr1p recognizes Pdr1p/Pdr3p-response element (PDRE) to activate genes involved in multidrug resistance of the budding yeast. To identify novel targets of Pdr1p, we compared transcriptomes among the yeast cells bearing wild, disrupted and gain-of-function alleles of PDR1 using a high-throughput fluorescent differential display PCR. Consequently, we identified 20 transcripts apparently regulated by Pdr1p, which are derived from well-known target genes as well as those that have never been described in the context of drug resistance. Intriguingly, among the latter, a previously unrecognized gene bearing a small putative open reading frame preceded by a functional PDRE was found.