Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring

Objectives

The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring.

Methods

Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring.

Results

All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months.

Conclusions

TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

Adverse Drug Event Profile Associated with Anti-dementia Drugs: Analysis of a Spontaneous Reporting Database

Adverse drug events (ADEs) rates associated with anti-dementia acetylcholinesterase inhibitors are estimated to be 5%-20% and show a wide range of symptoms. No report has examined whether there is a difference in the anti-dementia drugs' ADEs profile. This study aimed to establish whether anti-dementia drugs' ADEs profile differed. Data was based on the Japanese Adverse Drug Event Report (JADER) database. The reporting odds ratios (RORs) was used to analyze data for ADEs from April 2004-October 2021. The target drugs were donepezil, rivastigmine, galantamine, and memantine. The top ten most frequently occurring adverse events were selected. The association between the RORs and antidementia drug ADEs was evaluated, and compared the distribution rate of expression age related to ADEs and each ADEs' timing of onset due to anti-dementia drugs. The primary outcome was RORs. Secondary outcome were expression age and time-to-onset of ADE associated with anti-dementia drugs. A total of 705,294 reports were analyzed. The adverse events incidence differed. Bradycardia, loss of consciousness, falls, and syncope incidence were significantly diverse. The Kaplan-Meier curve results for the cumulative ADEs incidence showed that donepezil had the slowest onset, while galantamine, rivastigmine, and memantine had approximately the same timing of onset.

Emergency transanal total mesorectal excision for perforated rectal cancer: a two-case series

Background

Surgery for perforated rectal cancer is technically difficult because of paralytic dilatation due to generalized fecal peritonitis, the presence of a bulky tumor, and fecal retention due to obstruction. Transanal total mesorectal excision (TaTME) is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. It can provide a good surgical field linearly from the perineal side and reduce manipulations from the intraabdominal side. Here, we present two cases of emergency TaTME performed for perforated rectal cancer.

Case presentation

The patients were a 38-year-old female and a 75-year-old male. They were diagnosed with perforated rectal cancer and were in a state of septic shock. Emergency Hartmann’s procedure was performed in both cases. Intraoperative findings showed fecal contamination of the entire abdomen and dilated intestines and bulky tumors with perforation. The female patient had multiple uterine fibroids, and the male patient had an enlarged prostate. For both patients, dissection of the mesorectum to the anal side of the tumor and transection of the rectum on the anal side of the tumor via a linear stapler were considered difficult because of the insufficient surgical field of view into the pelvis. Therefore, a two-team approach with TaTME was adopted. En bloc resection of the rectum was completed by collaboration of the abdominal team and the transanal team, and the autonomic nerves were successfully preserved. Finally, the specimens were resected, and the anal edge of the rectum was closed with a purse-string suture by the transanal team. Although these two cases were emergency surgeries in difficult situations, the cancer lesions were successfully and safely removed without involvement of the resection margin.

Conclusions

This is the first report of emergency TaTME. Although these cases were emergency operations in a situation where it was difficult to pursue radical resection—and often times in these situations, the operation may end with only stoma creation—the specimens were safely resected. Emergency TaTME is a useful procedure for treatment of perforated rectal cancer.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair

BACKGROUND

In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available.

PURPOSE

The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS.

METHODS

Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant.

RESULTS

We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation.

CONCLUSION

In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Risk of Outlet Obstruction Associated With Defunctioning Loop Ileostomy in Rectal Cancer Surgery

BACKGROUND

The outlet obstruction (OO) rate is 5.4-18.4% after defunctioning ileostomy (DI) following rectal cancer resection to reduce the incidence and severity of anastomotic leakage; OO affects a patient's quality of life and prolongs hospitalization.

PATIENTS AND METHODS

A retrospective analysis was performed of patients who underwent anterior rectal resection and DI for rectal cancer.

RESULTS

Among 100 patients undergoing anterior rectal resection with DI for rectal cancer, 28 (28%) developed OO. Anastomotic leakage and a rectus abdominis muscle thickness ≥10 mm on preoperative computed tomography were significantly associated with the risk of OO in univariate analysis. Multivariate analysis also demonstrated that anastomotic leakage (odds ratio=4.320, 95% confidence interval=1.280-14.60, p=0.019) and rectus abdominis muscle thickness ≥10 mm (odds ratio=3.710, 95% confidence intervaI=1.280-10.70, p=0.016) were significantly risk factors for OO.

CONCLUSION

When OO is observed, an anastomotic leakage should be suspected, especially if there is a high rectus abdominis muscle thickness.

A screening system for identifying interacting proteins using biomolecular fluorescence complementation and transposon gene trap

We have established a new screening system for identifying interacting proteins by combining biomolecular fluorescence complementation (BiFC) and a transposon gene trap system. This system requires creation of a bait strain that stably expresses a fusion product of part of the fluorescent monomeric Kusabira-Green (mKG) protein to a protein of interest. A PiggyBac transposon vector is then introduced into this strain, and a sequence encoding the remainder of mKG is inserted into the genome and fused randomly with endogenous genes. The binding partner can be identified by isolating cells that fluoresce when BiFC occurs. Using this system, we screened for interactors of p65 (also known as RELA), an NF-κB subunit, and isolated a number of mKG-positive clones. 5′- or 3′-RACE to produce cDNAs encoding mKG-fragment fusion genes and subsequent reconstitution assay identified PKM, HSP90AB1, ANXA2, HSPA8, and CACYBP as p65 interactors. All of these, with the exception of CACYBP, are known regulators of NF-κB. Immunoprecipitation assay confirmed endogenously expressed CACYBP and p65 formed a complex. A reporter assay revealed that CACYBP enhanced 3κB reporter activation under TNFα stimulation. This screening system therefore represents a valuable method for identifying interacting factors that have not been identified by other methods.

Sacral neuromodulation for the prevention of a permanent stoma in patients with severe defecation disorder following intersphincteric resection

PURPOSE

Severe defecation disorder occurs frequently in coloanal anastomosis for low rectal cancer, and may affect quality of life. Sacral neuromodulation (SNM) has been reported to be successful after rectal resection, but there are no results for patients treated with intersphincteric resection (ISR).

METHODS

A retrospective single-center study of SNM was performed for patient with defecation disorder following ISR. Pre- and post-treatment bowel frequencies, fecal incontinence episodes, and Wexner, LARS and FIQL scores were assessed to evaluate the efficacy. A good response was defined as ≥ 50% reduction of bowel frequency per day or fecal incontinence episodes per week.

RESULTS

10 patients (7 males, mean age 67.5 years) underwent SNM. All patients had severe fecal incontinence with a median Wexner score of 15 (13-20) and a median LARS score of 41 (36-41). The Wexner score improved after SNM, but not significantly (p = 0.06). LARS and FIQL scores significantly improved after SNM (p = 0.02, p = 0.01). At the end of follow-up, the good response rate was 40%. Three cases without a good response required creation of a permanent stoma.

CONCLUSION

Seven out of 10 patients did not require a permanent colostomy after SNM. SNM should be considered before performing a permanent colostomy.

Low incidence of hepatitis B virus reactivation and subsequent hepatitis in patients with chronic hepatitis C receiving direct-acting antiviral therapy

To determine the clinical characteristics of hepatitis B virus (HBV) reactivation in patients undergoing interferon-free antihepatitis C virus (HCV) therapy, we examined HBV DNA in 25 HBV co-infected patients and 765 patients with resolved HBV infection during and after treatment with direct-acting antiviral agents (DAAs). Among those with HCV genotype 1, asunaprevir plus daclatasvir was administered to 160 patients, sofosbuvir (SOF) plus ledipasvir to 438 patients and paritaprevir plus ombitasvir and ritonavir to 25 patients. In total, 167 patients with genotype 2 were treated with SOF plus ribavirin. Three patients with an HBV DNA level ≥2000 IU/mL were treated with entecavir before anti-HCV therapy, without reactivation of HBV. In 3 of 22 (12%) HBV surface antigen (HBsAg)-positive patients with an HBV DNA level <2000 IU/mL, the viral load increased during treatment. However, hepatitis flare did not occur in these patients. There was no significant difference in clinical history between patients with and without HBV reactivation. Among 765 patients with resolved HBV infection, HBV reactivation occurred in 1 (0.1%) patient after initial resolution, whose HBV DNA level spontaneously decreased after DAA therapy. We compared anti-HBs titres at baseline with those at post-DAA therapy in 123 patients without HBsAg. There was no significant difference in anti-HBs levels between the two points (P = .79). In conclusion, HBV reactivation was rare in HBsAg-negative patients treated with DAA therapy. Additionally, hepatitis did not occur in HBV-reactivated patients with a baseline HBV DNA level <2000 IU/mL before DAA therapy.

Serum Wisteria floribunda agglutinin-positive Mac-2-binding protein for patients with chronic hepatitis B and C: a comparative study

We compared Wisteria floribunda agglutinin-positive Mac-2-binding protein (WFA⁺ -M2BP) levels between patients with chronic hepatitis B (n=249) and chronic hepatitis C (n=386) based on the degree of liver fibrosis. We examined WFA⁺ -M2BP levels in patients with F4 (cirrhosis), F3 or more (advanced fibrosis) and F2 or more (significant fibrosis) in the two groups. We further examined the relationship between five fibrosis markers and the degree of fibrosis. The WFA⁺ -M2BP values ranged from 0.25 cut-off index (COI) to 12.9 COI in patients with hepatitis B and 0.34-20.0 COI in patients with hepatitis C (P<.0001). The median WFA⁺ -M2BP values in F4 in the two groups were 2.83 COI in patients with hepatitis B and 5.03 COI in patients with hepatitis C (P=.0046). The median WFA⁺ -M2BP values in F3 or more in the two groups were 1.79 COI in patients with hepatitis B and 3.79 COI in patients with hepatitis C (P<.0001). The median WFA⁺ -M2BP values in F2 or more in the two groups were 1.49 COI in the hepatitis B cohort and 3.19 COI in the hepatitis C group (P<.0001). Among five liver fibrosis markers, WFA⁺ -M2BP had the highest correlation coefficient (r_s =.629) in terms of correlation with the degree of fibrosis in the patients with hepatitis C and had the second highest r_s value (.415) in the hepatitis B group. Although WFA⁺ -M2BP could be a useful indicator of liver fibrosis, WFA⁺ -M2BP levels in the two groups significantly differed even in the same degree of fibrosis. Individual cut-off values in each aetiology for the degree of fibrosis should be determined.

A rare variant in CYP27A1 and its association with atopic dermatitis with high serum total IgE

This study investigated rare variants associated with atopic dermatitis. We performed exome analyses on 37 patients who were diagnosed with atopic dermatitis by board-certified dermatologists and had total serum IgE levels greater than 1000 IU/ml. The exome analysis identified seven variants with <1% allele frequency in Asian (ASN) population of 1000 Genomes Project phase 1 data and >5% allele frequency in the atopic dermatitis exome samples. We then conducted a replication study using 469 atopic dermatitis patients with total serum IgE ≥1000 IU/ml and 935 Japanese controls to assess the presence of these 7 candidate variants. The replication study confirmed that CYP27A1 rs199691576 (A/G) was associated with atopic dermatitis with high serum IgE levels (P = 0.012, odds ratio = 2.1). CYP27A1 is involved in the metabolism of vitamin D3, which plays important roles in modulating immune function. Previous studies have reported polymorphisms in vitamin D pathway genes that are associated with allergy-related phenotypes. Our data confirm the importance of genes regulating the vitamin D pathway in the development of atopic dermatitis.

Sentinel node navigation surgery for lower rectal cancer

BACKGROUND

Lateral pelvic lymph node metastasis is generally present in 17% of patients with T3 lower rectal cancer. However, such lymph node metastases cannot be accurately detected before surgery. Since 2001, we have performed sentinel node navigation surgery for patients with T3 lower rectal cancer considering the lymph nodes located between the vesicohypogastric fascia and the pelvic nerve plexus as the lateral sentinel lymph node (LSN).

PATIENTS AND METHODS

Between 2001 and 2010, 101 patients with T3 lower rectal cancer without distant metastasis or peritoneal dissemination were prospectively enrolled in the study. Patients with negative lymph nodes in the mesorectum underwent only LSN dissection in the lateral pelvic space. Patients with metastatic lymph nodes detected in the mesorectum underwent lateral pelvic lymph node dissection (LPLD).

RESULTS

Fifty-three out of the 101 patients with pathologically-negative lymph nodes in the mesorectum and a negative LSN were clinically judged as having stage II disease because no recurrence was detected in the lateral pelvic space during the three years following surgery. The other 48 patients underwent LPLD because of a positive lymph node in the mesorectum, and were further divided into two sub-groups, 40 with a negative and 8 with a positive LSN. Only the eight patients with a positive LSN also had positive lymph nodes in the lateral pelvic space.

CONCLUSION

Patients with T3 lower rectal cancer in stage III may not require LPLD. LSN may be very useful to determine stage II disease during surgery.

Umbilical single incisional approach plus one port for partial transverse colectomy: initial operative experience

BACKGROUND/AIMS

Although single incision laparoscopy surgery (SILS) has recently been applied to various kinds of disease, there are few reports on partial transverse colectomy by SILS. We have been performing SILS plus one port procedure, SILS plus One.

SURGICAL PROCEDURE

After placing 3cm incision in the umbilical fossa, a SILS portTM was introduced, and a 5-mm port was inserted in the upper left quadrant of the abdomen, and laparoscopic procedure was started. After the greater omentum was divided, inferior margin of the pancreas was dissected in order to detect the gastrocolic trunk and root of the middle colic artery and vein. After a small mesocolon window was created near the root of middle colic artery, the middle colic artery and vein as well as accessory right colic vein were divided at their root. Both oral and anal margin of the mesocolon were incised by LigaSure™. The surgical specimen was extracted through the umbilical wound and intestinal anastomosis was performed manually using absorbent sutures.

RESULTS

Between 2010 and 2012, six consecutive early transverse colon cancer patients including three male underwent this procedure. The mean operative time was 165.0 (range = 150-180) min, the mean operative blood loss was 7.5 (range = 0-30) ml, the mean hospitalization after surgery was 10.5 (range = 10-12) days, and postoperative complications were not encountered.

CONCLUSION

SILS plus One for partial transverse colectomy is feasible and safe.

Single-incision clipless laparoscopic total colectomy

Although single incision laparoscopy surgery (SILS) has been applied to various kinds of surgical diseases, there have few reports on total colectomy by SILS. A 3-cm incision was placed in the umbilical fossa, through which a SILS port was placed. And this laparoscopic procedure was started as follows: Firstly, the greater omentum was divided. After the division was extended to both splenic and hepatic sides, each flexure of the colon was taken down. A mesocolon window was created below the descending to horizontal portion of the duodenum. The mesocolon including vessels from the left side of the window to the sigmoid colon was incised by LigaSure without clips. After intestinal transection was performed at the upper side of the rectum with a stapler, ileo-rectal anastomosis was performed by the double stapling technique. Between 2010 and 2012, eight consecutive patients underwent this procedure. The mean operative time was 228.1 (range 205-255) min, the mean operative blood loss was 64.0 (range 0-310) mL, the mean hospitalization after surgery was 10.8 (range 10-12) days, and no postoperative complications were encountered. Single incision clipless laparoscopic total colectomy using our original procedure seems to be feasible and safe.

Impact of chemotherapy with S-1 and oxaliplatin (SOX) in combination with molecular-targeting agents on colorectal liver metastases

AIM

The aim of this study was to evaluate the impact of chemotherapy with molecular-targeting agents on liver metastases from colorectal cancer.

PATIENTS AND METHODS

Six patients with synchronous colorectal liver metastases who underwent hepatectomy after chemotherapy with S-1 and oxaliplatin (SOX) between January 2010 and December 2011 at the Department of Surgery, Kashiwa Hospital, the Jikei University School of Medicine were enrolled. Two patients received only SOX as chemotherapy, while the others received SOX in combination with one of the three molecular-targeting agents, bevacizumab, cetuximab, and panitumumab.

RESULTS

In the two patients who received SOX alone, liver metastases completely disappeared at more than six months after starting chemotherapy as shown by computed tomographic (CT) scan. However, malignant cells were diffusely detected by pathological examination at the site of liver metastases, as detected by CT scan before chemotherapy. In the other four patients who received SOX in combination with molecular targets, the size of liver metastases appeared unchanged at three months after limited chemotherapy by CT scan. Pathologically, few malignant cells were detected, only at the borderline of the tumor, while most tumor cells inside the tumor were necrotized and been replaced by fibroconnective tissue.

CONCLUSION

Molecular-targeting agents may induce tumor necrosis rapidly from inside the tumor, which might not be detected by CT scan before surgery.

Feasibility study of oxaliplatin with oral S-1 or capecitabine as first-line therapy for patients with metastases from colorectal cancer

BACKGROUND/AIM

The aim of this study was to determine the feasibility of S-1 plus oxaliplatin (SOX) or capecitabine plus oxaliplatin (XELOX) as first-line therapy for patients with initially unresectable metastases from colorectal cancer.

PATIENTS AND METHODS

Fourteen patients with colorectal cancer who underwent elective colorectal resection between January 2009 and December 2010 at the Department of Surgery, Kashiwa Hospital, the Jikei University School of Medicine, with initially unresectable metastatic lesions were enrolled in this study. After curative resection for the primary colorectal cancer, they underwent adjuvant chemotherapy with SOX or XELOX, starting at one month after surgery.

RESULTS

Seven patients (50%) received SOX, and the others received XELOX as first-line therapy for initially unresectable metastases from colorectal cancer. Four (29%) patients had complete response for liver metastases over six months after chemotherapy, and liver metastases were subsequently judged to be completely resected by surgery. For the other ten patients, the median progression-free survival was 9.1 months and median overall survival was 24.1 months. There were no patients with grade 3 or 4 adverse reactions throughout the entire chemotherapy.

CONCLUSION

Oxaliplatin with oral S-1 or capecitabine as first-line therapy for patients with initially unresectable metastases from colorectal cancer is safe and feasible.

Is greater than 145{degrees} of deep knee flexion under weight-bearing conditions safe after total knee arthroplasty?: a fluoroscopic analysis of Japanese-style deep knee flexion

We investigated the characteristics of patients who achieved Japanese-style deep flexion (seiza-sitting) after total knee replacement (TKR) and measured three-dimensional positioning and the contact positions of the femoral and tibial components. Seiza-sitting was achieved after surgery by 23 patients (29 knees) of a series of 463 TKRs in 341 patients. Pre-operatively most of these patients were capable of seiza-sitting, had a lower body mass index and a favourable attitude towards the Japanese lifestyle (27 of 29 knees). According to two-/three-dimensional image registration analysis in the seiza-sitting position, flexion, varus and internal rotation angles of the tibial component relative to the femoral component had means of 148° (SD 8.0), 1.9° (SD 3.2) and 13.4° (SD 5.9), respectively. Femoral surface contact positions tended to be close to the posterior edge of the tibial polyethylene insert, particularly in the lateral compartment, but only 8.3% (two of 24) of knees showed femoral subluxation over the posterior edge. The mean contact positions of the femoral cam on the tibial post were located 7.8 mm (sd 1.5) proximal to the lowest point of the polyethylene surface and 5.5 mm (SD 0.9) medial to the centre of the post, indicating that the post-cam contact position translated medially during seiza-sitting, but not proximally. Collectively, the seiza-sitting position seems safe against component dislocation, but the risks of posterior edge loading and breakage of the tibial polyethylene post remain.

Normalization of serum p53 antibody levels in patients after curative resection for colorectal cancer

BACKGROUND

The aim of this study was to evaluate the significance of high serum p53 antibody (p53Ab) levels in relation to curative resection of colorectal cancer.

PATIENTS AND METHODS

Between 2007 and 2010, 24 patients with colorectal cancer with higher-than-normal preoperative serum p53Ab, measured by enzyme-linked immunosorbent assay, were enrolled in this study. After curative resection, their serum p53Ab and carcinoembryonic antigen (CEA) levels were measured at one, six, 12, 18, and 24 months after surgery. The relationship between clinicopathological features and the presence of serum p53Ab was evaluated.

RESULTS

None of the patients developed recurrence up to 24 months after the surgery. The positive rate for CEA was 33.3% before surgery, 16.7% at one month after surgery, and 0% at six months and more, while the rate for p53Ab was 75% at six months, 70.8% at 12 months, 58.3% at 18 months, and 54.2% at 24 months after surgery. The positive rate for serum p53Ab at 24 months after the surgery correlated with the one before and that at one month after the surgery.

CONCLUSION

For patients with colorectal cancer and high preoperative serum p53Ab levels, serum p53Ab does not seem to be a useful marker of recurrence after curative resection, since normalization of serum p53Ab levels requires years after surgery.

Anti-interferon-α neutralizing antibody is associated with nonresponse to pegylated interferon-α plus ribavirin in chronic hepatitis C

Pegylated interferon-α (PEG-IFN-α) plus ribavirin (RBV) treatment fails to achieve a sustained virological response (SVR) in approximately 20-50% of patients with chronic hepatitis C virus (HCV) infection. We assessed the contribution of an anti-IFN-α neutralizing antibody (NAb) on the nonresponse to treatment. NAbs were detected using an antiviral assay that assessed the neutralizing effects of serum samples against IFN. Serum samples were obtained at the end of the treatment and evaluated for the presence of NAbs using recombinant IFN-α as a standard. We studied 129 PEG-IFN-α/RBV-treated patients. In the 82 end-of-treatment responders, no NAbs were detected. Of the 47 patients who did not respond, seven (15%) were positive for NAbs. We also examined an additional 83 patients who had not responded to PEG-IFN-α treatment, and detected 12 with NAbs. Patients with good IFN-responsive characteristics, including HCV genotype 2/3 and major allele homozygotes for interleukin-28B, were included in the 19 patients with NAbs. No NAbs interfered with the antiviral activity of natural human IFN-β (nIFN-β) and re-treatement of patients with NAbs with nIFN-β/RBV achieved SVR. Our analyses revealed that the emergence of anti-IFN-α NAbs was a candidate causal factor of PEG-IFN-α-treatment failure. Therefore, these antibodies should be assayed in patients who do not respond to PEG-IFN-α therapy, and if detected, other effective treatments, i.e., medications that are not neutralized by anti-IFN-α NAbs, should be considered.

Glycation and phosphorylation of alpha-lactalbumin by dry heating: effect on protein structure and physiological functions

Alpha-lactalbumin (alpha-LA) was glycated with maltopentaose (MP) through the Maillard reaction (MP-alpha-LA) and subsequently phosphorylated by dry heating in the presence of pyrophosphate to investigate its structure and physiological functions. Glycation occurred effectively, and the sugar content of alpha-LA increased by approximately 22.3% through the Maillard reaction. The phosphorylation of MP-alpha-LA was enhanced with an increase in the dry-heating time from 1 to 5 d, and the phosphorous content of MP-alpha-LA increased by approximately 1.01% by dry heating at pH 4.0 and 85 degrees C for 5 d in the presence of pyrophosphate. The electrophoretic mobility of alpha-LA increased with an increase in the phosphorylation level. The circular dichroism spectra showed that the change in the secondary structure of the alpha-LA molecule by glycation and subsequent phosphorylation was slight. However, the Trp fluorescence intensity was increased by phosphorylation after glycation. In addition, the differential scanning calorimetry thermograms of alpha-LA showed that the denaturation temperature of MP-alpha-LA was decreased by phosphorylation. These results indicated that molten (partially unfolded) conformations of alpha-LA were formed by dry heating in the presence of pyrophosphate after glycation. The anti-alpha-LA antibody response was significantly reduced by glycation and subsequent phosphorylation. The suppressive effect of alpha-LA on the production of proinflammatory cytokines such as IL-6 and tumor necrosis factor-alpha from THP-1 cells after stimulation with lipopolysaccharide was significantly enhanced by glycation with MP and was further enhanced by phosphorylation after glycation. The Ca phosphate-solubilizing ability of alpha-LA was enhanced by phosphorylation. The apoptotic activity of alpha-LA was reduced by glycation and subsequent phosphorylation. These results suggest that phosphorylation by dry heating in the presence of pyrophosphate after glycation with MP through the Maillard reaction is a useful method for improvement of the physiological functions of alpha-LA.

Death comes early: apoptosis observed in ENS precursors

Cell death is a physiological and fundamental process in normal organogenesis. During the development of the nervous system, cell death or apoptosis occurs in early and late developmental time periods, affecting neural precursors and neurons respectively. In the development of the enteric nervous system (ENS), however, apoptosis of neurons has not been detected, a feature unique to enteric neurons. In this issue of Neurogastroenterology and Motility, Wallace et al. focused on an early phase of ENS development and identified apoptotic cell death in vagal neural crest cells, the primary cellular source for the ENS. Introduction of an antiapoptotic molecule in the vagal neural crest and its derivatives resulted in the overproduction of neurons in the foregut. Thus, unlike the neurons themselves, ENS precursors do undergo apoptosis, which may, by regulating the size of the ENS precursor pool, be a crucial factor in determining the final cell number in the ENS.

Genetic model system studies of the development of the enteric nervous system, gut motility and Hirschsprung's disease

The enteric nervous system (ENS) is the largest and most complicated subdivision of the peripheral nervous system. Its action is necessary to regulate many of the functions of the gastrointestinal tract including its motility. Whilst the ENS has been studied extensively by developmental biologists, neuroscientists and physiologists for several decades it has only been since the early 1990s that the molecular and genetic basis of ENS development has begun to emerge. Central to this understanding has been the use of genetic model organisms. In this article, we will discuss recent advances that have been achieved using both mouse and zebrafish model genetic systems that have led to new insights into ENS development and the genetic basis of Hirschsprung's disease.

Paired stimulation study of the median nerve sensory action potential in diabetic patients

OBJECTIVES

Conventional nerve conduction studies (NCS) are not sensitive to detect mild diabetic neuropathy. In order to detect subtle changes, we compared the conventional NCS with the relative refractory period (RRP) measurement of the median sensory nerve action potential by a paired stimulation method.

METHODS

Subjects were 29 diabetic patients whose conventional NCS were all normal. They were divided into two groups: neurologically symptomatic and asymptomatic groups. Twenty-eight age-matched control subjects were also studied.

RESULTS

The RRP of the symptomatic diabetic patients (5.9 +/- 0.5 ms) and that of the asymptomatic patients (5.6 +/- 0.5 ms) was significantly longer than that of the control subjects (4.9 +/- 0.6 ms). There was no significant difference in RRP between the symptomatic and asymptomatic patients. This may be due to the fact that NCS reflects mainly large myelinated fiber function and early symptoms represent mainly thin myelinated or unmyelinated fiber function.

CONCLUSIONS

The RRP measurement could reveal some mild involvement of peripheral nerves undetectable by conventional NCS, even though they caused no clinical symptoms.

Rotational acetabular osteotomy for advanced osteoarthritis secondary to developmental dysplasia of the hip

We evaluated the results of rotational acetabular osteotomy in 44 hips (42 patients) with advanced osteoarthritis secondary to developmental dysplasia. The mean age of the patients at surgery was 43.4 years (30 to 59) and the mean follow-up was 12.1 years (8 to 19). The mean Merle d'Aubigné clinical score improved from 10.8 points (8 to 15) pre-operatively to 13.5 points (6 to 18) at follow-up. Radiologically, this procedure produced adequate improvement regarding cover of the femoral head. At follow-up, the osteoarthritic stage assessed using the Japanese Orthopaedic Association grading, was improved in 11 hips (25%), unchanged in 22 (50%) and had progressed in 11 (25%). The mean pre-operative roundness index of the femoral head was significantly different in the 33 hips which had improved or maintained their osteoarthritic stage compared with the 11 which had progressed (53.7% vs 63.7%; p < 0.001). Osteoarthritis with a round femoral head is considered to be an indication for rotational acetabular osteotomy, even in advanced stages of the disease.

Rotational acetabular osteotomy with a resection of the lateral edge of the acetabulum for the treatment of advanced coxarthrosis

INTRODUCTION

We compared the functional and radiological results of a rotational acetabular osteotomy (RAO) with and without a resection of the lateral edge of the acetabulum. The purpose of the resection was to obtain good joint congruency.

MATERIALS AND METHODS

RAO was performed on 71 hips to treat advanced coxarthrosis caused by acetabular dysplasia. RAO without a resection (non-resection group) was performed in 54 patients (57 hips) with a median age of 43.1 years. The remaining 14 patients (14 hips), who had a median age of 44.6 years, received RAO with a resection of the lateral edge of the acetabulum (resection group).

RESULTS

The average postoperative total hip joint score was better than the average preoperative score in the non-resection group (P < 0.001), but not in the resection group. In the resection group, all hips displayed progressive osteoarthritic change and ten hips had chondrolysis of the hip joint and a collapse of the transferred acetabulum within 3 years. In the non-resection group, 15 hips showed progressive osteoarthritic change, 24 hips had no change, and 18 hips showed a decrease in the osteoarthritic stage.

CONCLUSION

Our findings demonstrated that resection of the lateral edge of the acetabulum is not a useful adjunct to the RAO procedure for the treatment of advanced coxarthrosis.