Preoperative Scoring System for Prediction of Early Adjacent Vertebral Body Fracture After Balloon Kyphoplasty Using X-Rays Taken in a Non-Weight-Bearing Position

BACKGROUND

Prevention of adjacent vertebral body fracture (AVF) following balloon kyphoplasty (BKP) is a key challenge. The objective of this study was to develop a scoring system that could be more extensively and effectively used to determine the surgical indications for BKP.

METHODS

The study involved 101 patients aged 60 years or older who had undergone BKP. Logistic regression analysis was used to identify risk factors for early AVF within 2 months following BKP. Scoring was based on the odds ratio for risk factors, and cut-off values were determined from the receiver operating characteristics curve. The correlation between the total scores and the incidence of early AVF, and the area under the curve for the logistic regression model predicting early AVF using the scoring system were investigated.

RESULTS

29 cases (28.7%) experienced early AVF after BKP. The scoring system was created as follows: 1) age (<75 years: 0 points (P), ≥75 years: 1P), 2) number of previous vertebral fractures (0: 0P, 1 or more: 2P), and 3) local kyphosis (<7°: 0P, ≥7°: 1P). The total scores were found to be positively correlated with the incidence of early AVF (r = 0.976, P = 0.004). The area under the curve of the scoring system for predicting early AVF was 0.796. The incidence of early AVF was 4.2% at ≤1P and 44.3% at ≥2P (P < 0.001).

CONCLUSIONS

A scoring system which can be applied to a broader patient population was developed. In cases where the total score is 2P or more, alternatives to BKP should be considered.

The relationship between global sagittal balance and the incidence of early adjacent vertebral fractures following balloon kyphoplasty

BACKGROUND

Recently, it is widely known that global sagittal balance (GSB) influences the postoperative outcome of the spine. The purpose of this study was to investigate the relationship between GSB and the incidence of early adjacent vertebral fracture (AVF) following BKP.

METHODS

This study included 96 patients (19 males, 77 females, mean age 77.4±5.5 years) who underwent BKP for osteoporotic vertebral fracture and who were over 60 years old. We investigated the effect of GSB on early AVF within 2 months after surgery. Of the 96 patients, 76 patients (16 males, 60 females, mean age 77.0±5.4) underwent BKP at the thoracolumbar junction (T11-L2) and were investigated independently. After the two-group comparison, logistic regression analysis was performed.

RESULTS

During the observation period (18.3±14.7 months), 27 of 96 patients (28.1%) suffered AVF after BKP, and 24 of 96 patients (25.0%) suffered early AVF. In the logistic regression analysis, spinopelvic parameters were not detected as significant risk factors. In cases of BKP at the thoracolumbar junction (T11-L2), 24 of 76 patients (31.6%) suffered AVF after BKP during the observation period (15.3±19.5 months), and 21 of 76 patients (27.6%) suffered early AVF. Logistic regression analysis detected PT: odds ratio 1.087 (P = 0.046*) and local kyphosis: 1.147 (P = 0.003*) as risk factors for early AVF. The cutoff value was PT≥29° from the ROC curve.

CONCLUSIONS

At the thoracolumbar junction, PT equal to or greater than 29° is one of the risk factors of early AVF following BKP.

Preoperative scoring system for predicting early adjacent vertebral fractures after Balloon Kyphoplasty

BACKGROUND

Adjacent vertebral fracture (AVF) is a major complication following Balloon Kyphoplasty (BKP). There is no scoring system for predicting AVF using only preoperative elements. The purposes of this study were to develop a scoring system for predicting early AVF after BKP based on preoperative factors and to investigate the appropriate surgical indication for BKP.

METHODS

Of 220 patients who underwent BKP at a single institution since 2011, 65 patients over the age of 60 who had undergone a standing whole spine X-ray preoperatively were enrolled. Factors affecting the occurrence of early AVF were examined. A scoring system was created consisting of the factors exhibiting significant differences, and the correlation between the total score and the incidence of early AVF was investigated.

RESULTS

Twenty of the 65 patients (30.8%) had early AVF. In a univariate analysis, age, previous vertebral fracture, pelvic tilt, and Local kyphosis significantly influenced early AVF. In a multivariate logistic regression analysis, age had an odds ratio of 1.136 (95% CI 1.001-1.289), previous vertebral fractures 4.181 (1.01-17.309), and Local kyphosis 1.103 (1.021-1.191). The scoring system was set as follows: ①Age (<75 years: 0 points(P), 75years≦: 1P), ②The number of previous vertebral fractures (0: 0 P, 1: 1P, 2: 2P, 3 or more: 3P), and ③Local kyphosis (<10°: 0P, 10°≦: 1P). There was a correlation between the total score and the incidence of early AVF (r = 0.812, ∗P = 0.05). The incidence of early AVF was 6.4% (2 cases/31 cases) for a score of ≦1P and 54.5% (18 cases/33 cases) for a score of ≧2P.

CONCLUSIONS

There was a correlation between the total score and the incidence of early AVF. A score of 1 point or less may represent the appropriate surgical indication for BKP.

Visualization of Nigrosome 1 from the Viewpoint of Anatomic Structure

BACKGROUND AND PURPOSE

Parkinson disease is related to neurodegeneration and iron deposition in the substantia nigra pars compacta and nigrosome 1. However, visualization of nigrosome 1 via MR imaging is poor owing to the bilateral asymmetry, regardless of whether it is healthy. We focused on the magic angle and susceptibility effect and evaluated the anatomic slant structure of nigrosome 1 by tilting subjects' heads in the B₀ direction.

MATERIALS AND METHODS

To investigate the effectiveness of the magic angle, we tilted the volunteers' heads to the right and left in the B₀ direction or not at all for evaluating correlations between the degree of head tilting and visualization of the right nigrosome 1 and left nigrosome 1 using 3D spoiled gradient-echo sequences with multiecho acquisitions. We evaluated the susceptibility of nigrosome 1 and the local field using quantitative susceptibility mapping to assess static magnetic field inhomogeneity.

RESULTS

The heads tilted to the right and left showed significantly higher contrasts of nigrosome 1 and the substantia nigra pars compacta than the nontilted heads. No significant differences were observed in the visualization and susceptibility between the right nigrosome 1 and left nigrosome 1 for each head tilt. The effect of the magic angle was remarkable in the nontilted heads. This finding was supported by quantitative susceptibility mapping because the anatomic slant structure of nigrosome 1 was coherent between the axis of nigrosome 1 and the magic angle.

CONCLUSIONS

The asymmetric visualization of nigrosome 1 is affected by the magic angle and susceptibility. The anatomic slant structure of nigrosome 1 causes these challenges in visualization.

Anatomical Evaluation of the Sacral Hiatus Using Ultrasound Imaging: Factors That Inhibit Needle Insertion During Caudal Epidural Block Procedures

OBJECTIVE

Caudal epidural blocks often fail due to the difficulty of appropriate needle insertion. This study aimed to evaluate the anatomy of the sacral hiatus using ultrasound imaging.

METHODS

This was a retrospective study involving 76 patients with spinal disorders. The following factors were analyzed to see if they affected the palpability of the sacral hiatus: sex, body mass index (BMI), and the morphology of the sacral hiatus on ultrasound imaging. The difficulty of needle insertion and the factors that influenced it were investigated in 28 of the 76 patients, who underwent landmark-based caudal epidural block procedures performed by the same doctor.

RESULTS

Among the 76 patients, the mean length of the sacral hiatus was 21.3 ± 5.6 mm, the mean distance from the skin to the sacral cornua was 5.2 ± 3.4 mm, and the mean angle of the sacral hiatus was 16.4 ± 5.5 degrees. Sacral base protrusion was present and absent in 35 and 41 cases, respectively. The sacral hiatus exhibited good and poor palpability in 53 and 23 cases, respectively. The mean distance from the skin to the sacral cornua and BMI were found to significantly influence the palpability of the sacral hiatus. Only sacral base protrusion significantly influenced the difficulty of needle insertion.

CONCLUSION

The mean distance from the skin to the sacral cornua and BMI were found to be associated with the palpability of the sacral hiatus, and sacral base protrusion was demonstrated to be associated with the difficulty of needle insertion into the sacral hiatus.

Japanese civilian and US military interaction in the evacuation of casualties from Camp Fuji

Historically, if US soldiers at Camp Fuji become severely ill or suffer trauma, they are transported by the ground ambulance, as the doctor-led air ambulance in eastern Shizuoka has never been permitted to land at Camp Fuji. However, it is widely recognised that severely ill or traumatised patients require time-dependent medical management. It was therefore agreed to undertake a joint exercise between the US medical assets of Camp Fuji and the doctor helicopters in eastern Shizuoka prefecture in evacuating a simulated severely ill or traumatised US soldier. The aim of this article is to describe the background and rationale between this collaboration between the civilian Japanese air ambulance and the US medical assets in Camp Fuji.

Comparison of osseous healing after sagittal split ramus osteotomy and intraoral vertical ramus osteotomy

The sagittal split ramus osteotomy (SSRO) is generally associated with greater postoperative stability than the intraoral vertical ramus osteotomy (IVRO); however, it entails a risk of inferior alveolar nerve damage. In contrast, IVRO has the disadvantages of slow postoperative osseous healing and projection of the antegonial notch, but inferior alveolar nerve damage is believed to be less likely. The purposes of this study were to compare the osseous healing processes associated with SSRO and IVRO and to investigate changes in mandibular width after IVRO in 29 patients undergoing mandibular setback. On computed tomography images, osseous healing was similar in patients undergoing SSRO and IVRO at 1year after surgery. Projection of the antegonial notch occurred after IVRO, but returned to the preoperative state within 1year. The results of the study indicate that IVRO is equivalent to SSRO with regard to both bone healing and morphological recovery of the mandible.

Posttransplant oxygen inhalation improves the outcome of subcutaneous islet transplantation: A promising clinical alternative to the conventional intrahepatic site

Subcutaneous tissue is a promising site for islet transplantation, due to its large area and accessibility, which allows minimally invasive procedures for transplantation, graft monitoring, and removal of malignancies as needed. However, relative to the conventional intrahepatic transplantation site, the subcutaneous site requires a large number of islets to achieve engraftment success and diabetes reversal, due to hypoxia and low vascularity. We report that the efficiency of subcutaneous islet transplantation in a Lewis rat model is significantly improved by treating recipients with inhaled 50% oxygen, in conjunction with prevascularization of the graft bed by agarose-basic fibroblast growth factor. Administration of 50% oxygen increased oxygen tension in the subcutaneous site to 140 mm Hg, compared to 45 mm Hg under ambient air. In vitro, islets cultured under 140 mm Hg oxygen showed reduced central necrosis and increased insulin release, compared to those maintained in 45 mm Hg oxygen. Six hundred syngeneic islets subcutaneously transplanted into the prevascularized graft bed reversed diabetes when combined with postoperative 50% oxygen inhalation for 3 days, a number comparable to that required for intrahepatic transplantation; in the absence of oxygen treatment, diabetes was not reversed. Thus, we show oxygen inhalation to be a simple and promising approach to successfully establishing subcutaneous islet transplantation.

Compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation for traumatic thoracolumbar kyphotic spine deformity

BACKGROUND

It remains unclear whether long fusion including lumbar-sacral fixation is needed in corrective surgery to obtain good global sagittal balance (GSB) for the treatment of traumatic thoracolumbar kyphotic spine deformity. The purposes of this study were to evaluate compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation and to evaluate the parameters affecting the achievement of good GSB post-operatively.

METHODS

Twenty (20) subjects requiring corrective surgery (distal end of fixation was L3) were included in this study. The radiographic parameters were measured pre-operatively and at one month after surgery. Sagittal Vertical Axis (SVA), Lumber Lordosis angle altered by fracture (fLL), Thoracic Kyphosis angle altered by fracture (fTK), Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Segmental Lumbar Lordosis (sLL: L3-S/L4-S), and local kyphotic angle were measured. The correlation between correction of local kyphotic angle (CLA) and the change in radiographic parameters was evaluated. Post-operatively, subjects with SVA<50 mm and PI-fLL<10°were regarded as the "good GSB group (G group). The radiographic parameters affecting the achievement of G group were statistically evaluated.

RESULTS

fLL, sLL:L3-S and sLL:L4-S were decreased indirectly because the local kyphosis was corrected directly (CLA: 26.5 ± 8.6°) (P < 0.001). CLA and the change in fLL showed significant correlation (r = 0.821), the regression equation being: Y = -0.63X+3.31 (Y: The change in fLL, X: CLA). The radiographic parameters significantly affecting the achievement of G group were: SVA, PT, PI-fLL, sLL: L3-S, and sLL: L4-S (P < 0.01).

CONCLUSION

The main compensatory mechanism was the decrease of lordosis in the lumbar spine. fLL was decreased to approximately 60% of CLA after surgery. SVA was not corrected by the compensatory mechanism.

Prevalence and risk factors of deep vein thrombosis in patients undergoing lumbar spine surgery

BACKGROUND

Spinal surgery is classified as a moderate risk for DVT. The occurrence of DVT after various spinal surgical procedures was reviewed retrospectively, and the perioperative risk factors in the high-risk group were identified. In addition, the administration of the factor Xa inhibitor to DVT subjects with unstable thrombosis was evaluated to reveal its effectiveness in the prevention of PTE and postoperative complications.

METHODS

This study included 588 subjects who underwent lumbar spine surgery. The patient population consisted of the following four groups: the fracture group (F group), the laminectomy group (La group), the TLIF group (T group), and the long fusion group (Lo group). Bilateral lower limb venous ultrasonography was performed on the day before surgery, the day after surgery, and one week after surgery. The incidence of DVT was determined for each group and potential risk factors were evaluated in the group with the highest incidence of DVT. Subjects with DVT who had unstable thrombosis received anticoagulant therapy (factor Xa inhibitor) and their treatment results were assessed.

RESULTS

The overall incidence of DVT was 32.3% (190/588). A significantly high incidence of DVT was observed in the Lo group (54.3%; 75/138). Logistic regression and ROC analysis of potential risk factors in the Lo group identified a D-dimer value of 19.5 ug/ml at one week postoperatively as a risk factor of DVT (p = 0.02; odds ratio, 4.09; 95% CI, 2.82-7.88). Overall, 15.8% of subjects (30/190) received anticoagulant therapy. These subjects experienced neither PTE nor epidural hematoma. A follow-up ultrasonography performed at three weeks postoperatively detected the disappearance/resolution of DVT in 86.7% of these subjects (26/30).

CONCLUSION

The incidence of DVT varied according to the invasiveness of the procedure. Successful management of DVT hinges on preoperative risk management involving prophylactic treatment and early diagnosis, in order to avoid PTE and other complications.

Simultaneous spawning by female stream goby Rhinogobius sp. and the association with brood cannibalism by nesting males

A laboratory experiment was conducted by varying the undersurface area of nesting substratum and the number of females in an experimental tank to elucidate the determinants of the mating pattern in the stream goby, Rhinogobius sp. cross-band type. Males with larger nests tended to attract two or more females to their nest in a tank. Moreover, males spawned simultaneously with multiple females and entire brood cannibalism by males was rarely observed under a female-biased sex ratio. When males spawned with a single female with low fecundity, however, entire brood cannibalism occurred at a high frequency, suggesting that a male guarding a nest with fewer eggs consumes the brood. Therefore, spawning behaviour of females that leads to a large egg mass would decrease the risk of entire brood cannibalism. In this species, simultaneous spawning by multiple females in a nest serves as a female counter-measure against entire brood cannibalism. These results suggest that a conflict of interest between the sexes through brood cannibalism is a major determinant of simultaneous spawning.

[Two Cases of Liver Metastasis from Pancreatic Cancer with a Complete Response Owing to Chemotherapy]

Case 1: The patient was a 42-year-old man who was diagnosed with intraductal papillary-mucinous carcinoma with liver metastasis. After S-1+gemcitabine and S-1 chemotherapy, the liver metastasis had disappeared and we performed a pancreaticoduodenectomy( PD). Case 2: The patient was a 70-year-old woman who was diagnosed with pancreatic cancer with liver metastasis. After gemcitabine chemotherapy, the liver metastasis had disappeared and we performed a PD. The prognosis of pancreatic cancer is dismal compared to other types of cancer, and for a Stage Ⅳb cancers, the 5-year survival rate is reported to be approximately 3%. We report 2 cases of liver metastases from pancreatic cancer that disappeared in response to chemotherapy. Both patients underwent primary tumor resection after chemotherapy and experienced long-term survival.

[A Case of Gemcitabine Refractory Lung Metastasis after Distal Pancreatectomy for Pancreatic Cancer, Effectively Treated with S -1 as Second Line Chemotherapy]

A 64-year-old man was diagnosed with pancreatic cancer by abdominal computed tomography (CT). The examination showed a pancreatic tail cancer and a distal pancreatectomy was performed in 2010. Histopathologically, this tumor was a moderately-differentiated tubular adenocarcinoma. He received gemcitabine adjuvant chemotherapy for a year. In 2012, a chest CT scan revealed 4 nodules in the lower left lobe. We diagnosed gemcitabine-refractory lung metastases after distal pancreatectomy for pancreatic cancer. S-1 chemotherapy was administered as a second line chemotherapy for metastatic pancreatic cancer. After 2 courses of this regimen, the lung metastases were reduced. After 6 courses, a clinical complete response was obtained. Four years and 6 months after the operation, the patient is well without any signs of recurrence, and S-1 chemotherapy is still ongoing.

[A Case of Advanced Gastric Cancer with Peritoneal Dissemination Effectively Treated with S-1 and Docetaxel Combination Chemotherapy]

A 72-year-old man underwent surgery for advanced gastric cancer. Systemic chemotherapy was started, using a regimen of S-1/CDDP for 4 courses, followed by 8 courses of S-1. Three years and 8 months after the surgery, abdominal CT demonstrated ascites, and the serum CA19-9 level was abnormally high (1,165.1 U/mL). Adenocarcinoma cells were found in the ascites. Treatment with S-1/docetaxel (DOC) was started. After 10 courses, the ascites disappeared and the serum CA19-9 value returned to normal. Four years and 7 months after the operation, the patient has been in good health, with no signs of recurrence.

[A Study of Preoperative Chemotherapy with S-1 plus Cisplatin for Advanced Gastric Cancer]

We studied the effects of preoperative chemotherapy with S-1 plus cisplatin for advanced gastric cancer. There were 16 patients who underwent radical surgery with neoadjuvant chemotherapy between 2000 and 2015. The indications for this were advanced gastric cancer with bulky N2 or N3 lymph nodes, or stage above T4a. Seven patients (43%) showed adverse events, all of which were tumors above Grade 3. Response evaluation showed PR in 13 cases (81%). The histopathological evaluation was Grade 0 in 8 patients (50%) and Grade 1a or above in 8 (50%). Death from recurrence within a year occurred in 4 cases, and 7 patients survived with no recurrence for over 5 years. All cases of survivors with no recurrence had a histopathological evaluation of Grade 1 or above. Three cases (75%) with recurrence and death within a year all had with Grade 0 tumors. We concluded that neoadjuvant chemotherapy with S-1 plus cisplatin was effective for advanced gastric cancer and that histopathological evaluation was invaluable for accurate prognosis.

[A Case of Colon Cancer with Multiple Liver Metastases Successfully Treated with Capecitabine/Oxaliplatin plus Bevacizumab]

A 69-year-old woman was diagnosed with descending colon cancer with multiple liver metastases, and a left hemicolectomy was performed. The patient was treated with capecitabine/oxaliplatin (CapeOX) plus bevacizumab (Bmab). After 5 courses of chemotherapy, the number and size of liver metastases remarkably reduced, and after the 12th course, because of peripheral neuropathy, a "stop-and-go"fashion of administering oxaliplatin (L-OHP) was initiated. After 14 courses, the liver metastases had disappeared. After the 33rd course of L-OHP treatment, the patient started receiving capecitabine therapy. The patient is recurrence-free 3 years after surgery, 14 months after achieving a complete response (CR). We report a case of long-term CR after surgery for descending colon cancer with multiple liver metastases, followed by a "stop-and-go" method of administering L-OHP or CapeOX plus Bmab therapy.

[A Case of Advanced Gastric Cancer with Long-Term Survival after Chemotherapy with Combined S-1 and CPT-11]

Here, we report a 54-year-old man diagnosed with type 3 advanced gastric cancer who underwent a total gastrectomy and splenectomy plus D2 lymphadenectomy. The pathologic diagnosis was Stage Ⅳ (T3N0H0P0CY1M1). Sixteen courses of combined S-1/CPT-11 chemotherapy were completed, at which time the CPT-11 was discontinued because of malaise, and S-1 alone was continued for a year. The patient is well and has been recurrence-free for 7 years. Thus, he is considered a long- term survivor who was treated with combination S-1/CPT-11 chemotherapy.

Pharmacological strategies for protection of extrahepatic islet transplantation

The safety and effectiveness of islet transplantation has been proven through world-wide trials. However, acute and chronic islet loss has hindered the ultimate objective of becoming a widely used treatment option for type 1 diabetes. A large islet loss is attributed, in part, to the liver being a less-than-optimal site for transplantation. Over half of the transplanted islets are destroyed shortly after transplantation due to direct exposure to blood and non-specific inflammation. Successfully engrafted islets are continuously exposed to the liver micro-environment, a unique immune system, low oxygen tension, toxins and high glucose, which is toxic to islets, leading to premature islet dysfunction/death. Investigations have continued to search for alternate sites to transplant islets that provide a better environment for prolonged function and survival. This article gathers courses and conditions that lead to islet loss, from organ procurement through islet transplantation, with special emphasis on hypoxia, oxidative stress, and antigen non-specific inflammation, and reviews strategies using pharmacological agents that have shown effectiveness in protecting islets, including a new treatment approach utilizing siRNA. Pharmacological agents that support islet survival and promote β-cell proliferation are also included. Treatment of donor pancreata and/or islets with these agents should increase the effectiveness of islets transplanted into extrahepatic sites. Furthermore, the development of methods designed to release these agents over an extended period, will further increase their efficacy. This requires the combined efforts of both islet transplant biologists and bioengineers.

Multiple roles of the PGE2 -EP receptor signal in vascular permeability

BACKGROUND AND PURPOSE

PGE2 is a major prostanoid that regulates inflammation by stimulating EP1-4 receptors. However, how PGE2 induces an initial inflammatory response to vascular hyper-permeability remains unknown. Here we investigated the role of the PGE2 -EP receptor signal in modulating vascular permeability both in vivo and in vitro.

EXPERIMENTAL APPROACH

We used a modified Miles assay and intravital microscopy to examine vascular permeability in vivo. Endothelial barrier property was assessed by measuring transendothelial electrical resistance (TER) in vitro.

KEY RESULTS

Local administration of PGE2 , an EP2 or EP4 receptor agonist into FVB/NJcl mouse ear skin caused vascular leakage, indicated by dye extravasation. Intravital microscopy and laser Doppler blood-flow imaging revealed that these treatments dilated peripheral vessels and increased local blood flow. Pretreatment with the vasoconstrictor phenylephrine inhibited the PGE2 -induced blood flow increase and vascular leakage. In contrast to the EP2 and EP4 receptor agonists, administration of an EP3 receptor agonist suppressed vascular leakage without altering vascular diameter or blood flow. In isolated HUVECs, the EP3 receptor agonist elevated TER and blocked thrombin-induced dextran passage. Inhibiting PKA restored the hypo-permeability induced by the EP3 receptor agonist.

CONCLUSIONS AND IMPLICATIONS

Activation of the PGE2 -EP2 or -EP4 receptor signal induces vasodilatation in mural cells, resulting in increased local blood flow and hyper-permeability. In contrast, activation of the PGE2 -EP3 receptor signal induces a cAMP-dependent enhancement of the endothelial barrier, leading to hypo-permeability. We provide the first evidence that endothelial cells and mural cells cooperate to modulate vascular permeability.

[A case of gastric cancer with N2 lymph node metastasis and pancreatic invasion effectively treated with docetax-el/S-1 as a neoadjuvant chemotherapy]

A 74-year-old man was diagnosed with advanced gastric cancer(cStage III B). Laparotomy showed N2 lymph node metastasis and pancreatic invasion. Radical resection appeared impossible and was thus not performed. Chemotherapy consisting of a combination of S-1(80mg/m 2, 2-week administration and 1-week rest), and docetaxel(40mg/m2day 1)was administered with the expectation of tumor downstaging. A partial response(PR)was obtained after five courses of this regimen in which the primary lesion and lymph node swelling remarkably improved. Total gastrectomy, splenectomy, partial colectomy, and D2 lymph node dissection were then performed. Pathological analysis revealed very few cancer cells in the primary lesion and that the lymph nodes had become scarred and fibrotic. The histological appearance was judged to be grade 2 and the final diagnosis was T1N0H0P0CY0M0, fStage I A, curability A. Currently, more than 6 years and 4 months after the operation, the patient is alive without any evidence of recurrence. Thus, docetaxel/S-1 combination therapy was an effective neoadjuvant chemotherapy for this case of advanced gastric cancer.

Pretreatment of donor islets with the Na(+) /Ca(2+) exchanger inhibitor improves the efficiency of islet transplantation

Pancreatic islet transplantation is an attractive therapy for the treatment of insulin-dependent diabetes mellitus. However, the low efficiency of this procedure necessitating sequential transplantations of islets with the use of 2-3 donors for a single recipient, mainly due to the early loss of transplanted islets, hampers its clinical application. Previously, we have shown in mice that a large amount of HMGB1 is released from islets soon after their transplantation and that this triggers innate immune rejection with activation of DC, NKT cells and neutrophils to produce IFN-γ, ultimately leading to the early loss of transplanted islets. Thus, HMGB1 release plays an initial pivotal role in this process; however, its mechanism remains unclear. Here we demonstrate that release of HMGB1 from transplanted islets is due to hypoxic damage resulting from Ca(2+) influx into β cells through the Na(+) /Ca(2+) exchanger (NCX). Moreover, the hypoxia-induced β cell damage was prevented by pretreatment with an NCX-specific inhibitor prior to transplantation, resulting in protection and long-term survival of transplanted mouse and human islets when grafted into mice. These findings suggest a novel strategy with potentially great impact to improve the efficiency of islet transplantation in clinical settings by targeting donor islets rather than recipients.

Novel multilayer Ti foam with cortical bone strength and cytocompatibility

The major functions required for load-bearing orthopaedic implants are load-bearing and mechanical or biological fixation with the surrounding bone. Porous materials with appropriate mechanical properties and adequate pore structure for fixation are promising candidates for load-bearing implant material. In previous work, the authors developed a novel titanium (Ti) foam sheet 1-2mm thick by an original slurry foaming method. In the present work, novel Ti foam is developed with mechanical properties compatible with cortical bone and biological fixation capabilities by layer-by-layer stacking of different foam sheets with volumetric porosities of 80% and 17%. The resulting multilayer Ti foam exhibited a Young's modulus of 11-12GPa and yield strength of 150-240MPa in compression tests. In vitro cell culture on the sample revealed good cell penetration in the higher-porosity foam (80% volumetric porosity), which reached 1.2mm for 21 days of incubation. Cell penetration into the high-porosity layers of a multilayer sample was good and not influenced by the lower-porosity layers. Calcification was also observed in the high-porosity foam, suggesting that this Ti foam does not inhibit bone formation. Contradictory requirements for high volumetric porosity and high strength were attained by role-sharing between the foam sheets of different porosities. The unique characteristics of the present multilayer Ti foam make them attractive for application in the field of orthopaedics.

mRNA of the pro-apoptotic gene BBC3 serves as a molecular marker for TNF-α-induced islet damage in humans

AIMS/HYPOTHESIS

TNF-α plays important roles in the pathogenesis of type 1 and type 2 diabetes mellitus. In light of this, we examined the involvement of a pro-apoptotic gene, BBC3 (also known as PUMA), in TNF-α-mediated beta cell dysfunction and destruction in human islets.

METHODS

Human islets were exposed in vitro to TNF-α alone or in combination with IFN-γ. Gene expression was assessed by RT-PCR using a set of single islets. Protein abundance and cellular localisation of BBC3 were assessed by immunoblot and immunohistochemistry. A marginal number of islets were transplanted into diabetic NODscid mice to correlate in vivo islet function with BBC3 expression.

RESULTS

BBC3 and IL8 mRNA were upregulated in TNF-α-stimulated islets in a dose-dependent manner and enhanced through addition of IFN-γ, but not upregulated by IFN-γ alone. Immunohistochemistry revealed that TNF-α in combination with IFN-γ upregulated basal BBC3 abundance in the cytoplasm of beta cells along with the perinuclear clustering of mitochondria partially co-localised with BBC3. TNF-α alone did not induce beta cell death, but did abrogate preproinsulin precursor mRNA synthesis in response to high glucose stimulation, which was inversely associated with upregulation of BBC3 mRNA expression by TNF-α. Higher BBC3 mRNA expression in islets correlated with decreased graft function in vivo.

CONCLUSIONS/INTERPRETATION

These results suggest that BBC3 mRNA can serve as a molecular marker to detect early TNF-α-induced beta cell stress and may help identify islet-protective compounds for the treatment of diabetes.

Immune responses to porphyromonas gingivalis infection suppress systemic inflammatory response in experimental murine model

Periodontitis is a localized infectious disease caused by periodontopathic bacteria such as Porphyromonas gingivalis (P. gingivalis), and the severity correlates to significance of immune responses. Recently, it has been reported that periodontitis is associated with the development of systemic disease such as diabetes and atherosclerosis because of increasing invasion of oral pathogens to the circulation. However, the association between local and systemic infectious responses is still unclear. In the present study, we examined the differences of biological responses in animals with or without bacterial infection. After Balb/c mice were infected subcutaneously with live P. gingivalis W83, serum, skin and liver were collected according to experimental protocol. The skin and liver tissues were observed pathologically by haematoxylin-eosin staining, and serum IL-6 levels were measured using ELISA method. Throughout the experimental period, conditions of the mice were observed continuously. As expected, severe infiltration of leukocytes were observed at inflamed skin corresponding to the number of bacterial challenges. Although no inflammatory appearance of skin was observed, serum IL-6 levels were increased dramatically (P <0.01, Student's t-test) and liver tissues were injured in the mice without bacterial challenge. Interestingly, although severe inflammatory appearance of the skin was observed, serum IL-6 levels were not increased and no inflammatory responses were observed in the liver of the 3-times bacterially challenged group. Importantly, immunoglobulin G against P. gingivalis W83 was detected in the blood of mice with 3-times bacterial challenge corresponding to improvement of weight loss and survival. In conclusion, although multiple infections develop severe localized inflammation, the immune system should be sufficient to protect the systemic inflammatory responses.

[A case of rectal cancer with sacrum metastasis treated with S-1 leading to a complete response]

The patient is a 47-year-old female. She had undergone abdominoperineal resection for rectal cancer at 39 years of age. Two years and 9 months after surgery, she was diagnosed with a vagina invasion. Radiation therapy and chemotherapy (UFT/ LV) were performed. After 4 courses of UFT/LV, a complete response (CR) was noted. Four years and 3 months after surgery, she was diagnosed with a sacrum metastasis. Chemotherapy with S-1 was performed. After 2 courses of S-1, a CR was noted. There has been no recurrence sign to date.

PDK1 regulates chemotaxis in human neutrophils

Phosphoinositide-dependent kinase (PDK1) plays a central role in signal transduction mediated by phosphatidylinositol 3-kinases (PI3K) and regulates cellular functions in neutrophils. Neutrophils from individuals diagnosed with localized aggressive periodontitis (LAP) present an in vivo phenotype with depressed chemotaxis. The aim of this study was to test the hypothesis that PDK1 regulates chemotaxis in neutrophils and is responsible for the abnormal neutrophil chemotaxis LAP. Neutrophil chemotaxis was significantly suppressed by the PDK1 inhibitor staurosporine. When cells were transfected with PDK1 siRNA, there was a significant reduction in chemotaxis, while superoxide generation was not significantly affected. In primary neutrophils from persons with LAP, PDK1 expression and activation levels were significantly reduced, and this reduction was associated with the reduced phosphorylation of Akt (Thr308) and chemotaxis. Analysis of these data demonstrates that PDK1 is essential for the chemotactic migration of neutrophils, and in the absence of PDK1, neutrophil chemotaxis is impaired.

Signet ring cell carcinoma of the ampulla of vater. A case report

CONTEXT

Signet ring cell carcinoma of the ampulla of Vater is extremely rare and only 12 cases have previously been described in the English language literature. We report a case of advanced signet ring cell carcinoma of the ampulla of Vater, with invasion of the duodenum and pancreas.

CASE REPORT

A 59-year-old man presented at a local hospital with upper abdominal pain and icterus. Obstructive jaundice was diagnosed and he was referred to our hospital. Abdominal computed tomography showed dilatation of the common bile duct and the pancreatic duct. Duodenoscopy indicated an irregularly shaped erosion on the ampulla of Vater. Histological examination of a biopsy revealed adenocarcinoma. Duodenography revealed irregularity of the second portion of the duodenum wall. The diagnosis was carcinoma of the ampulla of Vater, and a pancreaticoduodenectomy was performed. The histopathological findings detected signet ring cell carcinoma.

CONCLUSION

Although several cases have been reported, the detailed clinicopathological features and prognosis are not clear. Additional reports are warranted.

An endogenous regulator of inflammation, resolvin E1, modulates osteoclast differentiation and bone resorption

BACKGROUND AND PURPOSE

The inflammation-resolving lipid mediator resolvin E1 (RvE1) effectively stops inflammation-induced bone loss in vivo in experimental periodontitis. It was of interest to determine whether RvE1 has direct actions on osteoclast (OC) development and bone resorption.

EXPERIMENTAL APPROACH

Primary OC cultures derived from mouse bone marrow were treated with RvE1 and analysed for OC differentiation, cell survival and bone substrate resorption. Receptor binding was measured using radiolabelled RvE1. Nuclear factor (NF)-kappaB activation and Akt phosphorylation were determined with western blotting. Lipid mediator production was assessed with liquid chromatography tandem mass spectrometry.

KEY RESULTS

OC growth and resorption pit formation were markedly decreased in the presence of RvE1. OC differentiation was inhibited by RvE1 as demonstrated by decreased number of multinuclear OC, a delay in the time course of OC development and attenuation of receptor activator of NF-kappaB ligand-induced nuclear translocation of the p50 subunit of NF-kappaB. OC survival and apoptosis were not altered by RvE1. Messenger RNA for both receptors of RvE1, ChemR23 and BLT(1) is expressed in OC cultures. Leukotriene B(4) (LTB(4)) competed with [(3)H]RvE1 binding on OC cell membrane preparations, and the LTB(4) antagonist U75302 prevented RvE1 inhibition of OC growth, indicating that BLT(1) mediates RvE1 actions on OC. Primary OC synthesized the RvE1 precursor 18R-hydroxy-eicosapentaenoic acid and LTB(4). Co-incubation of OC with peripheral blood neutrophils resulted in transcellular RvE1 biosynthesis.

CONCLUSIONS AND IMPLICATIONS

These results indicate that RvE1 inhibits OC growth and bone resorption by interfering with OC differentiation. The bone-sparing actions of RvE1 are in addition to inflammation resolution, a direct action in bone remodelling.

Improvement of human islet cryopreservation by a p38 MAPK inhibitor

The activation of p38 mitogen-activated protein kinase (MAPK) has been shown to cause ischemia/reperfusion injury of several organs used for transplantation and also to play a significant role in primary islet graft nonfunction. Activation of p38 MAPK may also occur during islet cryopreservation and thawing. In this study, a p38 MAPK inhibitor (p38IH) was applied to human islet cryopreservation to improve islet yield and quality after thawing. Under serum-free conditions, human islets were cryopreserved, thawed and cultured using our standard procedures. Three types of solutions were tested: conventional RPMI1640 medium (RPMI), a newly developed islet cryopreservation solution (ICS), and ICS supplemented with a p38IH, SD-282 (ICS-p38IH). Activation or inhibition of p38 MAPK was demonstrated by the diminished phosphorylation of HSP27 substrate. Islet recovery on day 2 after thawing was highest with ICS-p38IH and islet viability was not significantly different in the three groups. beta Cell numbers and function were the highest in islets cryopreserved with ICS-p38IH. Glucose-stimulated human C-peptide levels were 86% of that of the nonfrozen islets when measured 4 weeks after transplantation into NODscid mice. This improvement may provide an opportunity to establish islet banks and allow the use of cryopreserved islets for clinical transplantation.

Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients

Although uremia is well known as the most common cause of pruritus, the mechanisms of pruritus in chronic hemodialysis patients remain unclear. The purpose was to characterize uremic pruritus in more detail and to investigate whether severe pruritus is a marker for poor prognosis. A total of 1773 adult hemodialysis patients were studied. A questionnaire was given to each patient to assess the intensity and frequency, as well as pruritus-related sleep disturbance. We analyzed the relationship between clinical and laboratory data and the severity of pruritus in hemodialysis patients and followed them for 24 months prospectively. In total, 453 patients had severe pruritus with a visual analogue scale (VAS) score more than or equal to 7.0. Among them, more than 70% complained of sleep disturbance, whereas the majority of patients with a VAS score of less than 7.0 had no sleep disturbance. Male gender, high levels of blood urea nitrogen, beta2-microglobulin (beta2MG), hypercalcemia, and hyperphosphatemia were identified as independent risk factors for the development of severe pruritus, whereas a low level of calcium and intact-parathyroid hormone were associated with reduced risk. During the follow-up, 171 (9.64%) patients died. The prognosis of patients with severe pruritus was significantly worse than the others. Moreover, severe pruritus was independently associated with death even after adjusting for other clinical factors including diabetes mellitus, age, beta2MG, and albumin. Severe uremic pruritus caused by multiple factors, not only affects the quality of life but may also be associated with poor outcome in chronic hemodialysis patients.

Extracellular secretion of Escherichia coli alkaline phosphatase with a C-terminal tag by type I secretion system: purification and biochemical characterization

Type I secretion system (TISS) of Gram-negative bacteria permits proteins to be secreted directly from the cytoplasm to the external medium by a single, energy-coupled step. To examine whether this system can be used as an extracellular production system of recombinant proteins, Escherichia coli alkaline phosphatase (AP) was fused to a C-terminal region of Pseudomonas sp. MIS38 lipase (PML) and examined for secretion using the E.coli cells carrying the heterologous TISS. PML is one of the passenger proteins of TISS and contains 12 repetitive sequences and a secretion signal at the C-terminal region. The fusion protein was efficiently secreted to the extracellular medium, while AP was not secreted at all, indicating that the secretion of AP is promoted by a secretion signal of PML. The repetitive sequences were not so important for secretion of the fusion protein, because the secretion level of the fusion protein containing entire repeats ( approximately 10 mg/l culture) was only 2-fold higher than that of the fusion protein without repeats. The fusion protein purified from the culture supernatant existed as a homodimer, like AP, and was indistinguishable from AP in enzymatic properties and stability.

Multipotent progenitor cells isolated from adult human pancreatic tissue

The supply of islet cells is a limiting factor for the widespread application of islet transplantation of type-1 diabetes. Islets constitute 1% to 2% of pancreatic tissue, leaving approximately 98% as discard after islet isolation and purification. In this report we present our data on the isolation of multipotent progenitor cells from discarded adult human pancreatic tissue. The collected cells from discarded nonislet fractions, after enzymatic digestion and gradient purification of islets, were dissociated for suspension culture in a serum-free medium. The cell clusters grown to a size of 100 to 150 mum contained cells staining for stage-specific embryonic antigens, but not insulin or C-peptide. To direct cell differentiation toward islets, clusters were recultured in a pancreatic differentiation medium. Insulin and C-peptide-positive cells by immunocytochemistry appeared within a week, reaching over 10% of the cell population. Glucagon and somatostatin-positive cells were also detected. The cell clusters were found to secrete insulin in response to glucose stimulation. Cells from the same clusters also had the capacity for differentiation into neural cells, as documented by staining for neural and glial cell markers when cultured as monolayers in media containing neurotrophic factors. These data suggest that multipotent pancreatic progenitor cells exist within the human pancreatic tissue that is typically discarded during islet isolation procedures. These adult progenitor cells can be successfully differentiated into insulin-producing cells, and thus they have the potential for treatment of type-1 diabetes mellitus.

Increased expression of cyclooxygenase-2 in human pancreatic islets treated with high glucose or ligands of the advanced glycation endproduct-specific receptor (AGER), and in islets from diabetic mice

AIMS/HYPOTHESIS

The cyclooxygenase-2 (PTGS2, previously known as COX2) enzyme and its products, such as prostaglandin E(2) (PGE(2)), have been implicated in the pathogenesis of several inflammatory diseases including islet dysfunction under diabetic conditions. In this study we evaluated whether diabetic conditions in vitro, such as high-glucose (HG) culture or AGE, or in vivo in animal models of diabetes can induce PTGS2 expression and activity in pancreatic islets.

MATERIALS AND METHODS

Isolated human pancreatic islets were treated for 24 h with HG (25 mmol/l) or with S100b (5 mg/l), a specific ligand for the AGE-specific receptor. PTGS2 and cyclooxygenase-1 (PTGS1, previously known as COX1) mRNA, protein expression and product PGE(2) were analysed by RT-PCR, Western blots and specific enzyme immunoassay respectively. Islet PTGS2 production in animal models was assessed by immunofluorescence.

RESULTS

Treatment of human pancreatic islets with HG and S100b led to a three-five-fold induction of PTGS2 mRNA (p<0.001). PTGS2 protein and its product PGE(2) (351.4+/-13.05 fg/ml vs control 39.4+/-0.11 fg/ml) were also increased (p<0.001). Pretreatment with specific inhibitors demonstrated the involvement of protein kinase C and oxidant stress in S100b- and HG-induced PTGS2 expression. However, insulin secretion was not significantly altered by S100b. Double immunofluorescent staining showed increased PTGS2 production in pancreatic islets from diabetic mice relative to corresponding controls.

CONCLUSION/INTERPRETATION

These results show for the first time that diabetes as well as diabetic conditions such as AGE and HG in vitro can directly upregulate the expression of the inflammatory PTGS2 gene in pancreatic islets. This might contribute to the pathogenesis of islet dysfunction in diabetes.

Maxacalcitol therapy decreases circulating osteoprotegerin levels in dialysis patients with secondary hyperparathyroidism

BACKGROUND

Osteoprotegerin is a natural glycoprotein which plays a critical role in osteoclast physiology. Elevated levels of circulating osteoprotegerin may account for the development of bone and mineral metabolic abnormalities in uremia. Little is known about the effects of vitamin D therapy on the circulating osteoprotegerin levels in dialysis patients.

PATIENTS AND METHODS

Fifty chronic dialysis patients whose plasma intact PTH levels were greater than 300 pg/ml were analyzed for the study. Following a four-week washout time during which all vitamin D administration was halted, 10 microg of maxacalcitol was intravenously injected thrice a week.

RESULTS

The circulating intact PTH, bone-specific alkaline phosphatase and intact osteocalcin levels were significantly lowered, while the serum calcium levels were elevated after the therapy. The osteoprotegerin levels significantly decreased after the therapy (p < 0.0001).

CONCLUSION

Maxacalcitol therapy reduced the circulating osteoprotegerin levels and improved secondary hyperparathyroidism. The observed effects were the opposite of those expected from previous in vitro studies. Osteoprotegerin may mediate and/or modify the effect of active vitamin D therapy in dialysis patients.

Isolation and analysis of lipase-overproducing mutants of Serratia marcescens

We have isolated a lipase-overproducing mutant, GE14, from Serratia marcescens 8000 after three rounds of N-methyl-N'-nitro-N-nitrosoguanidine mutagenesis. The mutant GE14 produced 95 kU/ml of extracellular lipase in the lipase medium, which was about threefold higher than that of produced by the original strain 8000. Enzymatic characteristics including specific activity of purified lipases from culture supernatants of GE14 and 8000 were almost same. The lipase gene (lipA) of GE14 contained two base substitutions; one in the promoter region and another in the N-terminal region of the lipA gene without an amino acid substitution. Promoter analysis using lipA-lacZ fusion plasmids revealed that these substitutions were responsible for the increase in the lipA expression level, independently. In contrast, no base substitution was found in the genes encoding the lipase secretion device, the Lip system. In addition, the genes coding for metalloprotease and the cell surface layer protein which are both secreted through the Lip system and associated with extracellular lipase production, also contained no base substitution. The strain GE14 carrying a high-copy-number lipA plasmid produced a larger amount of the extracellular lipase than the recombinant strains of 8000 and other mutants also did, indicating that GE14 was not only a lipase-overproducing strain, but also an advantageous host strain for overproducing the lipase by a recombinant DNA technique. These results suggest that the lipase-overproducing mutant GE14 and its recombinant strains are promising candidates for the industrial production of the S. marcescens lipase.

Inhibition of p38 Mitogen-Activated Protein Kinase Protects Human Islets From Cryoinjury and Improves the Yield, Viability, and Quality of Frozen-Thawed Islets

The development of an optimal islet cryopreservation method will permit transplantation of islets from multiple donors in a single procedure and contribute to alleviation of the islet shortage. In this study, we have improved human islet cryopreservation methods under serum-free conditions using an intracellular-based islet cryopreservation solution (ICS), especially supplemented with a p38 pathway inhibitor (p38IH) to suppress p38 mitogen-activated protein kinase (MAPK) activation. Three different solutions were compared for freezing and thawing of human islets (1) conventional RPMI1640 medium, (2) ICS, and (3) ICS supplemented with a p38IH, SD-282 (ICS-p38IH). Islet cryopreservation with ICS-p38IH significantly improved islet recovery, viability, and quality after thawing of cryopreserved islets. This improvement may allow the use of cryopreserved islets in clinical islet transplantation.

Peroxisome proliferator-activated receptor γ C161T polymorphisms and survival of Japanese patients with immunoglobulin A nephropathy

Peroxisome proliferator-activated receptor gamma (PPAR gamma) plays an important role in lipid metabolism, insulin sensitivity, atherogenesis, and immune regulation. A genetic polymorphism (C161T) at exon 6 of PPAR gamma gene (PPARG) was reported to be associated with the onset of coronary artery disease. However, there has been no report of an association with renal disease. Genomic DNAs were isolated from 225 Japanese patients with histologically confirmed immunoglobulin A nephropathy (IgAN). The PPARG C161T genotype was determined by polymerase chain reaction-restriction fragment length polymorphism. The association of the polymorphism with renal prognosis in IgAN patients was analyzed using the Kaplan-Meier method and Cox proportional hazard regression model. The PPARG polymorphism was not associated with the renal survival rate. However, when patients were stratified into those either with or without hypertension at the time of diagnosis, the renal survival of the CT/TT genotypes was significantly better in those without hypertension than those with the CC genotype. We report that the PPARG C161T polymorphism is associated with the survival of IgAN patients without hypertension. The T allele of the polymorphism might have a protective effect on the progression of IgAN.

Substitution of Dmo1 with normal alleles results in decreased manifestation of diabetes in OLETF rats

AIM

Dmo1 (Diabetes Mellitus OLETF type I) is a major quantitative trait locus for dyslipidaemia, obesity and diabetes phenotypes in the Otsuka Long Evans Tokushima Fatty (OLETF) rat strain. To evaluate possible metabolic and pathological improvements generated by correction of the Dmo1 genetic pathway, we produced congenic lines, in which both OLETF Dmo1 alleles are replaced by the F344-derived genome.

METHODS

Congenic animals were produced by introgressing F344-derived Dmo1 alleles into the OLETF rat. Congenic animals of the fourth generation (BC4) were intercrossed to obtain F1 animals (BC4:F1). Animals of the next generation, BC4:F2, were used for this study. We used 23 BC4:F2 males harbouring homozygous replacement of the OLETF Dmo1 region with the F344-derived genome. Seven animals with OLETF-derived Dmo1 alleles were used as controls.

RESULTS

Dmo1-F344/F344 congenic rats showed significant decreases in body weight, abdominal fat weight, serum triacylglycerols, total cholesterol, food consumption and blood glucose after glucose loading (13%, 39%, 45%, 27%, 18% and 27% respectively; p < 0.05) compared with Dmo1-OLETF/OLETF animals. Furthermore, histopathological analysis of the kidney showed that mesangial sclerosis, hyalin deposits and deposition of PAS-positive substance were significantly lower in Dmo1-F344/F344 animals (p < 0.05).

CONCLUSION

Improvements in metabolic parameters and histopathological scores show that correction of the Dmo1 genetic pathway in the diabetic and mildly obese OLETF rat strain produces wide-ranging therapeutic effects. Thus, this pathway might represent a new drug target also applicable to humans.