Earliest pulmonary vein potential guided cryoballoon ablation is associated with better clinical outcomes than conventional cryoballoon ablation: a result from two randomized clinical studies

Background

With regards to short-term outcome in atrial fibrillation (AF), the benefit of cryoballoon ablation (CBA) by pressing a balloon against the earliest pulmonary vein (PV) potential site during pulmonary vein isolation, (earliest potential [EP]-guided CBA) has been previously demonstrated.

Objective

The present study aimed to evaluate the long-term outcome of the EP-guided CBA.

Methods

This study included 136 patients from two randomized studies, who underwent CBA for paroxysmal AF for the first time. Patients were randomly assigned to the EP-guided and conventional CBA groups in each study. In the EP-guided CBA group, we pressed a balloon against the EP site when the time to isolation (TTI) after cryoapplication exceeded 60 s and 45 s in the first and second studies, respectively. The patients were followed up for 1 year after procedure. We compared the clinical outcomes between the EP-guided CBA group (68 patients) and the conventional CBA group (68 patients).

Results

No significant differences in baseline characteristics were observed between the two groups. Compared with the conventional CBA group, the EP-guided CBA group had a significantly higher success rate at TTI ≤90 s (98.5% vs. 90.0%, P<0.001); lower touch-up rate and total cryoapplication; and shorter procedure time, and fluoroscopy time. The recurrence at 1-year after ablation was significantly lower in the EP-guided CBA group than in the conventional CBA group (6.0% vs. 19.4%; P=0.019).

Conclusions

The EP-guided CBA approach can facilitate the ablation procedure and achieve low recurrence at 1-year after ablation.

Funding Acknowledgement

Type of funding sources: None. Earliest potential [EP]-guided CBAThe recurrence at 1-year after ablation

Molecular hydrogen stimulates the gene expression of transcriptional coactivator PGC-1α to enhance fatty acid metabolism

We previously reported that molecular hydrogen (H₂) acts as a novel antioxidant to exhibit multiple functions. Moreover, long-term drinking of H₂-water (water infused with H₂) enhanced energy expenditure to improve obesity and diabetes in db/db mice accompanied by the increased expression of fibroblast growth factor 21 (FGF21) by an unknown mechanism. H₂ was ingested by drinking of H₂-water or by oral administration of an H₂-producing material, MgH₂. The comprehensive gene expression profile in the liver of db/db mice was analyzed by DNA microarray. The molecular mechanisms underlying the gene expression profile was investigated using cultured HepG2 cells. Moreover, the effects on lifespan of drinking H₂-water were examined using wild-type mice that were fed a fatty diet. Pathway analyses based on comprehensive gene expression revealed the increased expression of various genes involved in fatty acid and steroid metabolism. As a transcription pathway, the PPARα signaling pathway was identified to upregulate their genes by ingesting H₂. As an early event, the gene expression of PGC-1α was transiently increased, followed by increased expression of FGF21. The expression of PGC-1α might be regulated indirectly through sequential regulation by H₂, 4-hydroxy-2-nonenal, and Akt/FoxO1 signaling, as suggested in cultured cell experiments. In wild-type mice fed the fatty diet, H₂-water improved the level of plasma triglycerides and extended their average of lifespan. H₂ induces expression of the PGC-1α gene, followed by stimulation of the PPARα pathway that regulates FGF21, and the fatty acid and steroid metabolism.

Molecular hydrogen regulates gene expression by modifying the free radical chain reaction-dependent generation of oxidized phospholipid mediators

We previously showed that H₂ acts as a novel antioxidant to protect cells against oxidative stress. Subsequently, numerous studies have indicated the potential applications of H₂ in therapeutic and preventive medicine. Moreover, H₂ regulates various signal transduction pathways and the expression of many genes. However, the primary targets of H₂ in the signal transduction pathways are unknown. Here, we attempted to determine how H₂ regulates gene expression. In a pure chemical system, H₂ gas (approximately 1%, v/v) suppressed the autoxidation of linoleic acid that proceeds by a free radical chain reaction, and pure 1-palmitoyl-2-arachidonyl-sn-glycero-3-phosphocholine (PAPC), one of the major phospholipids, was autoxidized in the presence or absence of H₂. H₂ modified the chemical production of the autoxidized phospholipid species in the cell-free system. Exposure of cultured cells to the H₂-dependently autoxidized phospholipid species reduced Ca²⁺ signal transduction and mediated the expression of various genes as revealed by comprehensive microarray analysis. In the cultured cells, H₂ suppressed free radical chain reaction-dependent peroxidation and recovered the increased cellular Ca²⁺, resulting in the regulation of Ca²⁺-dependent gene expression. Thus, H₂ might regulate gene expression via the Ca²⁺ signal transduction pathway by modifying the free radical-dependent generation of oxidized phospholipid mediators.

Haploinsufficiency of akt1 prolongs the lifespan of mice

There is increasing evidence that nutrient-sensing machinery is critically involved in the regulation of aging. The insulin/insulin-like growth factor-1 signaling pathway is the best-characterized pathway with an influence on longevity in a variety of organisms, ranging from yeast to rodents. Reduced expression of the receptor for this pathway has been reported to prolong the lifespan; however, the underlying mechanisms are largely unknown. Here we show that haploinsufficiency of Akt1 leads to an increase of the lifespan in mice. Akt1^+/– mice had a lower body weight than their littermates with less fat mass and normal glucose metabolism. Ribosomal biogenesis and the mitochondrial DNA content were significantly reduced in these mice, along with a decrease of oxidative stress. Consistent with the results obtained in mice, inhibition of Akt-1 promoted longevity in nematodes (Caenorhabditis elegans), whereas activation of Akt-1 shortened the lifespan. Inhibition of Akt-1 led to a decrease of ribosomal gene expression and the mitochondrial DNA content in both human cells and nematodes. Moreover, deletion of ribosomal gene expression resulted in a decrease of the mitochondrial DNA content and normalized the lifespan shortened by Akt-1 activation in nematodes. These results suggest that an increase of mitochondrial amount and energy expenditure associated with enhanced protein synthesis accelerates both aging and the onset of age-associated diseases.

Taurine ameliorates impaired the mitochondrial function and prevents stroke-like episodes in patients with MELAS

OBJECTIVE

Post-transcriptional taurine modification at the first anticodon ("wobble") nucleotide is deficient in A3243G-mutant mitochondrial (mt) tRNA(Leu(UUR)) of patients with myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). Wobble nucleotide modifications in tRNAs have recently been identified to be important in the accurate and efficient deciphering of codons. We herein examined whether taurine can alleviate mitochondrial dysfunction in patient-derived pathogenic cells and prevent clinical symptoms in MELAS patients.

METHODS AND RESULTS

The addition of taurine to the culture media ameliorated the reduced oxygen consumption, decreased the mitochondrial membrane potential, and increased the oxidative stress in MELAS patient-derived cells. Moreover, high dose oral administration of taurine (0.25 g/kg/day) completely prevented stroke-like episodes in two MELAS patients for more than nine years.

CONCLUSION

Taurine supplementation may be a novel potential treatment option for preventing the stroke-like episodes associated with MELAS.

Involvement of brown adipose tissue in subcutaneous fat necrosis of the newborn

BACKGROUND

Subcutaneous fat necrosis (SCFN) of the newborn is a rare condition that manifests within days after birth. The interscapular region, axillae and shoulders are the most commonly affected sites, corresponding to anatomic sites of brown adipose tissue (BAT) in newborns.

OBJECTIVE

We postulated a specific involvement of BAT in SCFN and searched for brown adipocytes at affected sites.

METHODS

Biopsy specimens were immunostained with antibodies against uncoupling protein 1 (UCP-1) and examined by electron microscopy. We also examined BAT by (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography and computed tomography (PET-CT) scanning.

RESULTS

A few cells in biopsy specimens from two patients bound antibodies against UCP-1, and brown adipocytes were detected at several stages of degeneration. PET-CT scans revealed lower uptake of (18)F-FDG at major sites of SCFN.

CONCLUSION

SCFN and BAT can be found at the same sites, suggesting a pathophysiological connection.

Phase I/II study of irinotecan and UFT for advanced or metastatic colorectal cancer

The aim of this study was to determine the recommended dose of irinotecan in combination with the fixed dose of oral UFT as first-line therapy in patients with advanced or recurrent colorectal cancer, and to evaluate the response rate and overall survival as a phase II study.

PATIENTS AND METHODS

Thirteen patients were recruited into a phase I trial. Four doses of irinotecan ranging from 60 to 150 mg/m2/day were administered intravenously on day 1 and day 16 in combination with UFT given orally from day 2 to day 15. In a phase II study, 53 patients received at least one cycle of this therapy.

RESULTS

The recommended dose of this combination was determined as irinotecan 120 mg/m2/day and UFT 400 mg/m2/day. Dose-limiting toxicities were neutropenia and prolonged leucopenia. On an intent-to-treat analysis, the response rate in the phase II study was 24.5% (95% confidence interval 13.8% to 38.2%). The median overall survival time was 20.3 months (95% confidence interval, 15.0-22.8 months). Out of 20 patients with stable disease, 17 who received more than 4 cycles of the regimen lived longer than the other 3 patients who received fewer than 3 cycles (p = 0.0353). Hematological adverse events were mainly grade 3/4 neutropenia observed in 6 out of 53 patients. Grade 3 non-hematological toxicities, such as diarrhea, anorexia, nausea/vomiting and alopecia were observed in 6 patients.

CONCLUSION

Irinotecan combined with oral UFT was effective and well-tolerated. This regimen may be considered as a first-line therapy for advanced or metastatic colorectal cancer and may result in fairly long survival, even for patients with stable disease.

Induction of osteoclast-like cells derived from the synovial lavage fluids of patients with temporomandibular joint disorders

OBJECTIVE

Although biochemical studies have examined the synovial fluid (SF) of patients with temporomandibular joint (TMJ) disorders (TMDs), the details of the molecular mechanism of bone destruction and remodeling remain unknown. In this study, we induced and characterized osteoclast-like cells from the SF of patients with TMD and investigated the participation of these cells in the pathogenesis of TMD.

METHODS

We collected SF cells from patients with TMD after a pumping procedure, cultured osteoclast-like cells, and examined their characteristics, including osteoclast markers and bone resorption activities. In addition, we obtained fibroblastic cells from the SF of TMD patients by continuous sub-culturing. Using these fibroblastic cells, we examined fibroblast markers using immunocytochemical staining and analyzed the receptor activator of nuclear-factor-kappaB ligand (RANKL) mRNA levels. Detection of soluble form of RANKL (sRANKL) in the SF was measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Osteoclast-like cells were induced from the SF cells of patients with TMD by adding recombinant human (rh) macrophage colony stimulating factor (M-CSF) and either 1,25-dihydroxy vitamin D3 [1,25(OH)2D3] or prostaglandin E2 (PGE2). These multinucleated giant cells were positive for tartrate-resistant acid phosphatase (TRAP) and had the ability to absorb bone. The fibroblastic cells from the SF of TMD patients were positive for fibroblast markers and RANKL mRNA was up-regulated. Detection of sRANKL in SF of patient group was significantly higher than control group.

CONCLUSION

The results suggest that the joint-infiltrating SF cells from TMD patients play important roles in the pathogenesis of these disorders, which is characterized by progressive bone destruction or remodeling.

Complex II inactivation is lethal in the nematode Caenorhabditis elegans

RNA-mediated interference (RNAi) was employed to systematically inactivate the four subunits of complex II in the mitochondrial electron transport chain. Embryonic lethality was the predominant result of inactivating three subunits (ceSDHB, ceSDHC, and ceSDHD) when using the soaking method to inactivate RNA. The feeding method was employed to deliver dsRNA from the fourth subunit (ceSDHA) to wild-type, mev-1 (mutated in ceSDHC of complex II), and gas-1 animals (mutated in a complex I gene). Survival was reduced only in the mev-1 genetic background, and in an oxygen-dependent fashion. Collectively, these data provide further evidence that compromised complex II integrity can result in sensitivity to oxidative stress.

Is the mass screening for neuroblastoma ineffective?

Though a recent study (Schilling et al. 2002) concluded that the mass screening for neuroblastoma targeting children age 12 months was ineffective, we pointed out several serious problems and reestimated its effectiveness using their data. They employed the subjects in the "control area" as controls, not the "non-participants" whose biases are fewer because their area is the same as that of the participants. The incidence of neuroblastoma among the subjects in the "control area" was about 25% smaller than that of the "non-participants". This leads to underestimation of the effectiveness of the mass screening. They combined false negatives with true positives to calculate the incidence of the "screened group". But since many spontaneous regression cases are included in the true positives, this method inflates the incidence of the "screened group", leading to underestimation of the effectiveness of the mass screening. When the false negatives are compared with the non-participants, the incidence of the cases in stage 4 among the latter is about 40% of that of the former, and the mortality is less than two-thirds. The percentage of spontaneous regression cases among the true positives is estimated to be about 40%. These results are better than those of the Japanese screening programs (targeting infants age 6 months), supporting the effectiveness of mass screening for neuroblastoma.

VBP-1 is necessary for morphogenesis in Caenorhabditis elegans

VBP-1 has been isolated as a novel protein binding to the von Hippel-Lindau (VHL) tumor suppressor gene product. The fundamental function of the gene was examined in the nematode, Caenorhabditis elegans (C. elegans). The C. elegans VBP-1 gene was expressed in adults only in the gonads and was also expressed in early stage embryos. Double-stranded RNA interference (RNAi) against VBP-1 resulted in an arrest of embryogenesis at morula stages. This suggests that the VBP-1 product is necessary for morphogenesis.

Contribution of HPLC mass screening for neuroblastoma to a decrease in mortality

The aim of this study is the estimation of the contribution of HPLC mass screening for neuroblastoma to the decrease in deaths due to this disease. The mortality rates of malignant neoplasms of the adrenal glands (ICD 9, 1940; ICD 10, C74; virtually all the cases of these codes are neuroblastoma during childhood) at 1-4 years of age in cohorts born in 1979-1984, 1985-1988, and 1989-1992 in the whole of Japan were calculated, using data obtained from the Ministry of Health and Welfare. The numbers of infants screened by HPLC in the cohorts were estimated through the reports of the Ministry of Health and Welfare and the database of the Japanese Society for Mass-screening. The mortality of the cohort born in 1989-1992, in which 77.8% of the live births were screened by HPLC, was 1.73 per 100,000 live births. This is about half of that (3.26) of the cohort born in 1979-1984, in which few infants were screened. On the assumption that cases of the 1985-1988 and 1989-1992 cohorts died according to the mortality rate of the 1979-1984 cohort, the expected numbers of deaths were estimated; that for the 1985-1988 cohort was 178.51 (of them, that for the infants screened by HPLC was 39.65), and that for the 1989-1992 cohort was 159.78 (of them, that for the infants screened by HPLC was 124.33). The observed numbers of deaths were 145 and 85, respectively. Assuming that non-HPLC methods have no effects and using 2 unknown quantities x (contribution of HPLC) and y (other factors), simultaneous equations (1) 178.51 - 39.65x - 178.51y = 145 and (2) 159.78 - 124.33x - 159.78y = 85 were made. Solving them, x = 0.5041 and y = 0.0757 were obtained. In conclusion HPLC screening targeting infants aged 6 months reduces death of adrenal neuroblastomas at 1-4 years of age by about 50%.

Metachronous triple cancers of the sigmoid colon, stomach, and esophagus: report of a case

We report herein an unusual case of metachronous triple cancers of the sigmoid colon, stomach, and esophagus. A 60-year-old man was initially admitted to our hospital for investigation of occult fecal blood. This was found to be caused by sigmoid colon cancer which was resected in July 1985 (T3, N0, M0; Stage II). A follow-up endoscopy performed in 1990 showed early gastric cancer, and a gastrectomy was performed in August 1990 (Tis, N0, M0; Stage 0). Another endoscopic examination performed as follow-up in 1993 revealed early cancer of the remnant stomach, and all the remnant stomach was surgically resected in March 1993 (Tis, N0, M0; Stage 0). He presented again in December 1996, complaining of discomfort in the chest which was found to be caused by cancer of the middle thoracic esophagus. Although surgery was considered necessary, the patient refused to undergo any further operations. Instead, radiation was administered from January 1997. An endoscopy after the completion of radiotherapy confirmed that the cancer had almost disappeared; however, it started to grow again from the beginning of 1998. He was hospitalized due to esophageal stenosis in April 1998, and died of carcinomatous cachexia in September of the same year.

Benign mediastinal teratoma complicated by cardiac tamponade: report of a case

We present herein the case of a 48-year-old woman with a benign mediastinal teratoma that had been followed up for 3 years, who developed acute cardiac tamponade. The patient had initially undergone an exploratory sternotomy, at which time the tumor was histologically diagnosed as a benign mature teratoma that could not be resected due to its severe, wide adhesion to the surrounding organs. However, following the development of cardiac tamponade, both sternotomy and right intercostal thoracotomy were employed, and the tumor could be excised with cardiopulmonary bypass standby. High levels of amylase and carbohydrate antigen 19-9 were revealed in the pericardiac effusion fluid. The mRNA expression of inflammatory cytokines including interleukin-1 (IL-1), IL-6, and IL-8 in the tumor tissue was also demonstrated by a reverse transcriptase-polymerase chain reaction analysis. This case illustrates the ultimate natural course of benign mediastinal teratoma and emphasizes the importance of early surgical excision, even when this tumor is asymptomatic.

The relationship between homovanillic/vanillylmandelic acid ratios and prognosis in neuroblastoma

A total of 44 cases with neuroblastoma cases (excluding true positive cases detected in mass screenings) who were born from 1979 to 1991, and had data concerning the clinical stage and values of vanillylmandelic acid (VMA) and homovanillic acid (HVA) at diagnosis (microg/mg creatinine) were followed up until the end of 1994. Deaths were confirmed using the record of vital statistics of the Hokkaido Government. The 60-month survival rate of those who had an HVA/VMA ratio of 1-2 was 80.0%. Conversely, those with ratios <1 or >2 had respective survival rates of 24.1% and 5.3%. Most of those with a ratio >2 died within 24 months of diagnosis. Many of the cases with a ratio <1 lived over 12 months but died within about 36 months. Many tumors of those cases with a ratio of 1-2 originated in extra-adrenal glands, and had negative n-myc amplification. Most of the patients with a ratio >2 were diagnosed at 1 year of age or older. The HVA/VMA ratio at diagnosis is useful in estimating both the survival period and the prognosis.

Total excision of mesenteric cysts by laparoscopic surgery: report of two cases

Mesenteric cysts are relatively rare tumors, and most patients present nonspecific abdominal symptoms until developing larger cysts. We report two cases of mesenteric cysts that were totally excised during laparoscopic surgery. The cysts of both patients were located in the mesenterium of the cecum or ascending colon. Under laparoscopy, the cyst was punctured to collect the cystic fluid for cytology and then completely removed without bowel resection. Histological examination revealed cystic lymphangiomas with endothelial cell lining. The postoperative course was uneventful. Laparoscopic treatment of benign abdominal cysts is an alternative safe and less invasive operation.

Deconjugation of bilirubin accelerates coprecipitation of cholesterol, fatty acids, and mucin in human bile--in vitro study

To examine the initial step of brown pigment gallstone formation, sterile human gallbladder bile samples were incubated with or without beta-glucuronidase in vitro. Enhanced bilirubin deconjugation achieved by adding beta-glucuronidase significantly accelerated the formation of a precipitate that contained bilirubin (28.2 +/- 3.8% of dry weight), cholesterol (14.3 +/- 5.2%), free fatty acids (12.0 +/- 1.3%), and glycoprotein (10.0 +/- 6.7%). Both the composition and scanning electron microscopic appearance of the precipitate were similar to these features in brown pigment gallstones. The cholesterol saturation index and nucleation time in the supernatant did not change with various incubation periods. The weight ratios of bilirubin to cholesterol in the precipitates correlated with those in bile (r = 0.76; P = 0.017). Gel chromatography of the precipitate showed high molecular weight glycoprotein to be the major constituent. Bilirubin, cholesterol, fatty acids, and mucin were found to coprecipitate in accordance with bilirubin deconjugation, which process may play an important role in an early stage of the formation of brown pigment gallstones.

Gallbladder carcinoma in the era of laparoscopic cholecystectomy

OBJECTIVE

To assess the usefulness of laparoscopic cholecystectomy for unsuspected and suspected gallbladder carcinoma.

DESIGN

Retrospective review with a mean follow-up of 27 months, ranging from 1 to 47 months.

SETTING

University hospital and 8 affiliated hospitals.

PATIENTS

Of 2616 laparoscopic cholecystectomies performed over 4 years, 24 gallbladder carcinomas were treated by laparoscopic cholecystectomy and retrospectively reviewed.

RESULTS

The clinical course depended on the histopathologic depth of invasion of gallbladder carcinoma. All 6 cases of pathologic tumor (pT) stage in situ (pTis) gallbladder carcinoma and 2 cases of pT1 gallbladder carcinoma showed no invasion to the lymphatic, venous, or perineural spaces, and these 8 patients were all doing well from 2 to 19 months (mean, 11 months) after laparoscopic cholecystectomy. Sixteen cases of pT2 or pT3 gallbladder carcinoma invaded the subserosal layer or the liver, and 5 of the 16 patients were dead of liver dysfunction, abdominal wound recurrence, or liver metastasis 5 days and 7, 12, 15, and 18 months after operation, although additional resection of the liver bed with lymph node dissection was performed after laparoscopic cholecystectomy in 4 of these 5 patients. Abdominal wall recurrence in the absence of distant metastasis was present in 3 (19%) of the 16 patients with pT2 or pT3 gallbladder carcinoma due to inoculation of cancer cells in the abdominal stab wounds where the gallbladder or laparoscope was removed.

CONCLUSIONS

Gallbladder carcinoma at the pTis or pT1 stage removed laparoscopically needs no other treatment. We recommend that the gallbladder be removed by vinyl bag and port sites be excised or washed with normal saline to prevent port site recurrence in patients with laparoscopic cholecystectomy for pT2 or pT3 carcinoma.

Multiseptate gallbladder: biliary manometry and scintigraphy

A 30-year-old man with multiseptate gallbladder, a very rare congenital anomaly, is presented. His presenting symptom was epigastric pain. A hypoplastic gallbladder with multiple septa was demonstrated by ultrasonography and endoscopic retrograde cholangiography. An injection of cerulein reproduced pain, and simultaneous biliary manometry and scintigraphy showed impairment of gallbladder filling and emptying. Laparoscopic cholecystectomy resulted in complete relief of the pain. Biliary manometry and scintigraphy are useful to determine the operative indication in a symptomatic patient with this entity.

Laparoscopic adrenalectomy: review of 14 cases and comparison with open adrenalectomy

We reviewed 14 cases of laparoscopic adrenalectomy and compared the results with those of a recent series of 15 consecutive patients undergoing a traditional open adrenalectomy for a benign tumor. The laparoscopic adrenalectomy group included nine patients with primary aldosteronism, three with Cushing's syndrome, one with pheochromocytoma, and one with a nonfunctioning incidentaloma. In the patient with pheochromocytoma, a good operative field was safely obtained by a combination of pneumoperitoneum at less than 6 mm Hg insufflation pressure and the abdominal wall-lift method. In both groups, the tumors were removed successfully in all cases. Laparoscopic adrenalectomy, which required neither a large skin and muscle incision nor any resection of the ribs, offered a lower morbidity and earlier recovery in spite of the longer operation time. The most important complication observed in laparoscopic adrenalectomy was that of pneumothorax secondary to an injury of the diaphragm and pleura during the dissection of the left adrenal gland using electrocautery. However, the injury wound was small, and the pneumothorax was resolved by suturing the tear under laparoscopy. These results suggest that laparoscopic adrenalectomy is a minimally invasive alternative to traditional open adrenalectomy and thus has the potential soon to become a standard procedure for the treatment of benign adrenal tumors.

Carcinoma of the ampulla of Vater synchronously associated with early gastric cancer--a report of two cases

We report two cases of carcinoma of the ampulla of Vater synchronously associated with early gastric cancers. The gastric lesions were diagnosed pre-operatively in one patient and at the time of examination of the resected specimen following pancreatoduodenectomy in the other. Specific problems in the diagnosis and management of these multiple primary carcinomas are discussed. Careful evaluation of the stomach prior to the surgical treatment for ampullary carcinoma is recommended.

Regulation of bile acid synthesis in the rat: relationship between hepatic cholesterol 7 alpha-hydroxylase activity and portal bile acids

Bile acid biosynthesis has been believed to be regulated by negative feedback control; however, recent experiments have cast considerable doubts on the concept. The aim of the study was to examine the consensus of the negative feedback regulation of bile acids by clarifying the correlation between the portal bile acids and the rate-limiting enzyme of bile acid biosynthesis, hepatic microsomal cholesterol 7 alpha-hydroxylase. We measured the enzyme activity and the portal bile acids in male Wistar rats that were orally administered three different bile acids or cholestyramine for 2 weeks. The serum level of 7 alpha-hydroxycholesterol was also determined to verify whether it would be a parameter of bile acid synthesis rate in the rat. The activity of cholesterol 7 alpha-hydroxylase increased about threefold in rats treated with cholestyramine when compared with controls. On the other hand, in rats fed ursodeoxycholic, chenodeoxycholic, and deoxycholic acids, the enzyme activities decreased to 40%, 26%, and 28%, respectively. Treatment with cholestyramine had no significant effect on the portal bile acid concentration. Administration of ursodeoxycholic and chenodeoxycholic acids resulted in a significant increase in the concentration of portal bile acids, whereas deoxycholic acid feeding did not significantly affect it. In the control group, conjugated cholic acid constituted a major part of the portal bile acids while the administered bile acid and its metabolites became predominant in each bile acid feeding group. Treatment with ursodeoxycholic acid made the portal bile acids more hydrophilic, but, by contrast, administration of chenodeoxycholic, deoxycholic acids, and cholestyramine made the portal bile acids more hydrophobic.(ABSTRACT TRUNCATED AT 250 WORDS)

Video-assisted thoracoscopic resection of a mediastinal cyst: report of a case

Video-assisted endoscopic surgery has recently been expanding its potential, which is shown by our report herein describing the case of a 23-year-old woman for whom successful thoracoscopic resection of a mediastinal cystic lesion was carried out. The patient's postoperative course was uneventful with minimal pain and a prompt recovery. Histological examination confirmed that the lesion was a benign cystic teratoma. We believe that video-assisted thoracoscopic surgery will become the standard procedure for most mediastinal cystic lesions in the future.

Conditions for solid-phase extraction of urinary bile acids with octadecylsilane-bonded silica

Fast atom bombardment mass spectrometry was used as a detection method in a study of the extraction of urinary bile acids with octadecylsilane-bonded silica. The procedure commonly used in many laboratories was found to result in significant losses of sulfated taurine-conjugated bile acids. Losses of other double conjugates and of bile acid and bile alcohol glucuronides were also seen. The losses were avoided by addition of an equal volume of 0.5 M triethylamine sulfate to the urine before passing it through the sorbent bed. Quantitative elution was then achieved with methanol. Batch variations were observed with sorbents from two different manufacturers.

Effect of biliary drainage on serum 7 alpha-hydroxycholesterol level in patients with obstructive jaundice

Percutaneous transhepatic biliary drainage was performed in 15 patients with obstructive jaundice and the serum 7 alpha-hydroxycholesterol level was monitored for 2 weeks by capillary gas-liquid chromatography-mass spectrometry. Before biliary drainage, the serum 7 alpha-hydroxycholesterol level was 130 +/- 52 pmole/ml, which was significantly lower than the normal value (238 +/- 100 pmole/ml). After biliary drainage, the serum 7 alpha-hydroxycholesterol level was decreased to 117 +/- 48 pmole/ml on the first day. There were two groups of patients as classified by the behavior of the serum 7 alpha-hydroxycholesterol level after the third day. In one group of patients (responders), the serum level increased significantly up to 525 +/- 83 pmole/ml at the end of the 2 weeks. In another group (nonresponders), the serum level did not increase and remained 145 +/- 86 pmole/ml. The serum bilirubin level tended to improve faster in the responders (decline index = -0.234 +/- 0.152) than in the nonresponders (decline index = -0.057 +/- 0.067; P < 0.05) and a statistically significant correlation was found between the decline index and the total 7 alpha-hydroxycholesterol level on Days 7 or 14. As the serum 7 alpha-hydroxycholesterol level is considered to reflect hepatic bile acid synthesis, which is one of the important functions of the liver, we conclude that the increased serum 7 alpha-hydroxycholesterol level after biliary drainage in the responders indicates recovered liver function and that the low serum level in the nonresponders suggests more severe hepatocellular damage in patients with obstructive jaundice.

Serum 7 alpha-hydroxycholesterol reflects hepatic bile acid synthesis in patients with obstructive jaundice after external biliary drainage

To examine the hypothesis that serum levels of 7 alpha-hydroxycholesterol reflect bile acid synthesis in the liver, we analyzed serum 7 alpha-hydroxycholesterol and bile acid output in 13 patients with obstructive jaundice after relief of biliary obstruction. Before biliary drainage, the serum level of 7 alpha-hydroxycholesterol was 92 +/- 12 pmol/ml (mean +/- S.E.M.) and was significantly lower than the control value (226 +/- 26 pmol/ml, p < 0.01). After biliary drainage, serum 7 alpha-hydroxycholesterol level and biliary bile acid outputs began to rise in some patients, indicating reversible liver dysfunction. In other patients, serum 7 alpha-hydroxycholesterol levels and bile acid outputs did not increase, suggesting severe or irreversible liver dysfunction. On and after the third day of biliary decompression, serum 7 alpha-hydroxycholesterol levels correlated well with bile acid excretion (p < 0.01, r = 0.93). Other liver function parameters, such as serum bilirubin, serum bile acids, albumin, and bile flow, also revealed significant correlation with serum 7 alpha-hydroxycholesterol levels. We conclude that the serum 7 alpha-hydroxycholesterol level clearly reflects bile acid synthesis in the liver and that it may serve as a useful parameter for the assessment of hepatic functional recovery in patients with obstructive jaundice after biliary drainage.

Effects of pravastatin and ursodeoxycholic acid on cholesterol and bile acid metabolism in patients with cholesterol gallstones

To investigate the effects of pravastatin and ursodeoxycholic acid (UDCA) on cholesterol and bile acid metabolism in humans, 41 patients with cholesterol gallstone disease were allocated to four groups and treated with pravastatin (20 mg/day), UDCA (600 mg/day), both pravastatin and UDCA, or neither drug (control) for 1-2 weeks prior to elective cholecystectomy. Cholesterol 7 alpha-hydroxylase activity and serum levels of total 7 alpha-hydroxycholesterol were significantly increased by pravastatin and unaffected by UDCA. 3-Hydroxy-3-methylglutaryl coenzyme A reductase activity was markedly increased by pravastatin and decreased by UDCA. UDCA significantly decreased biliary cholesterol concentration and the cholesterol saturation index and prolonged the nucleation time; however, pravastatin alone had little effect on biliary lithogenicity. Serum total and low-density lipoprotein (LDL)-cholesterol levels were reduced most by the combined administration of pravastatin and UDCA. In conclusion, at a dose of 20 mg/day, pravastatin increased bile acid synthesis but did not decrease biliary lithogenicity. UDCA had no significant effect on bile acid synthesis, but markedly decreased biliary lithogenicity.

Laparoscopic adrenalectomy: comparison with open adrenalectomy

The results of the first 6 cases of laparoscopic adrenalectomy were compared with the most recent 11 consecutive cases of traditional open adrenalectomy for the treatment of benign adrenal tumor. In both groups, all the tumors were less than 4 cm in diameter and were removed successfully with no significant complications. The weight of the resected specimen and estimated blood loss were not significantly different in the two groups, and none of the patients needed a blood transfusion. Although laparoscopic adrenalectomy required a significantly longer operation time (median 230 min vs. 165 min for an open operation), the postoperative recovery estimated by the duration of restricted oral intake or walking was shorter, and the incidence of patients requiring postoperative parenteral analgesics was also significantly lower in laparoscopic adrenalectomy. Although the number of patients treated with the laparoscopic procedure is still small, these results suggest that laparoscopic adrenalectomy is a minimally invasive alternative to open adrenalectomy and, with further improvement of the operative technique and equipment, may become a more reliable and standard procedure for the treatment of benign adrenal tumor.

Late development of cholangiocarcinoma after the treatment of hepatolithiasis

Although the association of cholangiocarcinoma with intrahepatic calculi (hepatolithiasis) is well recognized, the late development of cholangiocarcinoma after the treatment of hepatolithiasis has not been reported in detail. Of 109 consecutive patients with hepatolithiasis treated during 19 years, eight patients had cholangiocarcinoma, seven of whom had cholangiocarcinoma two to 14 years, with a mean of eight years, after the treatment of hepatolithiasis. Absence of cholangiocarcinoma was confirmed when stones were removed at the time of the initial treatment. The mean age was 56 years, with a female to male ratio of 2:5. At the time of detecting cholangiocarcinoma, three patients had no gallstones and four had gallstones at the corresponding site to the carcinoma. Cystic dilatation of the intrahepatic bile duct was often observed on the direct cholangiogram. The biles were all infected mainly with Escherichia coli and Klebsiella species. Thus, bile stasis and bacteria infection seems to be the important causative factor, causing cholangiocarcinoma rather than the calculi itself. Because the symptoms only mimic those of cholangitis, the possible presence of cholangiocarcinoma should be considered even after the treatment of hepatolithiasis for early detection and curative resection.

Cholesterol crystal appearance time of gallbladder bile in middle-aged women

The aim of our study was to examine the hypothesis that the cholesterol nucleation time of gallbladder bile might be rapid in women in their fourth and fifth decades, which increases their risk of cholesterol gallstones. Fifty-four gallbladder bile samples were collected from gallstone-free patients and patients with cholesterol gallstones in a functioning gallbladder. We examined the relations of nucleation time to age and sex in each group. The nucleation time of gallbladder bile tended to be prolonged with age, but there was no correlation between nucleation time and age in each group. Cholesterol nucleation time was not significantly different between age-matched females and males in each group, nor was it faster in middle-aged females than in older females. Thus, nucleation time was not rapid in middle-aged females even in the gallstone-free group. These results indicate that cholesterol nucleation time is not significantly influenced by either sex or age, and cannot therefore account for the higher frequency of cholesterol gallstone disease in females in the fourth and fifth decades.

Composite glandular-endocrine cell carcinoma of the extrahepatic bile duct: immunohistochemical study

A composite glandular-endocrine cell carcinoma of the extrahepatic bile duct in a 64 yr old Japanese man is reported. A nodular polyp measuring 1.9 x 1.1 cm was located in the confluence of the extrahepatic bile duct. Histologically, the tumor was composed of well differentiated tubular adenocarcinoma and small cell neuroendocrine carcinoma with a transition between the 2 components. The 2 areas of the tumor immunohistochemically revealed a clear-cut difference in functional differentiation. Tumor cells in the glandular component were immunoreactive to both carcinoembryonic antigen (CEA) and CAM 5.2, while those in the small cell area were immunoreactive to neuroendocrine markers such as neuron specific enolase (NSE), chromogranin A and serotonin. These results suggest that the tumor arose from a multipotential stem cell capable of differentiation in 2 directions.

Metabolism of intravenously administered 7 alpha-hydroxycholesterol-3 beta-stearate in the hamster

In order to investigate the metabolic fate of serum esterified 7 alpha-hydroxycholesterol, [4-14C]7 alpha-hydroxycholesterol-3 beta-stearate was synthesized from labeled cholesterol and administered to bile fistula hamsters intravenously. Bile samples were collected at every 20 min for 7 h. Radioactivity was detected in bile 40 min after the beginning of the infusion of the labeled compound and 56.5 +/- 5.7% (48.7-66.0%) of the administered radioactivity was recovered in bile during 7 h. The liver contained appreciable radioactivity (19.5 +/- 7.6% of the administered dose) at the time of sacrifice. Only a trace amount of radioactivity was detected in urine and blood. Cumulative recovery of the radioactivity was 76.3 +/- 8.6% (63.3-90.4%). Major radioactive metabolites in the bile samples were identified to be taurine- and glycine-conjugated cholic acid and chenodeoxycholic acid by radioactive thin-layer chromatographic analysis of the bile samples before and after enzymatic hydrolysis and 3 alpha-hydroxysteroid dehydrogenase treatment. The conversion was nearly complete and we could not detect neutral metabolites, such as the mother compound, free 7 alpha-hydroxycholesterol and bile alcohols, as well as glucuronidated or sulfated bile acids. It is concluded that serum esterified 7 alpha-hydroxycholesterol could be effectively taken up by the liver, hydrolyzed by cholesterol esterase and metabolized via the normal biosynthetic pathway to taurine- or glycine-conjugated primary bile acids to be excreted into bile.

Intraoperative endoscopic electrohydraulic lithotripsy of pancreatic stones

Two male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopic electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas.

Alteration of bile acid metabolism in two-thirds hepatectomized rat

Bile acid metabolism after two-thirds partial hepatectomy (PH) in rat was studied. Bile acid kinetics (i.e. synthesis rate and pool size) were determined by wash out method combined with gas liquid chromatography, and serum bile acids by gas liquid chromatography-mass spectrometry. Serum bile acid concentration was highest on the third day after PH, as the liver regeneration progressed but it gradually decreased with increasing cholic acid (CA)/chenodeoxycholic acid (CDCA), reflecting impaired hepatic uptake of bile acids and/or cholestasis during the early post-hepatectomy period. Predominance of CA in bile acid synthesis, pool, and biliary secretion was also found. On the third day after PH, liver weight recovered to 66% of the control value, but enhancement of bile acid synthesis was not observed. Consequently, pool size remained at 50% of control. On the seventh day, synthesis of bile acid, especially of CA, was enhanced and pool size and liver weight returned to 68 and 72% of the respective control values. Bile acid synthesis was returned to the control value on the fourteenth day with concomitant restoration of liver weight and bile acid pool size. These changes in bile acid kinetics parallel the events during hepatic regeneration after PH.

Profiling of eicosanoids in inflamed gall bladder wall by gas chromatography with selected-ion monitoring

The profiling of eicosanoids, including prostaglandin E2 (PGE2), prostaglandin F2 alpha (PGF2 alpha), 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), thromboxane B2 (TXB2) and leukotriene B4 (LTB4), in dog and human gall bladders was carried out by a combination of an effective and convenient clean-up procedure and gas chromatography with selected-ion monitoring. The clean-up procedure was based on the stepwise elution of their methyl ester derivatives from a silica gel column with n-hexane-ethyl acetate and ethyl acetate-methanol in various ratios. The LTB4 methyl ester was eluted with an n-hexane-ethyl acetate (2:1, v/v) fraction because LTB4 is more lipophilic than the other eicosanoids. The present method permitted the quantitation of trace amounts of eicosanoids, including LTB4, present in tissues in the order of pg/mg of protein, without interference from other endogenous substances. In experimental acalculous cholecystitis produced in dog, the levels of eicosanoids (except LTB4) were significantly changed. Of these eicosanoids, the level of 6-keto-PGF1 alpha was significantly higher in the seromuscular layer and correlated with the observed severe morphological changes. In human chronic cholecystitis with gallstones, the level of 6-keto-PGF1 alpha in the mucosal layer was significantly higher than that in the seromuscular layer. These data suggest that prostaglandin I2 may play an important pathophysiological role in the course of cholecystitis.

Bile acids and bile alcohols in a child with hepatic 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase deficiency: effects of chenodeoxycholic acid treatment

Duodenal bile, urine, plasma, and feces from a child with hepatic 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase deficiency were analyzed by fast atom bombardment mass spectrometry and gas chromatography-mass spectrometry to investigate the formation and excretion of abnormal bile acids and bile alcohols. The biliary bile salts consisted of glycocholic acid (25%) and of sulfated and glycine conjugated di- and trihydroxycholenoic acids (55%), two C27 bile acids, and eleven sulfated bile alcohols (mainly tetrols, 20%), all having 3 beta,7 alpha-dihydroxy-delta 5 or 3 beta,7 alpha,12 alpha-trihydroxy-delta 5 ring structures. In plasma, sulfated cholenoic acids constituted 65% and unconjugated 3 beta,7 alpha-dihydroxy-5-cholestenoic acid 25% of the total level, 71 micrograms/ml. The urinary excretion of the former was 30.4 mg/day and that of unsaturated bile alcohol sulfates, mainly pentols, 7 mg/day. The predominant bile acid in feces was an unconjugated epimer of 3 beta,7 alpha,12 alpha-trihydroxy-5-cholenoic acid, and small amounts of cholic acid were present. The minimum total excretion was 11.3 mg/day. Treatment with chenodeoxycholic acid resulted in marked clinical improvement and normalized liver function tests. Further studies are needed to define the mechanism of action. Plasma bile acids decreased to 1.6 micrograms/ml and urinary excretion to 3.4 mg/day. Chenodeoxycholic and ursodeoxycholic acids became predominant in all samples. The fecal excretion of unsaturated cholenoic acid sulfates increased to 40 mg/day compared to 89 mg/day of saturated bile acids. The results provide further support for a defective hepatic 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase deficiency, and indicate that the 3 beta-hydroxy-delta 5 bile acids are formed via 7 alpha-hydroxycholesterol. The formation of glycocholic acid may be due to an incomplete enzyme defect or to transformation of the 3 beta-hydroxy-delta 5 structure by bacterial and hepatic enzymes during an enterohepatic circulation.

Hepatolithiasis in East Asia: comparison between Japan and China

The incidence of hepatolithiasis is high throughout East Asia compared with the West, but the marked difference in the relative proportion of hepatolithiasis to all cholelithiasis cases exists even among countries of similar ethnic backgrounds. A retrospective study of cases was conducted in two areas in China with the aim of clarifying the presence of such regional difference in China itself. The relative proportion of hepatolithiasis was 21.2% in Shenyang, 9.2% in Beijing and 4.1% in Fukuoka, Japan. A significant difference in the location of stones was also found between Shenyang, Beijing and Fukuoka. Intra- and extrahepatic hepatolithiasis in all hepatolithiasis cases was 95% in Shenyang and 75% in Beijing. Involvement of both hepatic lobes was found in 73% in Shenyang and less than 60% in the other two, suggesting that hepatolithiasis of the old form or of an advanced stage still lingers in Shenyang. In conclusion, regional differences in the proportion and the type of hepatolithiasis exist in China itself, as well as in the Chinese population in Taiwan, Hong Kong and Singapore, as previously reported. The possible contribution of environmental factors to the occurrence of hepatolithiasis is again emphasized.

Treatment of chronic liver disease caused by 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase deficiency with chenodeoxycholic acid

Deficiency of 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase, the second enzyme in the sequence that catalyses the synthesis of bile acids from cholesterol, leads to chronic liver disease in childhood as well as to malabsorption of fat and fat soluble vitamins. A 4 year old boy with this condition has been successfully treated by oral administration of a bile acid--chenodeoxycholic acid. He had been jaundiced since birth, grew poorly because of rickets, and had severe pruritus. Plasma transaminase activities were persistently raised. Chenodeoxycholic acid 125 mg twice daily for two months, and then 125 mg daily, cured his jaundice and pruritus, returned his transaminase activities to normal, and eliminated the need for calcitriol for prevention of rickets. On this treatment he has so far remained well for two years. A diagnosis of 3 beta-hydroxy-delta 5-C27-steroid dehydrogenase deficiency should be considered in any child with unexplained chronic hepatitis or cirrhosis, especially if the liver disease is accompanied by a clinically obvious malabsorption of fat soluble vitamins. A simple colorimetric test of the urine confirms the diagnosis and effective treatment can be started.

Asymptomatic primary sclerosing cholangitis treated with ursodeoxycholic acid

Ursodeoxycholic acid treatment (600 mg/day) was evaluated in a patient with asymptomatic primary sclerosing cholangitis. Serum levels of biliary enzymes decreased to normal ranges within 1 month's treatment and remained normal for 26 months. Serum chenodeoxycholic acid had been replaced by ursodeoxycholic acid, and hepatic copper metabolism, assessed by x-ray probe analysis, improved during the treatment. However, neither biliary tract sclerosis nor portal tract pathology changed with the treatment. These observations suggest that ursodeoxycholic acid protects the liver in primary sclerosing cholangitis by improving the metabolism of bile acid and copper.

Pilot study of recombinant human alpha-interferon for chronic non-A, non-B hepatitis

Recombinant human alpha-interferon was administered to 15 patients with chronic non-A, non-B hepatitis as a part of a pilot study. Patients received injections of 2 million units per day of interferon three times weekly for 16 wk. The treatment schedule was completed in all but one, whose serum aminotransferase levels were continuously elevated during treatment. In seven of the 15 patients, elevated serum aminotransferase levels decreased rapidly during therapy and eventually fell into the normal or nearly normal range. However, once the therapy was stopped, a prompt return of aminotransferase levels to pretreatment values usually was observed. After 3 months of follow-up, aminotransferase activities remained normal in only two patients in whom liver histology showed marked improvement in intralobular degeneration and focal necrosis of hepatocytes. Anti-interferon antibody was detected in four patients at the end of therapy, and decreased 2',5'-oligoadenylate synthetase activity occurred in two patients and in another with relapsed aminotransferase level. Whether alpha-interferon therapy could control the disease activity in patients with chronic non-A, non-B hepatitis deserves further evaluation in a prospective controlled trial.

An outbreak of foodborne hepatitis A in a factory: a possible shift in age of patients in Japan

We investigated extensively an outbreak of hepatitis A at a factory in suburban Nagoya. Epidemiological study indicated a foodborne outbreak by a supplier of lunches. Serologically, all the employees younger than 30 years of age had been susceptible to hepatitis A virus, but the highest morbidity was observed in the 40-44 age group. The age difference in morbidity from foodborne hepatitis and susceptible populations suggests a shift in mean patient age linked to a shift in antibody prevalence to hepatitis A virus. In communities where the prevalence started shifting after development of sanitary systems, effective prophylaxis for foodborne hepatitis A will be necessary to prevent the disease in an increasing number of older patients in a few decades.

Copper-induced hypercholesterolemia of golden hamsters: enhanced synthesis of cholesterol in the liver

Effects of a subtoxic dose of copper on cholesterol metabolism were studied in male golden hamsters. Intraperitoneal injections of cupric acetate increased serum levels of cholesterol and phospholipids without liver damage. This lipidemia was associated with increased cholesterol of the liver. The participation of hemolysis was denied by peripheral red blood cell tests. Hepatic microsomal 3-hydroxy-3-methyl-glutaryl-CoA reductase was also elevated by copper administration. Biliary secretion of cholesterol increased but that of bile acids remained unchanged, suggesting no impaired degradation of cholesterol. We conclude that hepatic synthesis of cholesterol is enhanced by a subtoxic dose of copper, resulting in hypercholesterolemia.

Type of gallstones and deaths from stroke and coronary heart disease among cholecystectomized patients

A total of 841 Japanese patients who had undergone cholecystectomy for choleithiasis (550 for cholesterol stones and 291 for pigment stones) from 1951 to 1970 were investigated on death from stroke, coronary heart disease (CHD) and heart disease other than CHD in relation to the type of gallstones. Compared to patients with pigment stones, those having cholesterol stones had a 50% lower risk of dying from stroke which was statistically significant. The findings support the idea that westernization of Japanese diets may be responsible both for the decline in stroke mortality and for the changing pattern of gallstones in this country. The risk of CHD among cholesterol-stone patients was higher, but not significantly so, than that of pigment-stone patients whereas mortality from heart disease other than CHD did not differ much between the two groups. There were, however, few deaths from these diseases and the findings were therefore not conclusive.