Risk factors of dumping syndrome after fundoplication for gastroesophageal reflux in children

PURPOSE

In postoperative cases of fundoplication, the gastric emptying ability is promoted and sometimes exhibits dumping syndrome. Dumping syndrome often goes unrecognized in children. Furthermore, the risk factors for postoperative dumping syndrome are unknown. This study aimed to investigate the risk factors of developing dumping syndrome after fundoplication.

METHODS

A retrospective chart review of all consecutive patients between January 2003 and March 2018 (190 patients) who had fundoplication at our clinic was conducted. Regarding the risk factors of dumping syndrome, gender, age and body weight at the time of surgery, neurological impairment, severe scoliosis, microgastria, chromosomal abnormalities, complex cardiac anomalies, gastrostomy, and laparoscopic surgery were retrospectively studied.

RESULTS

17 patients (9%) developed dumping syndrome post-operatively. Multivariate analysis showed that significant risk factors for dumping syndrome included: undergoing surgery within 12 months of age (adjusted OR 10.3, 95% CI 2.6-45.2), severe scoliosis (adjusted OR 19.3, 95% CI 4.4-91.1), and microgastria (adjusted OR 26.5, 95% CI 1.4-896.4).

CONCLUSIONS

We identified that: age at fundoplication being within 12 months of age, severe scoliosis, and microgastria were risk factors for dumping syndrome after fundoplication, and that this information should be explaining to the family before conducting the fundoplication.

A rare case of neonatal colonic obstruction caused by a solitary intestinal tumor

Background

Intestinal obstruction caused by a tumor is very rare in newborns, and the preoperative diagnosis is difficult. We herein report a rare case of neonatal colonic obstruction due to solitary intestinal myofibroma with characteristic findings on gastrografin enema and the surgical strategy.

Case presentation

A 4-day-old female infant presented to our neonatal intensive-care unit with abdominal distention and bilious vomiting after feeding. A gastrografin enema showed that the transverse colon near the hepatic flexure was not delineated at the oral side. When pressure was applied, a small amount of contrast material moved into the mouth in the form of threads. Microcolon was not observed, and stenosis of the transverse colon was found 9 cm from the Bauhin valve. Partial resection and end-to-end anastomosis were performed. A pathological examination of the resected specimen suggested gastrointestinal stromal tumor (GIST). After obtaining a second opinion, the histology and immunohistological markers were deemed characteristic of infantile myofibroma.

Conclusion

If string sign and a napkin ring appearance are found in a case of neonatal intestinal obstruction, surgery should be performed with a tumor in mind. In cases of neonatal intestinal obstruction caused by a tumor, the lesion should be resected with a sufficient surgical margin before the pathological examination.

Long-Term Outcomes After Pediatric Tracheostomy-Candidates for and Timing of Decannulation

BACKGROUND

Although pediatric tracheostomy has been a widely performed, life-saving procedure, its long-term outcomes have remained unclear. This study aimed to review outcomes after tracheostomy at a Japanese tertiary hospital and clarify candidates for and timing of decannulation.

MATERIALS AND METHODS

Hospital records of critically ill children who underwent tracheostomy from 2001 to 2014 were retrospectively reviewed, subsequently analyzing outcomes according to demographics, complications, and decannulation. After excluding those who were lost to follow-up or had irreversible neuromuscular impairment, the remaining patients were divided into the decannulation (D group) and nondecannulation (ND group) groups and compared.

RESULTS

In total, 184 patients who underwent tracheostomy were analyzed (median age at operation: 0.5 y). The major indication for tracheostomy was irreversible neuromuscular impairment (46%). Surgery-related and overall mortality rates were 1% and 25%, respectively, while the successful decannulation rate was 21%. No significant difference in surgical indications or comorbidities was observed between the D (n = 39) and ND (n = 50) groups, except for infection (7 in D group versus 0 in ND group; P = 0.002) and chromosome-gene disorder (15% versus 34%; P = 0.04). The ND group had a significantly higher mortality rate than the D group (46% versus 3%; P < 0.0001). The median time to decannulation was 3.6 years, while that for infection was 0.7 y.

CONCLUSIONS

Patients who underwent tracheostomy at our institution due to temporary infections achieved more successful and earlier decannulation compared to other indications. Chromosome-gene disorder as a comorbidity can negatively affect decannulation.

Long-term follow-up for anorectal function after anorectoplasty in patients with high/intermediate imperforate anus: a single center experience

PURPOSE

The aim of this study was to evaluate the clinical outcomes and postoperative anorectal function in the patients with high/intermediate imperforate anus (HIA/IIA) treated in our institution. In addition, we report our novel procedure, laparoscopically assisted anorectoplasty with anterior perineal incision (LAARP-API), which allows direct approach to the anterior edge of the puborectal sling and muscle complex, and is useful for the creation of a pulling-through route for the rectal pouch.

METHODS

From 1976 to 2016, 22 patients with HIA and 43 patients with IIA underwent sacroperineal/sacroabdominoperineal pull-through anorectoplasty (SP/SAP), Potts procedure (Potts), SP with API (SP-API) or LAARP-API. Clinical data and anorectal function of those patients were retrospectively evaluated using the Japanese clinical score.

RESULTS

Of the 22 cases of HIA, 15 were treated by SAP, 2 were SP and 5 were LAARP-API. Of the 43 cases of IIA, one was treated by SAP, 31 were SP, two were Potts and nine were SP-API. The mean score of anorectal function of HIA/IIA both increased with age. In IIA, the score after SP-API was significantly higher than the score after SP.

CONCLUSION

Long-term outcomes of our anorectoplasty for HIA/IIA are good with excellent anorectal function score.

Is a nasogastric tube necessary after transumbilical laparoscopic-assisted appendectomy in children with perforated appendicitis?

BACKGROUND

This study assessed the necessity of postoperative nasogastric tube (NGT) use in acute pediatric cases of perforated appendicitis.

METHODS

All cases of acute pediatric perforated appendicitis managed with transumbilical laparoscopic-assisted appendectomy at our hospital from 2011 to 2017 were retrospectively reviewed. Sixty-two cases were selected and divided into two groups based on NGT placement.

RESULTS

There were no significant differences between the two groups in most parameters of patient demographics, or surgical data. Notably, the mean time to first oral intake and to regular diet was significantly shorter in no-NGT group (1 day vs 3 days, P < 0.0001; and 4 days vs 7 days, P = 0.003, respectively). Postoperative length of stay was significantly shorter in no-NGT group (7 days vs 9 days, P < 0.0001).

CONCLUSION

Considering the results of our analysis, we believe that routine NGT placement is not always necessary in these situations.

Non-operative management of congenital tracheal stenosis: criteria by computed tomography

OBJECTIVES

Whether to perform surgical or conservative treatment for congenital tracheal stenosis (CTS) is controversial. Thus, the computed tomography (CT) criteria for conservative treatment of CTS were investigated.

METHODS

From 2005 to 2017, 28 CTS cases were included. The operative cases and preoperative death cases constituted the required intervention group (group I), and the non-operative surviving cases constituted the observation group (group O). The diameter of the tracheal narrowest part (DTNP) on CT was evaluated as a criterion for non-operative follow-up.

RESULTS

Chest CT was performed 19 times in 19 group I cases and 18 times in 9 group O cases. The median age of the patients that underwent CT scan examinations was 3.4 months (range 0-25 months) in group I and 22 months (range 0-60 months) in group O. The cut-off values of the non-operative criteria were 40.8% (AUC: 0.82, p < .01) normal for age of the trachea's narrowest part, and 41.6% normal for body weight (AUC: 0.92, p < .01), respectively.

CONCLUSIONS

DTNP is 40% and more of the normal diameter appears necessary for non-surgical management. The present study suggests that the criteria for conservative management of CTS are that the DTNP is not less than 40% of the normal tracheal diameter, with a few symptoms.

Unexpected gap between intraoperative caliber change of the intestine and normoganglia in patients with intestinal aganglionosis

PURPOSE

Intestinal aganglionosis (IA) is so rare that the entity remains unclear. The aim of the present study was to compare the outcomes of patients with IA and those with total colonic aganglionosis (TCA).

METHODS

The hospital records were retrospectively reviewed from 1977 to 2018. Outcomes were analyzed for the IA group and the TCA group, including clinical presentation, initial management, and operative details.

RESULTS

There were six patients were managed in IA (all male) and seven patients in TCA (4 male). The median age at the first operation was significantly younger in IA than TCA (2 days vs 24 days, p = 0.01). The gap between the intraoperative caliber change (CC) of the intestine and the initial stoma location was not significantly different (7.5 cm vs 12 cm, p = 0.61), but the rate of stoma dysfunction was significantly higher in IA (83% vs 0%, p = 0.005). The gap between the CC and the ganglionated bowel was significantly longer in IA (85 cm vs 10 cm, p = 0.003).

CONCLUSION

Patients with IA appear to have a high risk for stoma dysfunction after the first operation because of the unexpected gap between the CC and normoganglia. The initial location of the stoma requires careful consideration.

Characteristics, management, and outcomes of congenital biliary dilatation in neonates and early infants: a 20-year, single-institution study

BACKGROUND

The aim of the present study was to investigate the characteristics, management, and outcomes of congenital biliary dilatation (CBD) in neonates and infants (<1 year old) in a single institution over the past 20 years.

METHODS

From 1997 to 2016, 21 patients <1 year old underwent definitive surgery for CBD. Open surgery (OS) was performed between 1997 and 2008, and laparoscopic surgery (LS) has been performed since 2009.

RESULTS

The bile duct showed cystic dilatation in all patients. Sixteen (76.2%) of the 21 patients were diagnosed prenatally, and the incidence increased with time (OS 63.6%, LS 90%). Fourteen patients (66.7%) were symptomatic before surgery, with jaundice in 11 (52.4%), acholic stool in seven (33.3%), and vomiting in three (14.3%). There were no significant differences in operation time and blood loss, but the postoperative fasting period and hospital stay were significantly shorter in the LS group (P < 0.05). There were no intraoperative complications, but there was one postoperative early complication in one LS group patient, who had bile leakage and was treated with redo hepaticojejunostomy.

CONCLUSION

The incidences of prenatally diagnosed and asymptomatic patients increased with time. Although longer follow-up is needed, LS for CBD could be safely performed even in neonates and early infants.

Serial intralesional triamcinolone acetonide injections for acquired subglottic stenosis in premature infants

PURPOSE

Long-term intubation of premature infants sometimes induces acquired subglottic stenosis (SGS), causing glottic or supraglottic problems. These kinds of SGS often require tracheostomy and subsequently make decannulation difficult. The aim of our study was to clarify the efficacy of repeated intralesional steroid injections to the stenosis.

METHODS

Six children with acquired SGS, who were treated with triamcinolone acetonide injections to the subglottic space just below the vocal folds between September 2015 and December 2017 were retrospectively reviewed.

RESULTS

The patients' mean age was 4.3 (range 1.3-4.4) years, the mean gestational age at birth was 25 (23-28) weeks, and the mean birth weight was 591 (456-734) g. The degree of SGS was grade II in one patient and III in five patients, with both tracheostoma and glottic or supraglottic abnormalities. They generally underwent ten procedures, every 3-4 weeks. In most cases, the patency of the injected space improved by 25-220%, and the symptoms were relieved. One patient achieved decannulation, and another one underwent laryngotracheal reconstruction and decannulation. Two patients started using a speech cannula. There were no severe complications.

CONCLUSION

Serial intralesional steroid injections are likely to be effective in improving the patency of acquired SGS.

New prognostic classification and managements in infants with esophageal atresia

PURPOSE

The aim of this study was to investigate the risk factors for in hospital mortality in infants with esophageal atresia (EA) without critical chromosome abnormality disorders and develop a new prognostic classification to assess the influence of external risk factors on the prognosis of EA, which could provide more effective treatment strategies in clinical practice.

METHODS

A retrospective chart review of all consecutive patients between January 1994 and December 2017, which included 65 EA infants who were admitted to Shizuoka Children's Hospital, was conducted. Based on multivariate analysis data and ROC analysis, the discrimination of the new prognostic classification was quantified and compared with that of the Spitz classification using the area under the ROC curve (AUC).

RESULTS

Multiple logistic regression analysis showed that birth weight of < 1606 g (adjusted OR, 13.16; 95% CI, 1.16-352.75), and complex cardiac anomalies (adjusted OR 22.39; 95% CI 2.45-569.14) were significant risk factors for death. We have created a new classification close to Spitz classification using the presence of complex cardiac anomalies and birth weight. The mortality rates were 0% for class I (n = 0/40), 7.1% for class II (n = 1/14), 33.3% for class III (n = 3/9), and 100% for class IV (n = 2/2). The AUC of the new classification was better than that of the Spitz classification (0.939 vs 0.812, respectively; p = 0.04).

CONCLUSION

New prognostic classification can improve the stratification of EA patients and be a useful predictor of survival.

Microlaryngoscopic surgery for pyriform sinus fistulas in children: a report of two cases

Background

A pyriform sinus fistula (PSF) is a rare branchial anomaly that causes recurrent cervical infections. Open neck surgery has widely been accepted as a definitive treatment for PSFs, and endoscopic surgery has been reported in recent years. However, both approaches are not satisfactory because of high recurrence rates and postoperative complications. Microlaryngoscopic surgery (MLS) is a transoral surgical technique involving the use of an operating microscope. In this report, we present a new procedure involving MLS for resection and closure of a PSF without a skin incision.

Case presentation

Technique: MLS was performed under general anesthesia with endotracheal intubation. The patient was placed in the supine position, and a direct laryngoscope was inserted to expose the pyriform sinus, which was then magnified using an operating microscope. The mucosal layer was carefully resected using scissors and cupped forceps with sharp edges. The fistula was securely sutured using absorbable suture material. Case 1: A 9-year-old boy with recurrent neck abscesses since 8 years of age presented to our hospital after receiving antibiotics and undergoing drainage in other hospitals. After admission to our hospital, barium esophagography and oral contrast coronal computed tomography showed a PSF on the left side, and open neck surgery was performed to resect the fistula. He was eventually discharged from the hospital without any problem. However, a PSF recurred 2 weeks later. As reoperation with the cervical approach was considered difficult owing to severe adhesions, we adopted MLS as a definitive operation. The postoperative course was uneventful. No recurrence was observed during an 18-month follow-up. Case 2: A 10-year-old girl presented to our hospital with recurrent left-sided neck swelling since 6 years of age. After inflammation control, a PSF was identified on the left side on barium esophagography and computed tomography. MLS was performed safely, and the postoperative course was uneventful. No recurrence was observed during a 10-month follow-up.

Conclusions

MLS allows excellent visualization and effective closure for PSFs, and this approach is suitable for recurrence after open neck surgery. Therefore, MLS might become a first-line treatment for PSFs in children.

Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution

Background: Single-incision laparoscopic appendectomy (SILA) is a potentially safe and feasible alternative to conventional laparoscopic appendectomy using three ports (CLA). However, the safety and efficacy of SILA for complicated appendicitis (gangrenous and perforated) remain unclear. The aim of this study was to evaluate the outcomes of transumbilical laparoscopic-assisted appendectomy (TULAA) not only for simple appendicitis but also for complicated appendicitis, and to compare them with the outcomes of CLA. Methods: All cases of acute pediatric appendicitis who underwent laparoscopic appendectomies in our hospital from 2007 to 2016 were retrospectively reviewed. CLA was performed between January 2007 and October 2011, and TULAA was performed between November 2011 and December 2016. In this study, patients' demographics and operative outcomes for simple appendicitis (catarrhal and phlegmonous) and complicated appendicitis were analyzed, comparing the results of TULAA and CLA. Results: In total, 262 patients underwent laparoscopic appendectomy: CLA in 103 patients and TULAA in 159 patients. All appendectomies were performed in the acute phase. Complicated appendicitis accounted for 60 CLA cases and 81 TULAA cases. There were no significant differences in patients' demographics. Mean operative time in simple appendicitis was significantly shorter in TULAA than in CLA. In addition, complication rates in complicated appendicitis were significantly lower in TULAA than in CLA. Moreover, in each comparison, the postoperative hospital stay was significantly shorter in TULAA than in CLA. Conclusion: In our institution, TULAA has shown to be a safe and effective alternative for both simple and complicated appendicitis in children compared with CLA.

Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study

INTRODUCTION

Hepatoportoenterostomy (HPE) with the Kasai procedure is the treatment of choice for biliary atresia (BA) as the initial surgery. However, the appropriate level of dissection level of the fibrous cone (FC) of the porta hepatis (PH) is frequently unclear, and the procedure sometimes results in unsuccessful outcomes. Recently, indocyanine green near-infrared fluorescence imaging (ICG-FCG) has been developed as a form of real-time cholangiography.

METHODS

We applied this technique in five patients with BA to visualize the biliary flow at the PH intraoperatively. ICG was injected intravenously the day before surgery as the liver function test, and the liver was observed with a near-infrared camera system during the operation while the patient's feces was also observed.

RESULTS

In all patients, the whole liver fluoresced diffusely with ICG-containing stagnant bile, whereas no extrahepatic structures fluoresced. The findings of the ICG fluorescence pattern of the PH after dissection of the FC were classified into three types: spotty fluorescence, one patient; diffuse weak fluorescence, three patients; and diffuse strong fluorescence, one patient. In all five patients, the feces evacuated after HPE showed distinct fluorescent spots, although that obtained before surgery showed no fluorescence. One patient with diffuse strong fluorescence who did not achieve JF underwent living related liver transplantation six months after the initial HPE procedure. Four patients, including three cases involving diffuse weak fluorescence and one case involving spotty fluorescence showed weak fluorescence compared to that of the surrounding liver surface.

CONCLUSION

We were able to detect the presence of bile excretion at the time of HPE intraoperatively and successfully evaluated the extent of bile excretion using this new technique. Furthermore, the ICG-FCG findings may provide information leading to a new classification and potentially function as an indicator predicting the clinical outcomes after HPE.

Notizen: Deoxycyclopaldic Acid and Cyclopaldic Acid, Plant Growth Regulators, Produced by Penicillium sp

Deoxycyclopaldic acid (1) and cyclopaldic acid (2) were isolated from cultures of the fungus Penicillium sp. as plant growth regulators and their structures were established by spectroscopic evidence. Deoxycyclopaldic acid was found in nature for the first time. The biological activities of 1 and 2 have been examined using bioassay methods with lettuce and rice seedlings.

Effects of rapamycin on granulation formation in response to centrally doubled coiled stents as a tracheal substitute

INTRODUCTION

In experiments involving tracheal wall defects in rabbits, metallic coil stents inevitably induce granulation formation in the defects. We examined the involvement of the mammalian target of rapamycin (mTOR) signaling pathway in granulation formation and examined the effects of rapamycin.

METHODS

The anterior half of the tracheal wall was removed for a longitudinal length of six tracheal rings. Metallic coils were placed into the tracheal lumen through a wall defect. The rabbits were sacrificed two months after undergoing an endoscopic examination, and the granulation tissue in the tracheal defects was removed for a Western blot analysis and immunohistochemical analysis. Rapamycin (0.5 mg kg(-1) day(-1)) was administered three times per week intramuscularly. The data were expressed as the relative expression versus the expression of actin.

RESULTS

The level of mTOR phosphorylation in the resected trachea was 0.72±0.45, and it significantly increased in the granulation tissue to 11.6±5.2, with concomitant increases in the phosphorylation levels of p70S6K and S6RP in all five rabbits. Although the systemic administration of rapamycin significantly decreased the levels of phosphorylated mTOR to 4.0±2.4 in the five treated rabbits, the clinical outcomes were unsatisfactory. Three of the five treated rabbits exhibited signs of wound complications, and wet granulation tissue that caused respiratory symptoms was found inside and outside of the coils in four rabbits.

CONCLUSIONS

Although rapamycin effectively reduced the mTOR activity in the granulation tissue, the granulation formation process seemed to be disturbed, most likely owing to the immunosuppressive effects of rapamycin.

The relationship between anagliptin concentration showing over 80% inhibition of plasma dipeptidyl peptidase-4 activity and its protective effect against glucagon-like peptide-1 degradation

In dipeptidyl peptidase-4 (DPP-4) inhibitors, the inhibition of plasma DPP-4 activity by 80% is considered sufficient to have an effect on glycemic control improvement through the elevation of intact glucagon-like peptide-1 (GLP-1). To clarify whether or not the 80% inhibition is sufficient to protect against GLP-1 degradation, we investigated rats with a continuous infusion of exogenous GLP-1. When GLP-1 was infused into the femoral or portal vein, the steady state active GLP-1 levels in plasma significantly increased (P<0.05) at the 80% inhibitory concentration (IC80) of anagliptin (a highly selective DPP-4 inhibitor) against plasma DPP-4 activity, compared with control. In addition, the peptide levels increased in a concentration-dependent manner at drug concentrations from IC80 to 10-fold IC80, and the levels at the 10-fold IC80 were significantly higher (P<0.05) than those at IC80. The concentration dependency on GLP-1 increment was also confirmed based on the experiment in which the endogenous active GLP-1 levels were measured after an oral carbohydrate load. These findings suggest that an almost complete inhibition (80%) of plasma DPP-4 activity was insufficient to protect GLP-1 degradation, and much higher drug concentrations such as 10-fold IC80 are necessary to potently protect GLP-1 from degradation by DPP-4 commonly present in blood and tissues.

Risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts

BACKGROUND AND AIM

The aim of this study was to elucidate the risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts.

METHODS

A retrospective analysis of 94 patients who had undergone cyst excision for congenital choledochal cysts was conducted. The median age at the time of cyst excision and median follow-up time after cyst excision were 7 years and 181 months, respectively.

RESULTS

Biliary tract cancer developed in four patients at 13, 15, 23, and 32 years after cyst excision. The cumulative incidences of biliary tract cancer at 15, 20, and 25 years after cyst excision were 1.6%, 3.9%, and 11.3%, respectively. The sites of biliary tract cancer were the intrahepatic (n = 2), hilar (n = 1), and intrapancreatic (n = 1) bile ducts. Of the four patients with biliary tract cancer after cyst excision, three patients underwent surgical resection and one patient received chemo-radiotherapy. The overall cumulative survival rates after treatment in the four patients with biliary tract cancer were 50% at 2 years and 25% at 3 years, with a median survival time of 15 months.

CONCLUSIONS

The risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts seems to be relatively high in the long-term. The risk of biliary malignancy in the remnant bile duct increases more than 15 years after cyst excision. Despite an aggressive treatment approach for this condition, subsequent biliary malignancy following cyst excision for congenital choledochal cysts shows an unfavorable outcome.

Enhancement by tetraphenylboron of inhibition of mitochondrial respiration induced by 1-methyl-4-phenylpyridinium ion (MPP(+))

The effect of tetraphenylboron (TPB(?)), an activator of a membrane transport of lipophilic cations, on the inhibition of mouse liver mitochondrial respiration induced by a neurotoxin, 1-methyl-4-phenylpyridinium ion (MPP(+)), and by some structurally related compounds was studied. Of the compounds tested, MPP(+) and 4-phenylpyridine (4-PP) significantly inhibited the respiration in an ADP-activated oxidation of substrates (state 3). TPB(?), dose-dependently, shortened the lag time of MPP(+)-induced inhibition and thus lowered the concentrations of MPP(+) for the inhibition. However, TPB(?), even at the high concentration (10 ?M), did not significantly affect 4-PP-induced inhibition. Carbonyl-cyanide-m-chlorophenylhydrazone (CCCP) blocked the respiratory inhibition by MPP(+), independent of K(+) concentration in the medium, and valinomycin blocked the inhibition only in the medium containing high K(+) concentration. Determination of the intramitochondrial MPP(+) concentration revealed about 1000-fold concentrated MPP(+) from that in the medium during the incubation with TPB(?), indicative of potentiation of MPP(+) transport into mitochondria by TPB(?). This might account for the enhancement of respiratory inhibition by MPP(+). In the case of 4-PP, it will penetrate the mitochondrial membrane and intrinsically inhibit the respiration, but cannot accumulate in mitochondria. The present results indicate that, although the inhibitory potency of MPP(+)per se is similar to 4-PP, MPP(+) will be highly concentrated within mitochondria by the membrane potential, as the drive force for its transport.

Effects of neuromodulation with sacral magnetic stimulation for intractable bowel or bladder dysfunction in postoperative patients with anorectal malformation: a preliminary report

BACKGROUND AND PURPOSE

The effects of neuromodulation with sacral magnetic stimulation (SMS) were examined in postoperative patients with bowel or bladder dysfunction.

PATIENTS AND METHODS

SMS was performed at the S3 level using a MagPro® instrument (Medtronic Inc., USA) while the patients were under light sedation. One treatment course consisted of stimulation delivered at 15 Hz for 5 s, 10 times over an interval of 1 min. Three patients with bladder or bowel dysfunction refractory to conservative treatment were examined.

RESULTS

Case 1 is a 7-year-old male with a rectourethral fistula. This patient developed a hyperdynamic bladder after a laparoscopic pull-through operation at the age of 7 months. The administration of an anticholinergic agent slightly improved the condition. SMS was started at the age of 4 years with one trial each year. A marked expansion of bladder volume from 20 ml before trial to 120 ml after the third trial was obtained. Case 2 (a 4-year old female with a recto-vaginal fistula) and Case 3 (a 8-year-old female with an ano-vestibular fistula) showed severe constipation after radical surgery during infancy. Case 2 needed appendicostomy. After SMS, bowel movements could become controllable with enemas. No adverse effects were observed for any of the three cases.

CONCLUSIONS

These results suggest that SMS might be a useful modality to improve postoperative bowel or bladder dysfunction.

Risk factors for regrowth of intracranial meningiomas after gamma knife radiosurgery: importance of the histopathological grade and MIB-1 index

INTRODUCTION

The influence of histopathological grade and MIB-1 index of intracranial meningioma on the results of its radiosurgical management is not clear. The objective of the present retrospective study was to make an evaluation of these factors along with an analysis of other variables associated with progression-free survival after gamma knife radiosurgery (GKR).

PATIENTS AND METHODS

Thirty-four intracranial meningiomas with known detailed histopathological diagnosis were analyzed. Tumors of WHO histopathological grades I, II, and III were diagnosed in 24, 3, and 7 cases, respectively. The median MIB-1 index was 1.3% (range: 0-31.9%). In 14 cases the MIB-1 index was 3.0% and more. In 26 cases the treatment was done at the time of tumor recurrence. Median volume of the neoplasm at the time of GKR was 4.1 mL (range: 0.4-43.1 mL). Median marginal dose was 12 Gy (range: 8-19 Gy). Median length of follow-up constituted 63 months (range: 19-132 months).

RESULTS

Actuarial progression-free survival at 1, 3, 5, and 10 years constituted 100, 94, 83, and 58%, respectively. Histopathological grade II or III (p<0.0001), MIB-1 index 3% and more (p=0.0004), and non-skull base location (p=0.0026) of the tumor showed negative associations with progression-free survival in multivariate analyses. Actuarial progression-free survival at 5 years after GKR for benign and non-benign meningiomas constituted 100 and 45%, respectively (p<0.0001).

CONCLUSION

Radiosurgery is a highly effective management option for benign intracranial meningiomas, but growth control of non-benign ones is significantly worse. It requires close neuroradiological follow-up and necessitates the search for modified treatment strategies.

Dynamics of metabolic changes in intracranial metastases and distant normal-appearing brain tissue after stereotactic radiosurgery: a serial proton magnetic resonance spectroscopy study

The present study evaluated the dynamics of metabolic changes in intracranial metastases and distant normal-appearing brain after stereotactic radiosurgery (SRS). Forty neoplasms were evaluated with single-voxel proton magnetic resonance spectroscopy ((1)H-MRS) both before and after treatment. From one to six examinations (median, 3) were done in each individual case during follow-up. At the time of each investigation additional (1)H-MRS was obtained from the normal-appearing brain distant from the radiosurgical target. Investigated metabolites included N-acetylaspartate (NAA), choline-containing compounds (Cho), creatine (Cr), and mobile lipids (Lip). Within the first month after SRS responded tumors showed a statistically significant increase in NAA/Cho ratio, and decrease of Cho content and Lip-to-normal brain Cr (nCr) ratio. By contrast, statistically significant metabolic alterations were not detected in stabilized tumors. Statistically significant volumetric and metabolic changes were not marked between three and 12 months after treatment in non-progressing lesions. Alternatively, decrease of NAA/Cho ratio, NAA content and Cr content, and increase in Lip/nCr ratio and Cho content were evident in progressive neoplasms, and subtle metabolic alterations could be revealed even before the increase in the lesion volume. Metabolic characteristics of normal-appearing brain distant from the radiosurgical target did not show statistically significant changes within the first year after treatment. In conclusion, additional use of serial (1)H-MRS during follow-up after SRS for intracranial metastases permits detailed evaluation of the metabolic tumor response and may be potentially helpful for early prediction of recurrence.

Metabolic characteristics of intracranial metastases, detected by single-voxel proton magnetic resonance spectroscopy, are seemingly not predictive for tumor response to gamma knife radiosurgery

Metabolic characteristics of intracranial metastases, detected with proton magnetic resonance spectroscopy (1H-MRS) have known associations with clinical predictors of tumor response to radiosurgery. Therefore, it can be suspected that the metabolic profile of the neoplasm by itself might have some prognostic significance for the outcome after irradiation. Twenty-six intracranial metastases, which underwent metabolic evaluation with single-voxel 1H-MRS before gamma knife radiosurgery (GKR) and were followed for at least 3 months after treatment, were selected for retrospective analysis. The tumors most frequently originated from the lungs (9 cases), breast (7 cases), colon and rectum (5 cases). The average volume of the investigated intracranial neoplasm was 5.4+/-2.0 mL. The average marginal irradiation dose was 18.6+/-2.3 Gy. The mean follow-up after GKR constituted 8.0+/-5.5 months. Tumor response to GKR was identified in 13 cases on average 2.2+/-1.8 months after treatment. Local recurrence was marked in 10 cases on average 8.7+/-4.1 months after treatment. None of the investigated 1H-MRS metabolic parameters of intracranial metastases showed a statistically significant association with the outcome after GKR. The negative results of the present study make doubtful the predictive value of metabolic characteristics of intracranial metastases, detected with single-voxel 1H-MRS, for the outcome after radiosurgery.

Identification of homozygous deletions of tumor suppressor gene FAT in oral cancer using CGH-array

Homozygous deletions (HD) provide an important resource for identifying the location of candidate tumor suppressor genes. To identify the tumor suppressor gene in oral cancer, we employed high-resolution comparative genomic hybridization (CGH)-array analysis. We identified a homozygous loss of FAT (4q35), a new member of the human cadherin superfamily, from genome-wide screening of copy number alterations in one primary oral cancer. This result was evaluated by genomic polymerase chain reaction in 13 oral cancer cell lines and 20 primary oral cancers and Southern blot in the cell lines. We found frequent exonic HD of FAT in the cell lines (3/13, 23%) and in primary oral cancers (16/20, 80%). FAT expression was absent in these cell lines. Homozygous deletion hot spots were observed in exon 1 (9/20, 45%) and exon 4 (7/20, 35%). Moreover, loss of gene expression was identified in other types of squamous cell carcinoma. The methylation status of the FAT CpG island in squamous cell carcinomas correlated negatively with its expression. Our results identify mutations in FAT as an important factor in the development of oral cancer and indicate the importance of FATs function in some squamous cell carcinomas.

Sensitivity to radiation-induced apoptosis and neuron loss declines rapidly in the postnatal mouse neocortex

Therapeutic brain irradiation can cause progressive decline in cognitive function, particularly in children, but the reason for this effect is unclear. The study explored whether age-related differences in apoptotic sensitivity might contribute to the increased vulnerability of the young brain to radiation. Postnatal day 1 (P1) to P30 mice were treated with 0-16 Gy whole-body X-irradiation. Apoptotic cells were identified and quantified up to 48 h later using the TdT-UTP nick end-labelling method (TUNEL) and immunohistochemistry for activated caspase-3. The number of neuron-specific nuclear protein (NeuN)-positive and -negative cells were also counted to measure neuronal and non-neuronal cell loss. Significantly greater TUNEL labelling occurred in the cortex of irradiated P1 animals relative to the other age groups, but there was no difference among the P7, P14 and P30 groups. Irradiation decreased the %NeuN-positive cells in the mice irradiated on P1, whereas in P14 animals, irradiation led to an increase in the %NeuN-positive cells. These data demonstrate that neocortical neurons of very young mice are more susceptible to radiation-induced apoptosis. However, this sensitivity decreases rapidly after birth. By P14, acute cell loss due to radiation occurs primarily in non-neuronal populations.

Evaluation of clinical and serological data from Taenia solium cysticercosis patients in eastern Inner Mongolia Autonomous Region, China

Neurocysticercosis (NCC) is one of the major causes of neurological disease in China. ELISA and immunoblotting using glycoproteins purified by preparative isoelectric focusing were used to detect human cysticercosis in Tongliao area, Inner Mongolia, China in 1998. Approximately 89% (39 of 44 inpatients and outpatients with suspected NCC at Tongliao City Hospital) were residents of Inner Mongolia. About 53% were male and 77% were of working age (18-59 years), and 32% were farmers. Immunoblotting and ELISA showed a high correlation. Of the 44 patients, 31 positive by cerebral computed tomography (CT) scan were confirmed serologically to have cysticercosis. In the ELISA, patients with no lesions by CT scan had lower OD values, similar to those of normal serum. These findings confirm that both ELISA and immunoblotting assays are sufficiently sensitive to detect asymptomatic or symptomatic cysticercosis patients.

Kinetic pathway to double-gyroid structure

We have investigated the structural development during order-order transitions to the double-gyroid (DG) phase of nonionic surfactant/water systems based on two-dimensional small-angle x-ray scattering patterns from highly oriented ordered mesophases. The lamellar (L) to DG transition proceeds through two intermediate structures, a fluctuating perforated layer structure having ABAB stacking and a hexagonal perforated lamellar structure with ABCABC stacking (HPLABC). For a hexagonally packed cylinder (H) to DG transition, we also observed the HPLABC structure as the intermediate phase, thus the HPLABC is an entrance structure for the DG phase. The hexagonal perforated lamellar (HPL) structure consists of hexagonally packed holes surrounded by the planar tripods, and the transition from HPL structure to the DG phase proceeds by rotation of the dihedral angle of connected tripods. A geometrical consideration shows that large deformations of HPL planes are necessary to form the DG structure from the HPLABC structure, whereas the transition from a HPL structure with ABAB stacking (HPLAB) to the DG structure is straightforward. In spite of the topological constraints, the HPLABC structure is observed in the kinetic pathway to the DG structure.

Static and dynamic structures of spherical nonionic surfactant micelles during the disorder-order transition

We have investigated the static and dynamic structures of nonionic surfactant micelles, a C(12)E(8)/water binary system, during the disorder-order transition using small angle x-ray scattering, static light scattering, and dynamic light scattering techniques. In the disordered phase, the micelles have spherical shape and intermicellar interactions are governed by the hard core and weak long ranged attractive potentials. With increase of the micellar concentration, the disordered micelles transform to the three characteristic ordered micellar phases, a hexagonally close packed lattice, a body centered cubic lattice, and an A15 lattice having area-minimizing structure. The stability of these phases is well explained by balance of a close packing rule and a minimal-area rule proposed by Ziherl and Kamien [Phys. Rev. Lett. 85, 3528 (2000)]. The role of hydrodynamic interactions in surfactant micellar solutions was compared with that in hard sphere colloidal particle suspensions.

Hymenolepis microstoma: direct life cycle in immunodeficient mice

The mouse bile duct tapeworm Hymenolepis microstoma requires beetles as the obligatory intermediate host. However, when congenitally athymic NMRI-nu mice were infected with the mature tapeworm and allowed to eat their own faeces with tapeworm eggs, the oncospheres penetrated the intestinal tissue and developed to cysticercoids. After excysting, growth to adult worms occurs in the lumen of the small intestine and bile duct. Furthermore, the same happened when NMRI-nu mice, non-obese diabetic severe combined immunodeficiency (NOD/Shi-scid) mice and NOD/Shi-scid, IL-2 Rgamma(null) (NOG) mice were orally inoculated with shell-free eggs of this parasite. Differences between the cysticercoids of H. microstoma and H. nana developed in the mouse intestinal tissues were: (i) the time course for the development of fully matured cysticercoids of H. microstoma in mice was about 11 days but only 4 days for H. nana; and (ii) cysticercoids of H. microstoma developed in mice had a tail while those of H. nana had none.

Inter-lamellar interactions modulated by addition of guest components

We have investigated the effects of a guest component (polymer or spherical colloidal particle) confined between flexible lamellar slits on the inter-lamellar interaction by means of a small-angle X-ray scattering technique and a neutron spin echo technique. The dominant interaction between flexible lamellar membranes without guest components is the Helfrich mechanism. The addition of a neutral polymer into the lamellar phase induces an attractive inter-lamellar interaction and finally destabilizes the lamellar phase. On the other hand, spherical colloidal particles confined between flexible lamellar membranes reduce the undulational fluctuations of lamellae and bring a repulsive inter-lamellar interaction. The behavior of the layer compression modulus of the lamellar membrane containing colloidal particles is well described by the entropical repulsive inter-lamellar interaction driven by steric hindrance.

Recent advances in basic and applied science for the control of taeniasis/cysticercosis in Asia

Detection of seven specific bands by immunoblot (IB) using glycoproteins (GPs) purified by lentil-lectin affinity chromatography has been the gold-standard for neurocysticercosis (NCC) serodiagnosis since 1989. However, due to the presence of contaminants, it was impossible to apply the GPs to ELISA. Our group at Asahikawa Medical College (AMC) succeeded in purifying the GPs by preparative isoelectric focusing; these higher quality GPs were suitable for ELISA. Based on the results of both IB and ELISA testing, developed at AMC for a field survey in Irian Jaya, it became evident that that area had pandemic NCC. We found many NCC patients, pigs full of cysts, and one dog infected with two cysts: these findings were based on serology. Recently, we conducted another survey to detect of the worm carriers of T. solium. Three of the 38 local people were positive by copro-antigen specific to Taenia species; these three patients expelled segments of Taenia spp and these were confirmed as those of T. solium by mitochondrial DNA analysis. When viable eggs of any taeniid species could be obtained, they can be developed into metacestodes in NOD-scid mice; it then becomes possible to analyze morphological dynamics, metacestode antigenicity, the efficacy of new metacestocidal drugs, and mitochondrial DNA. Mitochondrial DNA analysis of the specimens obtained in Irian Jaya was compared with that of other isolates worldwide. T. solium is now divided into two genotypes: the Asian type, and the Africa-American type. Some aspects of the pathological differences between the Asian and Africa-American types and the antigenic components of these two types are discussed.

Taenia solium taeniasis/cysticercosis in Papua, Indonesia in 2001: detection of human worm carriers

A preliminary study to detect human worm carriers of Taenia solium in Papua (Irian Jaya), Indonesia was carried out using stool examinations for the detection of copro-antigens and adult proglottids after chemotherapy, and confirmation by mitochondrial DNA analysis using expelled proglottids and metacestodes developed in NOD/Shi-scid mice from eggs of expelled proglottids. Approximately 8.6% of the local population in Kama (5/58), 1 km from the local capital city centre, Wamena, were confirmed to harbour adult T. solium using these techniques.

Evaluation of tongue inspection and serology for diagnosis of Taenia solium cysticercosis in swine: usefulness of ELISA using purified glycoproteins and recombinant antigen

Evaluation of serology using glycoproteins (GPs) purified by preparative isoelectric focusing (pH 8.8) and recombinant chimeric antigen (RecTs) of Taenia solium was carried out using (1) blood samples on filter papers from pigs infected with different doses of eggs of T. solium in Mexico, (2) serum samples from pigs found infected naturally in Vietnam and Ecuador and (3) serum samples from pigs suspected to be infected with T. solium by tongue inspection in Tanzania. Antibody responses (IgG) were detectable in experimentally infected pigs confirmed harbouring 16 or more cysts at necropsy from 30 days after egg inoculation. One of three pigs naturally infected and harbouring 2.5 cysts/kg muscle and most of pigs harbouring=5.0 cysts/kg were also seropositive by ELISA. Although pigs may be infected with other taeniid species such as Taenia hydatigena, pigs harbouring this parasite were negative in ELISA. Approximately, 76 and 78% of sera from pigs having nodule(s) in the tongue (positive tongue inspection) were serologically positive by both ELISA and immunoblot, respectively. Furthermore, approximately 34 and 18% of sera from pigs having no nodules in the tongue (negative tongue inspection) were also seropositive by ELISA and immunoblot, respectively. ELISA using the two antigens was more sensitive than immunoblot and reliable for differentiation of pigs infected with cysticerci of T. solium from those either uninfected or infected with other taeniid species. Pigs without nodule by tongue inspection should be checked serologically in endemic areas.

Cysticercosis/taeniasis: recent advances in serological and molecular diagnoses

Serodiagnosis by immunoblot, using recombinant chimeric T. solium antigen and native glycoprotein antigens, has been applied for neurocysticercosis cases. Specific antibodies against both antigens were detected in serum samples from NCC patients involving multiple cysts in the brain, whereas it was not always easy to detect specific antibodies in NCC cases with a solitary cyst or calcified lesion(s). On the other hand, the diagnosis for human taeniasis or worm carriers has been routinely performed by stool examination. In this study, multiplex PCR has been established to differentiate taeniasis using Taenia mitochondrial DNA in fecal samples from worm carriers. Furthermore, the molecular identification of human taeniid cestodes by base excision sequence scanning thymine-base analysis has also been introduced. This method provides four thymine-base peak profiles unique for Asian and American/African genotypes of T. solium, T. saginata and T. asiatica. By comparing thymine base peak profiles, it is possible to differentiate human taeniid cestodes without DNA sequencing. The approaches are powerful tools for the routine diagnosis of taeniasis and the molecular identification of taeniid cestodes.

Dogs as alternative intermediate hosts of Taenia solium in Papua (Irian Jaya), Indonesia confirmed by highly specific ELISA and immunoblot using native and recombinant antigens and mitochondrial DNA analysis

Serology (ELISA and immunoblot) using native glycoproteins, affinity purified glycoproteins, and a recombinant antigen is known to be highly specific to Taenia solium cysticercosis in humans and pigs. These techniques were applied for dogs in the highly endemic area of cysticercosis in Papua (Irian Jaya), Indonesia. Analysis of dog sera by both ELISA and immunoblot revealed 7 of 64 dogs were highly positive. Examination of two sero-positive dogs revealed cysticerci of T. solium in the brain and heart of these dogs. Mitochondrial DNA analysis confirmed that they were the same as T. solium previously confirmed from pigs and biopsies from local people from Irian Jaya. It is suggested that the life cycle of T. solium may be completed not only between humans and pigs but also between humans and dogs.

NOD-scid mouse as an experimental animal model for cysticercosis

The major three species of human taeniid cestodes, Taenia solium, T. saginata and T. saginata asiatica (= T. asiatica) which require humans as the definitive host are still not rare in developing countries. Among these, T. solium is the most serious with medical and economic importance. Neurocysticercosis (NCC) in humans is now recognized as the major cause of neurologic disease in the world. As these human taeniid cestodes obligatory require domestic animals such as swine, cattle and swine as the major intermediate host animals respectively, it is not easy to analyze the basic research in these domestic animals. In this brief review, we introduce experimental animal model for these three species in order to obtain fully developed metacestode stage in severe combined immunodeficiency (scid) mice. Non-obese diabetic scid (NOD-scid) mice are expected to be a satisfactory animal model and to have advantages for analysis by several view points of developmental biology with gene expression throughout development, antigenic homology of cyst fluid of these three species, evaluation of drug efficacy or metacestocidal drug designs, confirmation of unknown taeniid gravid segments for identification based on the morphology and DNA analysis of metacestodes. The animal model is not only available for human Taenia spp but can also be applied to other taeniid cestodes of economic importance or in veterinary parasitology.

Differential serodiagnosis of cystic and alveolar echinococcosis using native and recombinant antigens in Japan

Our group at Asahikawa Medical College has established differential serodiagnosis for zoonotic larval cestodiases such as alveolar echinococcosis (AE), cystic echinococcosis (CE) and neurocysticercosis (NCC) using purified specific antigens. In this brief review, we introduce (a) four imported CE cases in Japan, easily identified serologically, (b) most recent advances in serology for differentiation of AE and monitoring of prognosis of AE in Japan. It includes application of affinity purified Em18 and prototype of a recombinant Em18 antigen. Serology using affinity purified Em18 antigens is showing much higher sensitivity for detection of AE cases which are usually undetectable by the ongoing serology for AE authorized in Hokkaido, Japan. As serology for AE, CE or NCC is still not popular in the majority of Asian countries, we expect that this review paper stimulates researchers who are interested in serology or serodiagnosis for these larval cestodiases including AE, CE and NCC.

A phylogenetic hypothesis for the distribution of two genotypes of the pig tapeworm Taenia solium worldwide

Genetic polymorphism was determined among 13 isolates of Taenia solium from various regions using PCR-amplified sequences of 2 mitochondrial genes: cytochrome c oxidase subunit 1 and cytochrome b. The 2 phylogenies obtained were similar to each other regardless of the genes examined. The isolates from Asia (China, Thailand, Irian Jaya and India) formed a single cluster, whereas the isolates from Latin America (Mexico, Peru, Ecuador, Bolivia and Brazil) combined with those from Africa (Tanzania, Mozambique and Cameroon) to form an additional cluster. These results and historical data of swine domestication, distribution of pigs and colonization suggest that T. solium was introduced recently into Latin America and Africa from different regions of Europe during the colonial age, which started 500 years ago, and that the tapeworm of another origin independently spread in Asian countries.

Comparison of the antigenicity of protoscoleces and microvesicles of Echinococcus multilocularis prepared from rats

Rats are known to be relatively resistant to infection with Echinococcus multilocularis. However, when rats are inoculated with the parasite tissues, E. multilocularis proliferates slowly at first but after 6 months the cysts increase in size considerably and contain large numbers of protoscoleces. As rats survive for 18 months or longer, approximately 100 ml of packed protoscoleces can be produced from each rat. A comparison of the antigenicity of the protoscoleces and microvesicles by immunoblot methods showed that both Em18 and Em16 are shared components between both protoscoleces and microvesicles, although the latter have some additional antigenic components. In antigens prepared from protoscoleces, the banding patterns around Em18 were much simpler than those from microvesicles. Therefore, for serodiagnosis of E. multilocularis, antigens should be carefully prepared from protoscoleces rather than microvesicles from the rat.

B16-BL6 melanoma cells release inhibitory factor(s) of active pump activity in isolated lymph vessels

We investigated whether supernatant cultured with melanoma cell lines B16-BL6 and K1735 or the Lewis lung carcinoma cell line (LLC) can regulate lymphatic pump activity with bioassay preparations isolated from murine iliac lymph vessels. B16-BL6 and LLC supernatants caused significant dilation of lymph microvessels with cessation of pump activity. B16-BL6 supernatant produced dose-related cessation of lymphatic pump activity. There was no significant tachyphylaxis in the supernatant-mediated inhibitory response of lymphatic pump activity. Pretreatment with 3 x 10(-5) M N(omega)-nitro-L-arginine methyl ester (L-NAME) or 10(-7) M or 10(-6) M glibenclamide and 5 x 10(-4) M 5-hydroxydecanoic acid caused significant reduction of supernatant-mediated inhibitory responses. Simultaneous treatment with 10(-3) M L-arginine and 3 x 10(-5) M L-NAME significantly lessened L-NAME-induced inhibition of the supernatant-mediated response, suggesting that endogenous nitric oxide (NO) plays important roles in supernatant-mediated inhibitory responses. Chemical treatment dialyzed substances of <1,000 molecular weight (MW), producing complete reduction of the supernatant-mediated response. In contrast, pretreatment with heating or digestion with protease had no significant effect on supernatant-mediated response. These findings suggest that B16-BL6 cells may release nonpeptide substance(s) of <1,000 MW, resulting in significant cessation of lymphatic pump activity via production and release of endogenous NO and activation of mitochondrial ATP-sensitive K(+) channels.