Utility of 5-aminolaevulinic acid fluorescence-guided endoscopic biopsy for malignant mesothelioma in a cat and dog

Malignant mesothelioma (MM) is uncommon in cats and dogs and can be challenging to diagnose. Adequate tissue sampling is required for superior diagnostic accuracy. Protoporphyrin IX, a metabolite of 5-aminolaevulinic acid (5-ALA), is a photosensitiser for photodynamic diagnosis (PDD). To the best of our knowledge, no study has reported the use of 5-ALA-PDD to detect MM in veterinary medicine. The present study describes the use of 5-ALA-PDD for MM diagnosis in a cat and dog, as well as the effectiveness of intracavitary chemotherapy. We evaluated the use of PDD with 5-ALA hydrochloride (5-ALA-PDD) in two cases of MM. A 12-year-old cat presented with a 1-month history of respiratory distress, and a 9-year-old dog presented with a 3-month history of mild abdominal distention. We endoscopically biopsied lesions in both the cases using 5-ALA-PDD. Histopathological examination revealed mesothelioma, and immunohistochemical staining was positive for calretinin. Both patients were treated with carboplatin. The cat died of respiratory failure. Although, the dog's condition improved 21 days after the first chemotherapeutic drug administration, the dog died on day 684 owing to cardiac-related issues. 5-ALA-PDD is thus, safe and feasible for the diagnosis of MM in veterinary medicine.

The orthostatic hypotension in patients with Stanford type A aortic dissection after surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Orthostatic hypotension (OH) is sometimes observed during cardiac rehabilitation in patients with surgery for aortic dissection. However, little is known about the primary determinant of OH and influence of surgical range on incidence of OH.

Purpose

The aim of this study was to elucidate the incidence of OH in patients with surgery for aortic dissection, and compare it between the patients with ascending aortic replacement surgery (ascending group) and those with ascending aorta and hemiarch or total arch replacement surgery (arch group).

Methods

We analyzed 59 patients who underwent emergent surgery due to Stanford type A aortic dissection from January 2014 to March 2018, and compared the incidence of OH between ascending group (n = 28, age 69.8 ± 11.3 years) and arch group (n = 31, age 64.1 ± 13.0 years).

Results

The incidence of OH in total patients was 30.5%. There were no significant differences in patient characteristics including body tall, body weight, antihypertensive use and progress of rehabilitation between 2 groups. The arch group showed a significant higher incidence of OH as compared with ascending group (arch group: 46.4% vs. ascending group: 16.1%, p = 0.03). Moreover, the patients who occurred OH were significantly taller than those who did not occur OH.

Conclusions

OH was observed in about one third of patients with surgery for aortic dissection and it showed a close relationship with patient’s height and the range repaired by surgical operation. More careful cardiac rehabilitation is needed for tall patients with large area replacement of aorta.

Chronotropic incompetence and exercise capacity after mitral valve surgery: the importance of blood hemoglobin level

Background

Chronotropic incompetence (CI) is sometimes observed during exercise training of cardiac rehabilitation in patients with cardiac surgery, however, little is known concerning the differences between patients with mitral valve (MV) and aortic valve (AV) surgery.

Purpose

Because the possibility exists that cardiac sympathetic nerves might be impaired by left atrium incision, we hypothesized that the incidence of CI was higher in patients with MV surgery (Mitral Valve Replacement and Mitral Valvuloplasty) as compared with patients with AV surgery (Aortic Valve Replacement). And if so, which factor determines the exercise capacity of patients after MV surgery. We thus aimed this study to elucidate the hypothesis with cardiopulmonary exercise testing (CPX).

Methods

We performed CPX by ramp loading with ergometer exercise in total 61 patients who had undergone elective cardiac valve operation (25 patients with MV surgery, age 59.2±9.9 years; 36 patients with AV surgery, age 64.6±12.3 years). We analyzed chronotropic response index (CRI), peak oxygen uptake (peak VO2/W), anaerobic threshold (AT), and peak oxygen pulse (peak VO2/HR) with CPX, and blood hemoglobin concentration (Hb).

Results

The value of CRI was significantly decreased in the patients with MV surgery compared with those with AV surgery (MV; 0.19±0.10 vs. AV; 0.41±0.17, p<0.001). Peak VO2, peak VO2/HR and Hb were not significantly different between patients with MV and those with AV surgery. Patients with MV surgery showed correlations between peak VO2 and Hb (r=0.45, p<0.05), AT and Hb (r=0.52, p<0.01), and a strong correlation between peak VO2 and peak VO2/HR (r=0.63, p<0.001), but not in those with AV surgery.

Conclusions

The present study demonstrated that higher incidence of CI was shown in patients with MV surgery as compared with those with AV surgery. The exercise capacity of patients with MV surgery was determined by peak VO2/HR and Hb. These results suggest that 1) left atrium incision impairs cardiac sympathetic nerves and causes CI, 2) peak VO2/HR which is consisted of arterio-venous oxygen difference and Hb is critical indicator for exercise capacity in patients with MV surgery with CI.

Main results

Funding Acknowledgement

Type of funding source: None

Low prevalence of the 'gang of seven' and absence of the O80:H2 serotypes among Shigatoxigenic and enteropathogenic Escherichia coli (STEC and EPEC) in intestinal contents of healthy cattle at two slaughterhouses in Belgium in 2014

AIMS

The purpose of this survey was to estimate the respective prevalence of the 'gang of seven' and 'non-gang of seven' serotypes of Shigatoxigenic and enteropathogenic Escherichia coli and to identify the O80:H2 serotype in 245 intestinal contents collected at two slaughterhouses in Belgium in 2014.

METHODS AND RESULTS

After overnight enrichment growth, the 69 intestinal contents testing positive with PCR targeting the eae, stx1 and stx2 genes were inoculated onto four agar media. Of the 2542 colonies picked up, 677 from 59 samples were PCR confirmed. The most frequent virulotypes were eae+ in 47 (80%) samples, stx2+ in 20 (34%) samples and eae+ stx1+ in 16 (27%) samples. PCR-positive colonies belonged to different virulotypes in 36 samples. No colony was O80-positive, whereas two eae+ colonies from two samples were O26:H11, 50 eae+ stx1+ and eae+ from eight samples were O103:H2 and two eae+ stx1+ stx2+ colonies from one sample were O157:H7.

CONCLUSIONS

The 'non-gang of seven' serotypes are more frequent than the 'gang of seven' serotypes and the O80:H2 serotype was not detected among Shigatoxigenic and enteropathogenic Escherichia coli in the intestines of cattle at these two slaughterhouses.

SIGNIFICANCE AND IMPACT OF THE STUDY

Although the identification protocols of Shigatoxigenic Escherichia coli focus on the 'gang of seven' serotypes, several other serotypes can be present with possible importance in public health. Innovative selective identification procedures should be designed.

Abstract P5-07-11: The ectopic FOXA1 expression correlates to the luminal breast cancer stem cells

Background: It is known that ER-positive breast cancer constitutes approximately 70% of all breast cancer and the particular population of these, called as luminal A breast cancer can lead to late recurrence, possibly due to the presence of dormant tumor cells. It is also argued that there are many similar biological characteristics between dormant cells and cancer stem cells (CSCs). So we hypothesized that some part of CSCs would be involved in the late recurrence of luminal type breast cancer and looked for the factors correlateing late recurrence by comparing CSC-enriched population and other population. Materials and Methods: We used the MCF-7 and HCC1500 human breast cell lines. Moreover, we isolated the BC#1 breast cancer cell from metastatic pleural effusion of a breast cancer patient (79 years old, ER+, PgR+, HER2 score 0). These cells are cultured in the adhesion culture condition or the mammosphere culture condition. The immunohistochemical characteristics such as ER, PgR, HER2, Cytokeratin (CK) 8, CK5/6 status of these cells were confirmed. The analysis of the ALDH activity and the CD44+/24- expression as the CSC marker were carried out using flow cytometry. The expression of target genes was analyzed using quantitative RT-PCR. Protein expression was determined by western-blotting. To assess the self-renewal potential of CSCs and the proliferation of immature cancer cells, we used mammosphere formation assay and colony formation assay. To investigate the effects of 4-hydroxytamoxifen(4-OHT) on mammosphere formation assay, 1µm of 4-OHT added to the medium in the particular experiment. Results: BC#1 was confirmed as luminal type by immunohistochemistry and qRT-PCR. The expression tendency between two CSC markers are almost same and correlated to the mammosphere formation capacity. We also confirmed that mammosphere culture have an increased ALDH-positive population compared with adherent culture cells. Using flow cytometry, we divided the cell lines and isolated cells into two populations, ALDH-positive and negative. By qRT-PCR analysis, ALDH-positive population showed higher expression of FOXA1 (ER expression related gene) than ALDH-negative population. In addition, we found the significantly higher expression of FOXA1 gene, and RPRM gene (p53 induced G2/M arrest related gene) in mammosphere culture samples than in adhesion culture samples. In terms of the effects of 4-OHT, 4-OHT resistant mammosphere samples showed significantly increased FOXA1 gene expression level. Finally, we established shFOXA1 MCF-7 cells to investigate the relationship between self-renewal potential and FOXA1 expression. We found that colony formation in shFOXA1 MCF-7 cells decreased compared with control while there is no significant difference in the number of mammospheres. Conclusion: CSC-enriched population showed higher FOXA1 expression and our results suggested that the expression of FOXA1 correlate to the proliferation of immature breast cancer cell rather than the induction of self-renewal potency of CSCs. Moreover, there is no report argued about the correlation between CSCs and G2/M arrest related gene like RPRM so that the biological mechanism should be investigated in future.

Citation Format: Tachi K, Shiraishi A, Bando H, Yamashita T, Tsuboi I, Kato T, Ichioka E, Tsushima Y, Ikeda T, Iguchi A, Hara H, Ohneda O. The ectopic FOXA1 expression correlates to the luminal breast cancer stem cells [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-07-11.

Identification of Shiga toxin-producing (STEC) and enteropathogenic (EPEC) Escherichia coli in diarrhoeic calves and comparative genomics of O5 bovine and human STEC

Escherichia coli producing Shiga toxins (Stx) and the attaching-effacing (AE) lesion (AE-STEC) are responsible for (bloody) diarrhoea in humans and calves while the enteropathogenic E. coli (EPEC) producing the AE lesion only cause non-bloody diarrhoea in all mammals. The purpose of this study was (i) to identify the pathotypes of enterohaemolysin-producing E. coli isolated between 2009 and 2013 on EHLY agar from less than 2 month-old diarrhoeic calves with a triplex PCR targeting the stx1, stx2, eae virulence genes; (ii) to serotype the positive isolates with PCR targeting the genes coding for ten most frequent and pathogenic human and calf STEC O serogroups; and (iii) to compare the MLSTypes and virulotypes of calf and human O5 AE-STEC after Whole Genome Sequencing using two server databases (www.genomicepidemiology.org). Of 233 isolates, 206 were triplex PCR-positive: 119 AE-STEC (58%), 78 EPEC (38%) and 9 STEC (4%); and the stx1+eae+ AE-STEC (49.5%) were the most frequent. Of them, 120 isolates (84% of AE-STEC, 23% of EPEC, 22% of STEC) tested positive with one O serogroup PCR: 57 for O26 (47.5%), 36 for O111 (30%), 10 for O103 (8%) and 8 for O5 (7%) serogroups. The analysis of the draft sequences of 15 O5 AE-STEC could not identify any difference correlated to the host. As a conclusion, (i) the AE-STEC associated with diarrhoea in young calves still belong to the same serogroups as previously (O5, O26, O111) but the O103 serogroup may be emerging, (ii) the O5 AE-STEC from calves and humans are genetically similar.

Effects of sitagliptin on plasma incretin concentrations after glucose administration through an esophagostomy tube or feeding in healthy cats

We investigated the effect of sitagliptin, a dipeptidyl peptidase 4 inhibitor, on plasma incretin concentrations after glucose administration through an esophagostomy tube or feeding in healthy cats. Six cats were used for the glucose administration experiment and 5 cats were used for the feeding experiment. Glucose administration through an esophagostomy tube increased plasma glucagon-like peptide 1 (GLP-1) concentrations by 6-fold, whereas plasma glucose-dependent insulinotropic polypeptide (GIP) concentrations did not change. Feeding increased both plasma GLP-1 concentrations by 1.5-fold and GIP concentrations by 4.6-fold. Sitagliptin was administered through an esophagostomy tube (25 and 50 mg per cat) in the glucose administration experiment and orally (25 mg per cat) in the feeding experiment. Sitagliptin treatment potentiated the GLP-1 response to glucose by 1.5-fold (P < 0.05). In addition, postprandial plasma GLP-1 concentration was higher by 2-fold when sitagliptin was administered (P < 0.05). In contrast, administration of sitagliptin did not affect plasma GIP concentrations after glucose administration or feeding. Sitagliptin enhanced insulin secretion following glucose administration by 1.5-fold (P < 0.05); however, it did not influence the plasma glucose concentration. Furthermore, sitagliptin had no effect on the postprandial plasma glucose and insulin concentrations. In conclusion, this study provides no evidence that sitagliptin is beneficial for management of feline diabetes mellitus.

The TRIM-FLMN protein TRIM45 directly interacts with RACK1 and negatively regulates PKC-mediated signaling pathway

The receptor for activated C-kinase (RACK1), a scaffolding protein that participates in the protein kinase C (PKC) signaling pathway, has an important role in shuttling active PKCs to its substrate. Indeed, recent studies have revealed that RACK1 has an important role in tumorigenesis and that enhancement of the feed-forward mechanism of the c-Jun N-terminal kinase (JNK)-Jun pathway via RACK1 is associated with constitutive activation of MEK (MAPK-ERK kinase)-ERK (extracellular signal-regulated kinase) signaling in human melanoma cells. Taken together, RACK1 additionally has a very important role in the mitogen-activated protein kinase (MAPK) signaling pathway. Here, we show that one of the tripartite motif-containing (TRIM) family ubiquitin ligases, TRIM45, is a novel RACK1-interacting protein and downregulates MAPK signal transduction. Importantly, the expression of TRIM45 is induced when growth-promoting extracellular stimuli activate the MAPK signaling pathway, resulting in attenuation of activation of the MAPK pathway. These findings suggest that TRIM45 functions as a member of the negative feedback loop of the MAPK pathway.

Sensitive pupil response of early-onset alzheimer's patients to a dilute mixture of cholinergic antagonist and α-Adrenergic stimulant

To investigate possible differences in pupil dilation and light reflex in Alzheimer's disease patients that can be attributed to the age of onset of the disease, a statistical comparison was made of pupil dilation and light reflex among early- and late-onset Alzheimer's disease, Down syndrome, and patients with vascular dementia, and normal controls. The subjects included 53 probable Alzheimer's disease outpatients, including both early-onset type (AD: n=21) and late-onset type (SD: n=32). They were compared with normal controls (n=15), Down syndrome patients (DS: n=6), and patients with vascular dementia (VD: n=9). All subjects and controls were dark-eyed Japanese. Pupil dilation and light reflex were tested in 21 AD and 32 SD patients, and were compared with those in the control subjects; 6 DS and 9 VD patients. The measured maximum increase in pupil diameter after instilling a mixture of anticholinergic and α -adrenergic stimulating drugs (Midrin-P®), in one eye was significantly greater in AD and DS than in the controls. However, there was no difference among SD, VD, and controls, suggesting a stronger pupil response to these drugs in AD than in SD. Pupil movement in response to light became significantly smaller and faster after instillation of the drugs in Alzheimer's disease patients. The above findings may be useful for the early detection of Alzheimer's disease.

High susceptibility to severe infectious complications at reinduction chemotherapy in patients who relapse after stem cell transplantation

Patients who relapse after stem cell transplantation (SCT) usually appear to be liable to severe infectious complications at reinduction chemotherapy compared to patients at the first induction therapy, though this is not statistically substantiated. The aim of this study was to analyze episodes of infectious complications during reinduction chemotherapy among patients who relapsed after SCT compared with those at the first induction chemotherapy. Between February 1988 and March 2004, 145 children received SCT, and 17 (12 with hematologic malignancies and 5 with solid tumors) were enrolled as eligible subjects for this study. Positive blood cultures (sepsis) were present in six patients exclusively at the reinduction therapy but none at the first induction (P = .009). Three of the six patients progressed to septic shock. Moreover, all patients positive for blood cultures were those with hematologic malignancy (P = .007), and every patient with septic shock had received allogenic transplantation. Our results showed that reinduction chemotherapy needs attention for severe infectious complications, particularly among patients with hematologic malignancies receiving allogenic transplantations. Possible immaturity of the reconstructed systemic immune system and/or insufficient recovery of mucosal protective functions in the patients after SCT are discussed in view of their high susceptibility to severe infectious complications.

The syndrome of inappropriate secretion of antidiuretic hormone associated with SCT: clinical differences following SCT using cord blood and BM/peripheral blood

Previously, we reported the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) as an underestimated complication associated with SCT. In the present report, we analyzed detailed data on a larger number of patients with SIADH following SCT and found different SIADH clinical features following cord blood SCT (CBSCT) and BMT/PBSCT. The median onset of SIADH following CBSCT and BMT/PBSCT was 19 and 46 days after SCT, respectively, and the median numbers of WBC at the onset of SIADH were 1.0 and 3.1 x 10(9)/l, respectively. Furthermore, severe symptoms such as seizures, somnolence and rigidity of limbs were observed only in patients with CBSCT (8/15 vs 0/10). These differences were statistically significant (P<0.01). Although the precise basis for SIADH following SCT still remains unknown, the different features of SIADH observed following CBSCT and BMT/PBSCT may provide important clues to the disease mechanism following SCT. Additionally, we confirmed our previous results that patients with SIADH showed a higher overall survival and event-free survival rates. However, we first suggested that they had some neurological disorders and that neurological sequelae such as developmental delay and seizures would consequently occur.

Depressed contractile reserve and impaired calcium handling of cardiac myocytes from chronically unloaded hearts are ameliorated with the administration of physiological treatment dose of T3 in rats

AIM

Chronic cardiac unloading causes a time-dependent upregulation of phospholamban (PLB) and depression of myocyte contractility in normal rat hearts. As thyroid hormone is known to decrease PLB expression, we examined whether thyroid hormone restores the depressed contractile performance of myocytes from chronically unloaded hearts.

METHODS

Cardiac unloading was induced by heterotopic heart transplantation in isogenic rats for 5 weeks. Animals were treated with either vehicle or physiological treatment dose of 3,5,3'-triiodo-L-thyronine (T3) that does not cause hyperthyroidism for the last 3 weeks (n=20 each).

RESULTS

In vehicle-treated animals, myocyte relaxation and [Ca2+]i decay were slower in unloaded hearts than in recipient hearts. Myocyte shortening in response to high [Ca2+]o was also depressed with impaired augmentation of peak-systolic [Ca2+]i in unloaded hearts compared with recipient hearts. In vehicle-treated rats, protein levels of PLB were increased by 136% and the phosphorylation level of PLB at Ser16 were decreased by 32% in unloaded hearts compared with recipient hearts. By contrast, in the T3-treated animals, the slower relaxation, delayed [Ca2+]i decay, and depressed contractile reserve in myocytes from unloaded hearts were all returned to normal levels. Furthermore, in the T3-treated animals, there was no difference either in the PLB protein level or in its Ser16-phosphorylation level between unloaded and recipient hearts.

CONCLUSION

These results suggest that the treatment with physiological treatment dose of thyroid hormone rescues the impaired myocyte relaxation and depressed contractile reserve at least partially through the restoration of PLB protein levels and its phosphorylation state in chronically unloaded hearts.

Preproghrelin Leu72Met variant contributes to overweight in middle-aged men of a Japanese large cohort

OBJECTIVE

To investigate whether Leu72Met polymorphism of the preproghrelin gene is associated with overweight/obesity in middle-aged and older Japanese.

DESIGN

Cross-sectional analysis.

SUBJECTS

A total of 2238 community-dwelling middle-aged and older Japanese people (age: 40-79 years) who participated in the first wave of examinations in the National Institute for Longevity Sciences - Longitudinal Study of Aging from April 1998 to March 2000.

MEASUREMENTS

The Leu72Met polymorphism of prepoghrelin gene, anthropometric variables including body weight, body mass index (BMI), waist circumference, waist-to-hip ratio and whole-fat mass and biochemical variables including serum lipid levels, fasting plasma glucose, insulin and homeostasis model assessment for insulin resistance.

RESULTS

The frequencies of the Leu72Leu, Leu72Met and Met72Met alleles were 63.4, 32.7 and 4.0%, respectively. No differences in the genotype distributions of the Leu72Met polymorphism were found between genders or age groups, and no significant associations were observed between polymorphism and anthropometric variables in women and older men. However, middle-aged men who were 72Met allele carriers showed a higher body weight change from body weight at 18 years of age, as well as a higher waist circumference and a tendency to a higher waist-hip-ratio than noncarriers. Although there were no significant differences in the genotype distribution according to BMI in women and older men, a significantly higher frequency of the 72Met allele was found in the higher BMI group (BMI> or =25 kg/m(2)) of middle-aged men than in the normal-weight group. No significant associations were observed between polymorphism and serum lipid, glucose or insulin levels.

CONCLUSIONS

These results suggest that the 72Met allele of the preproghrelin gene is a contributing factor for midlife weight change in men.

Significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome

Although eosinophilia after stem cell transplantation (SCT) has been addressed in recent reports, the significance of eosinophilia in disease outcome after SCT has not been well studied. In this study, we investigate the frequency of eosinophilia after SCT to determine its prognostic value. The subjects were 113 patients with malignant or nonmalignant diseases who underwent SCT treatment. In these patients, eosinophilia was detected in 44 cases (38.9%), on average 67.5 days after transplantation, and the mean maximum absolute eosinophil count was 840.5 x 10(6)/l. To study the basis of eosinophilia after SCT, various serum cytokine levels during SCT in patients both with and without eosinophilia were analyzed. Statistical analysis indicated that the overall patient survival rates improved in those with eosinophilia compared to those without eosinophilia (88.7 vs 43.0%, P=0.0034). In particular, in patients with malignant diseases, those with eosinophilia showed a higher event-free survival (81.1 vs 44.6%, P=0.0025) and a lower relapse rate (16.0 vs 43.0%, P=0.0287) than those without eosinophilia. In conclusion, we propose that eosinophilia after SCT could be a useful prognostic marker for determining favorable outcomes in patients with malignant diseases. The reasons for this good prognosis in SCT patients with eosinophilia are discussed.

NADPH oxidase inhibitor, apocynin, restores the impaired endothelial-dependent and -independent responses and scavenges superoxide anion in rats with type 2 diabetes complicated by NO dysfunction

OBJECTIVE

We investigated the effect of apocynin, an NADPH oxidase inhibitor, in the impairment of vascular responses in Otsuka Long-Evans Tokushima Fatty (OLETF) rats (type 2 diabetic rat model) with or without (w/wo) N-nitro-l-arginine methyl ester treatment.

METHODS

Male OLETF and littermate Long-Evans Tokushima Otsuka (LETO) (28 weeks old) rats were separated as follows: LETO w/wo apocynin (Gp C, Gp C-apo), OLETF w/wo apocynin (Gp DM, Gp DM-apo) and OLETF plus l-nitro arginine acetate ester w/wo apocynin (Gp DMLN, Gp DMLN-apo). Five days after, peritoneal macrophages were stimulated with thioglycolate. Two days after, they were evaluated.

RESULTS

Plasma glucose and lipid levels remained unchanged. Acetylcholine-induced nitric oxide-dependent (NO-dependent) relaxation and nitroglycerin-induced NO-independent relaxation were improved in the Gp DMLN-apo, compared with that in Gp DMLN. Tone-related basal NO release and plasma NO(2) (-) and NO(3) (-) tended to be lower in Gp DM and Gp DMLN groups. The increased amount of superoxide anion released from macrophages in Gp DM and Gp DMLN was restored by apocynin. Intimal thickening was observed in aortae of Gp DM and Gp DMLN animals; however, there was little in aortae of Gp DM-apo and Gp DMLN(-) apo rats. Increased tumour necrosis factor-alpha (TNF-alpha) in the Gp DM and Gp DMLN was also restored by apocynin treatment.

CONCLUSION

Apocynin restores the impairment of endothelial and non-endothelial function in diabetic angiopathy in OLETF without changing plasma glucose and lipid levels. NO and O(2) (-) may play a role in this process by decreasing TNF-alpha levels.

Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion complicating stem cell transplantation

Hyponatremia is a common electrolyte disorder in hospitalized patients. Although there are a few case reports of hyponatremia following stem cell transplantation (SCT), no reports concerning the incidence are currently available. We describe the occurrence of hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) following SCT. In a single center analysis of 140 patients, hyponatremia and SIADH were observed in 40 and 11.4% of patients, respectively, following SCT. Risk factors for SIADH included young age, transplantation from an HLA-mismatched or unrelated donor, cord blood transplantation, and graft-versus-host disease prophylaxis with methyl prednisolone. Multivariate analysis revealed that transplantation from an HLA-mismatched donor and performance of SCT in a child below 4 years of age were risk factors for SIADH. For patients who underwent SCT from an HLA-mismatched or unrelated donor, those with SIADH showed a significantly higher overall survival rate (90.9 vs 40.2%) and event-free survival rate (77.8 vs 33.8%) compared to those without SIADH. Overall, our data show that hyponatremia and SIADH are relatively common complications following SCT, especially in children below 4 years of age and after SCT from an HLA-mismatched donor.

Metformin Ameliorates Treatment of Obese Type 2 Diabetic Patients with Mental Retardation; its Effects on Eating Behavior and Serum Leptin Levels

The metabolic effects of a biguanide, metformin, on glycemic control and eating behavior were investigated in 16 type 2 diabetic subjects with mental retardation who were habitual overeaters and had difficulty in controlling their appetites. The subjects (n = 16) received metformin (750 mg/day) for 6 months and body weight, body mass index (BMI) were measured monthly. They had repetitive metabolic and hormonal studies. Their eating behavior was analyzed by questionnaires given by their guardians before and after treatment. Metformin treatment significantly reduced their body weights (p < 0.01), body mass index (BMI) (p < 0.01), the levels of HbA1c (p < 0.001), fasting blood glucose (FBG) (p < 0.05), serum insulin (p < 0.05), C-peptide (p < 0.01), triglyceride (p < 0.01), and total cholesterol (p < 0.05). Insulin resistance index (FBG (mg/dl) x serum insulin levels ( micro U/ml) x 1/405) was significantly reduced after 1-month treatment. The serum leptin levels were significantly decreased after 4 month's treatment and thereafter (p < 0.05). Analysis of the questionnaires before and after treatment showed that the daily intake of regular and additional foods significantly decreased after treatment (p < 0.01 and p < 0.001, respectively) with improvements of eating behavior. We conclude that metformin may have beneficial effects not only to control glycemia but also to correct eating behavior in obese type 2 diabetic patients with the difficulty in controlling their appetites. The improvement was related to the reduction of insulin resistance and serum leptin levels.

Smell identification test as an indicator for cognitive impairment in Alzheimer's disease

OBJECTIVES

The aim of the present study was to assess olfactory dysfunction in patients with Alzheimer's disease (AD) and to compare utility of the olfactory tests as possible clinical markers.

METHODS

Two olfactory identification tests (The Cross-Cultural Smell Identification Test [CC-SIT] and the Picture-based Smell Identification Test [P-SIT]) and the Mini Mental State Examination (MMSE) were administered to patients with AD and age-matched controls. Apolipoprotein E (Apo E) genotypes of patients with AD were identified.

RESULTS

Patients with AD had significantly lower olfactory identification scores than age-matched non-demented elderly subjects in both olfactory assessments. In the AD group, the coefficient of correlation between the MMSE scores and the P-SIT scores was higher than that between the MMSE scores and the CC-SIT scores. Receiver operating curve (ROC) analyses for both tests indicated that the P-SIT discriminated AD patients from controls more reliably than did the CC-SIT. Within AD patients, those who were carrying one or two ApoE epsilon4 alleles had a higher coefficient of correlation between the MMSE scores and the P-SIT scores than patients without the ApoE epsilon4 allele.

CONCLUSIONS

The results suggest that a short and simple non-lexical olfactory identification test can be useful as a clinical marker of AD appropriate for Japanese elderly population.

Frosted branch angiitis: a review

The purpose of this study is to present the first report of a case of primary frosted branch angiitis from the UK and to review the characteristics of this rare disease. Primary frosted branch angiitis causes characteristic florid translucent retinal perivascular sheathing of both arterioles and venules in association with variable uveitis, retinal oedema and visual loss, normally with good recovery. A total of 57 cases have been reported in the world literature. Atypical, typically focal frosted branch angiitis may also occur secondary to other causes of intraocular inflammation, especially cytomegalovirus retinitis. Primary frosted branch angiitis has a characteristic presentation but a variable course, typically affecting children or young adults. The disease is likely to represent a common immune pathway in response to multiple infective agents. The optimal treatment is unclear.

[Spinal cord protection during most or all of descending thoracic or thoracoabdominal aneurysm repair]

OBJECTIVES

The purpose of this study is to evaluate usefulness of perfusion cooling for regional spinal cord hypothermia during most or all of thoracic or thoracoabdominal aneurysm repair.

METHODS

From 1987 to 2003, 103 patients underwent most or all of thoracic or thoracoabdominal aneurysm repair. Forty-eight patients underwent operation using distal aortic perfusion, mild hypothermia and segment sequential repair (group MH). Fifty-five patients underwent the same operation as group MH except epidural perfusion cooling and drainage of cerebrospinal fluid (CSF) [group EC & CSFD]. The aorta was replaced sequentially in segment and several paris of intercostal and lumbar arteries were reconstructed in 2 groups.

RESULTS

Cardiopulmonary bypass time of group MH and group EC & CSFD was averaged 235 and 241 minutes, respectively. The lowest CSF temperature in group EC & CSFD was averaged 24.7 degrees C, and the difference between nasopharyngeal and CSF temperature was averaged 6.4 degrees C. The rate of spinal cord injury of group MH and EC & CSFD was 10.4% and 3.6%, respectively. Hospital mortality of group MH and EC & CSFD was 8.3% and 5.5%, respectively. The incidence of spinal cord injury and hospital mortality of group EC & CSFD were decreased compared to them of group MH.

CONCLUSION

We conclude that the perfusion cooling of epidural space and CSF drainage are effective method in reducing postoperative spinal cord injury.

Longitudinal follow-up study of adenoviral vector-mediated gene transfer of dopamine d2 receptors in the striatum in young, middle-aged, and aged rats: a positron emission tomography study

Overexpression of dopamine D(2) receptors by adenoviral vector-mediated gene transfer in the rat striatum was evaluated by positron emission tomography in vivo and by ex vivo autoradiography in 5-, 13-, and 24-month-old Fischer 344 rats. Each rat had hemilateral gene transfer of D(2) receptors mediated by adenoviral vectors (AdCMV.DopD(2)R) in the striatum with contralateral striatal injection of control vectors (AdCMV.LacZ). At day 2 or 3 after vector injection positron emission tomography or ex vivo autoradiography was performed. The binding potential of a radiolabeled D(2) receptors ligand, [11C]raclopride, was significantly higher in the D(2) receptors gene-transferred striatum than the control side in each age group at a similar degree. The binding potential in the AdCMV.DopD(2)R-injected striatum of 24-month-old rats was similar to that in the AdCMV.LacZ-injected striatum of 5-month-old rats (0.99+/-0.14 versus 0.91+/-0.08). A significant age-associated decrease of the binding potential of [11C]raclopride was found in the control vector-injected side, and a significant increase of the binding potential in the adenoviral vector-injected side in all three age groups, suggesting no aging effect on the overexpression of D(2) receptors. A group of rats underwent follow-up assessment by positron emission tomography. The overexpression of D(2) receptors decreased with time in all three groups; however, the decrease rate of the D(2) receptors expression was significantly smaller in the 24-month-old group than in the 5-month-old group. We confirmed that the adenoviral vector-mediated gene transfer of D(2) receptors compensated the decreased density of striatal D(2) receptors in the 24-month-old rats up to the level in the control striatum of 5-month-old rats, and the decrease rate of the overexpression was significantly smaller in aged rats.

Physicians's reports on the impact of living wills at the end of life in Japan

CONTEXT

A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan.

OBJECTIVES

To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died.

DESIGN

Self administered survey and qualitative study using open question and content analysis.

SETTING

Japan.

PARTICIPANTS

Physicians known to have cared for a patient who had presented a living will prior to death.

MEASUREMENTS

The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills.

MAIN RESULTS

Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective.

CONCLUSIONS

Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.

Deficiency of the cysteine protease cathepsin S impairs microvessel growth

During angiogenesis, microvascular endothelial cells (ECs) secrete proteinases that permit penetration of the vascular basement membrane as well as the interstitial extracellular matrix. This study tested the hypothesis that cathepsin S (Cat S) contributes to angiogenesis. Treatment of cultured ECs with inflammatory cytokines or angiogenic factors stimulated the expression of Cat S, whereas inhibition of Cat S activity reduced microtubule formation by impairing cell invasion. ECs from Cat S-deficient mice showed reduced collagenolytic activity and impaired invasion of collagens type I and IV. Cat S-deficient mice displayed defective microvessel development during wound repair. This abnormal angiogenesis occurred despite normal vascular endothelial growth factor and basic fibroblast growth factor levels, implying an essential role for extracellular matrix degradation by Cat S during microvessel formation. These results demonstrate a novel function of endothelium-derived Cat S in angiogenesis.

Involvement of the entorhinal cortex in the stress response to immobilization, but not to insulin-induced hypoglycaemia

Although the involvement of the limbic system in the neuroendocrine responses to some stressors has been documented, the specific role of the entorhinal cortex has not been elucidated. In this study, we investigated the involvement of the entorhinal cortex in stress responses. Fos immunoreactivity, a widely used marker for neuronal activation, was detected in the entorhinal cortex of rats subjected to immobilization stress, whereas no marked staining was observed in the entorhinal cortex of the control and insulin-induced hypoglycaemia groups. Lesion of the entorhinal cortex produced by ibotenic acid significantly attenuated the adrenocorticotropic hormone (ACTH) release evoked by immobilization; however, no significant change in ACTH release was observed in insulin-induced hypoglycaemia. No significant difference between entorhinal-lesioned rats and control rats was observed in blood glucose concentrations when subjected to either immobilization or to insulin-induced hypoglycaemia. Together, these results indicate that the entorhinal cortex is closely involved in the stress response to immobilization but not to insulin-induced hypoglycaemia.

Rise in plasma leptin levels after stimulation of hypothalamic cholinoceptive neurons by neostigmine in rats

To investigate the role of hypothalamic cholinergic neurons in the regulation of plasma leptin levels, we injected neostigmine, a cholinesterase inhibitor, or vehicle alone into the third cerebral ventricle in free moving male Wistar rats and then measured plasma leptin levels. The administration of neostigmine (5 x 10(-9) or 5 x 10(-8) mol) increased plasma leptin levels 3-6 h after stimulation in a dose-dependent manner, while intravenous injection of neostigmine (5 x 10(-8) mol) had no effect. Atropine (5 x 10(-8) mol) concomitantly injected with neostigmine (5 x 10(-8) mol) prevented neostigmine-induced increase in plasma leptin. The expression of leptin messenger ribonucleic acid (mRNA) in epididymal white adipose tissue was significantly increased at 4 and 6 h after neostigmine injection compared with that before the injection. Plasma levels of corticosterone were significantly increased at 30 min after stimulation with neostigmine and this increase was sustained for 6 h after stimulation. Furthermore, bilateral adrenalectomized rats showed no increase in plasma leptin levels after stimulation. In conclusion, stimulation of hypothalamic cholinoceptive neurons increased plasma leptin levels in rats by increasing leptin production in adipocytes. This increase may be due to an increase in glucocorticoids from the adrenal glands. These results suggest that plasma leptin levels can be regulated by hypothalamic cholinoceptive neurons.

Noninvolvement of hypertriglyceridemia and hyperleptinemia in blood pressure increases induced by dietary lard in rats

We investigated whether hypertriglyceridemia and hyperleptinemia are involved in the development of increases in blood pressure induced by dietary lard. Rats received either chow alone or chow in which 50% of the energy content was from substituted lard. Each group was divided into two groups according to whether the diet included bezafibrate or not. In another series of experiments, rats were fed either chow alone or chow in which 50% of the energy content was from substituted lard, safflower oil, or sucrose. Systolic blood pressure (SBP) was measured every week during each 7-week feeding period. A steady-state plasma glucose method was used to determine insulin sensitivity after lard substitution with or without bezafibrate. After the 7-week feeding period, the plasma levels of glucose, immunoreactive insulin, triglyceride and leptin were measured. In rats fed with a high lard diet, SBP, plasma levels of immunoreactive insulin, triglyceride, leptin and steady-state plasma glucose concentrations significantly increased, compared with levels of these substances in controls. Bezafibrate treatment completely reversed these effects. In rats fed with a high safflower oil or a high sucrose diet, no significant change was seen in SBP and plasma immunoreactive insulin levels. However, the plasma triglyceride levels were increased by dietary lard or sucrose. Moreover, the plasma leptin level was also increased by dietary lard and safflower oil. Neither dietary hypertriglyceridemia nor hyperleptinemia were involved in the development of increases in blood pressure induced by dietary lard.

Outcomes of written living wills in Japan--a survey of the deceased ones' families

A study was recently done to investigate the outcomes of written living wills in Japan, which, unlike the United States, does not legally recognize advance directives. This study collected demographic information and predictors of living will use among families and guardians who used the living will form provided by the Japan Society for Dying with Dignity. According to the results of the study, affliction with cancer and death in a hospital was the best predictor of written living will use. Research on physicians' treatment limitation and withdrawal behaviors in the clinical setting is needed to better understand the actual impact of living wills. Such research can provide better understanding of where boundaries of self-determination are drawn and how to respect autonomy in Japan.

[Aortobronchial fistula after replacement of descending thoracic aorta with ringed graft; report of a case]

A 79-year-old male patient complicated with aortobronchial fistula after replacement of descending thoracic aorta with ringed graft. He underwent replacement of the aortic arch using a four branched vascular graft and open stent grafting to replace the descending thoracic aorta after removing the ringed-graft through median sternotomy. This procedure is useful for patients as the left thoracotomy is risky and the distal anastomotic site of the descending thoracic aorta is too far to anastomose.

Epidural cooling for regional spinal cord hypothermia during most or all of descending thoracic or thoracoabdominal aneurysm repair

PURPOSE

Hypothermia has some protective effect against ischemia of the spinal cord in thoracoabdominal aneurysm repair. Its method is divided into systemic or regional cooling. Several experimental studies of the regional cooling of the spinal cord have been performed, however, clinical reports are few. The purpose of this study is to evaluate the effect and safety of perfusion cooling of the epidural space during thoracic or thoracoabdominal aortic replacement.

METHODS

Between January 1998 to June 2001 37 patients (True aneurysm: 18 patients, type B aortic dissection: 19 patients) underwent thoracic or thoracoabdominal aortic replacement with an aid of epidural perfusion cooling. The age ranged from 23 to 78 years old with a mean age of 61 years old. Separate perfusion of upper and lower body was used in all cases. Temperature was lowered to around a 31 degrees C or 32 degrees C. In cases where proximal cross-clamping was danger, deep hypothermic circulatory arrest was used.

RESULTS

Ten patients underwent most or all of descending thoracic aneurysm repair with no spinal cord injury and hospital death. Number of patients of the Crawford type I, type II, and type III were 14, 8 and 5 patients, respectively. One Crawford type II patients was complicated with postoperative spinal cord injury (2.7%). There was one hospital death (2.7%) in Crawford type III. The mean epidural cooling time was 150 minutes, and mean infusion volume of cold saline was 981 cc. The mean lowest cerebrospinal fluid (CSF) temperature was 24.3 degrees C, and mean temperature differences between nasopharynx and CSF was 6.3 degrees C.

CONCLUSION

Perfusion cooling of the epidural space during most or all of the descending thoracic or thoracoabdominal aneurysm repair was effective in reducing postoperative spinal cord injury and a safe method in clinical situations.

Fluctuations of Emax of the left ventricle: effect of atrial natriuretic polypeptide

Recently the circadian rhythm of fluctuations in heart rate variability (HRV) has gained increasing attention, and the use of appropriate treatment corresponding to the circadian rhythm has become an important issue. However, the question has been raised as to whether the rhythm of fluctuation is only limited to HRV, and if a rhythm is also present in the contraction of the heart. The mathematical technique of electrical circuit simulation of the cardiovascular system was used to observe the Emax rhythm. In this study, the therapeutic effect of various drugs, including atrial natriuretic polypeptide (ANP), was confirmed. The effect of inotropic drugs including ANP on Emax was observed, and the results based on an old and a new method of determining Emax . were examined. Furthermore, the chaos analysis of Emax was also made. The time series of Emax showed an increased complexity due to the administration of ANP. In conclusion, it might be important to consider not only the fluctuation of HRV, but also an analysis of the fluctuation in the contraction of the heart.

Mechanism of the development of gastric ulcer after percutaneous endoscopic gastrostomy

BACKGROUND AND STUDY AIMS

The present study was carried out in order to elucidate the mechanism of the development of gastric ulcer, one of the serious complications of PEG tube placement.

PATIENTS AND METHODS

This retrospective study included 92 patients who underwent gastric endoscopy after PEG tube placement. Gastric ulcers detected at gastroscopy were examined in relation to the length of the protrusion from the PEG tubes intragastric bumper and the use of histamine H 2 -receptor antagonists.

RESULTS

Gastric ulcers were found in nine of the 92 patients, and in all nine the ulcer was found on the posterior wall of the gastric body, where the tip of the PEG tube was attached. Seven of the 21 patients (33.3 %) who had a PEG tube with a long protrusion from the intragastric bumper developed gastric ulcer. By contrast, only two of the 71 patients (2.8 %) who had a PEG tube with a short protrusion developed gastric ulcer. The use of H 2 -blockers had no significant impact on the development of gastric ulcer.

CONCLUSIONS

The occurrence of gastric ulcer after PEG placement was attributable to the shape of the PEG tube within the intragastric space, and not to the use of H 2 -blockers, suggesting that appropriate placement of the PEG tube is an important factor in preventing gastric ulcer.

[Recurrent low output syndrome after the weaning from mechanical circulatory support for postcardiotomy cardiogenic shock]

We reviewed the cases of recurrent low output syndrome (LOS) after the weaning from mechanical circulatory support for postcardiotomy cardiogenic shock. Twelve patients were divide into 2 groups according to whether low output syndrome recurred or not, consisting of a recurrent low output syndrome (+) group [re-LOS (+) group, n = 6] and a recurrent low output syndrome (-) group [re-LOS (-) group, n = 6]. Between 2 groups, there was no statistical difference in preoperative left ventricular ejection fraction (LVEF), aortic closs-clamping time and cardiac index at the weaning from mechanical circulatory support. Only the LVEF at the weaning in the re-LOS (+) group was significantly less than that in the re-LOS (-) group (0.39 +/- 0.08 vs 0.62 +/- 0.19, p < 0.05). All patients in the re-LOS (-) group survived to discharge, while in the re-LOS (+) group, although 3 patients were re-supported by intra-aortic balloon pumping, 4 of 6 patients died of multiple organ failure and 2 survivors were in New York Heart Association class III. The results suggest that the key to survive to discharge after the weaning from mechanical circulatory support is whether the cardiac contraction could recover or not.

[True aneurysm of the ascending aorta and/or aortic arch; determinants of late surgical outcome]

To identify significant predictors of late mortality, multivariate analysis were applied to the clinical outcome of 150 consecutive patients with true aneurysm of the ascending aorta and/or aortic arch operated between January, 1987 and December, 2000. Mean follow-up was 53.0 months with a total of 6,682 patient-months of follow-up. Multivariate analysis revealed that operation date (before December, 1996), presence of preoperative cerebrovascular disease, rupture and postoperative phrenic nerve palsy were independent determinants of late mortality. The overall 5-year and 10-year actuarial survival rates were 66.0% and 48.2%. The 5-year and 10-year event free rate of cardiovascular and/or cerebrovascular death were 88.9% and 71.7%. Preoperative evaluation of the brain, operation prior to aneurysm rupture and phrenic nerve protection during operation is necessary to improve long-term survival rate.

Dietary restriction of choline reduces hippocampal acetylcholine release in rats: in vivo microdialysis study

We fed rats with a diet deficient in choline for 12 weeks and studied how dietary choline deficiency affected their behavior and their ability to release acetylcholine in discrete regions of rat brain using step-through passive avoidance task and in vivo microdialysis. In comparison with the control, rats fed the choline-deficient diet showed poorer retention of nociceptive memory in the passive avoidance task. Average choline level in cerebrospinal fluid in the choline-deficient group was significantly less (33.1%) than that of control rats. In vivo microdialysis showed no difference in the pattern of acetylcholine release enhanced by intraperitoneal administration of scopolamine hydrochloride (2 mg/kg) in the striatum between the two groups, whereas in the hippocampus, the maximum and subsequent increase of acetylcholine from the baseline by scopolamine injection was significantly lower in the choline-deficient group than in the control. From the results of our study, we speculate that long-term dietary restriction of choline can affect extra- and intracellular sources of substrates required for acetylcholine synthesis, and eventually limit the ability to release acetylcholine in the hippocampus. Reduced capacity to release acetylcholine in the hippocampus implies that the mechanism, maintaining acetylcholine synthesis on increased neuronal demand, may vary in discrete regions of the brain in response to dietary manipulation. The vulnerability of the mechanism in the hippocampus to dietary choline restriction is indicated by impaired mnemonic performance we observed.

Cryopreserved aortic homograft replacement in 3 patients with noninfectious inflammatory vascular disease

OBJECTIVE

Although mechanical prosthetic heart valves are most commonly used for aortic valve replacement in patients with aortic regurgitation due to noninfectious inflammatory vascular disease, postoperative perivalvular leakage and/or detachment of the prosthetic valve occurs due to the fragility of the aortic annulus. Aortic root replacement with cryopreserved homografts is reported to be useful in such patients.

METHODS

Three patients having aortic regurgitation associated with severe long standing noninfectious inflammatory vascular disease-2 patients with Takayasu's arteritis and 1 patient with Behçet disease--had the aortic root replacement by a cryopreserved aortic homograft valve and conduit.

RESULTS

All surgery was successful and the postoperative course uneventful. Echocardiography showed neither aortic regurgitation nor graft detachment at 6-39 months after operation.

CONCLUSIONS

Homograft valve and conduit replacement is appropriate in patients with aortic regurgitation associated with noninfectious inflammatory vascular disease, with mid-term results favorable.

Involvement of the bed nucleus of the stria terminalis in hippocampal cholinergic system-mediated activation of the hypothalamo--pituitary--adrenocortical axis in rats

This study was designed to determine the effect of the bed nucleus of the stria terminalis (BNST) in hippocampal cholinergic system-mediated activation of the hypothalamo--pituitary--adrenocortical (HPA) axis in the rat. Neurons in the BNST were lesioned by bilateral injection of the cell-selective neurotoxin, ibotenic acid (1.5 microg/microl of solution per side). Two weeks later, neostigmine was microinjected into the rats' hippocampus. Rats in which ibotenic acid had been injected into the BNST showed attenuated expression of c-Fos in the hypothalamic paraventricular nucleus (PVN) and blunted elevation of plasma adrenocorticotropic hormone (ACTH) after microinjection of neostigmine into the hippocampus compared with rats in which saline had been injected into the BNST. The results of this study indicate that the BNST relays signals of hippocampal cholinergic system-mediated activation of the HPA axis in rats.

Open surgical repair for a perigraft leak after endovascular stent-graft emplacement of descending thoracic aneurysm

Although transluminal stent-graft implantation is less invasive for treating an aneurysm in the thoracic descending aorta, this technique is not always successful. Here, we report two cases of a perigraft leak identified after stent-graft deployment, and complete occlusion of the leak could not be attained by additional stent-graft deployment. Open surgical repair using a stented graft was performed through a median sternotomy without opening the left pleura. This procedure should be considered as one of the less-invasive techniques for treating a perigraft leak after endovascular stent-graft emplacement.