Thoracoscopic McKeown esophagectomy in a patient with an azygos lobe

BACKGROUND

The azygos lobe is a relatively rare anatomical variation, and there have been no reports, until date, of thoracoscopic McKeown esophagectomy for esophageal cancer in a patient with an azygos lobe. The azygos lobe can be diagnosed by chest X-ray or CT, and is usually not associated with any symptoms. However, surgeons should be aware that transthoracic surgical procedures in patients with an azygos lobe could be associated with a high risk of complications.

CASE PRESENTATION

An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day.

CONCLUSIONS

Although there was a firm adhesion in the thoracic cavity, preoperative recognition of the azygos lobe could help in preventing intraoperative injury. Especially, esophageal surgeons are required to deal with the azygos lobe safely to avoid serious intraoperative injury.

Effective Postoperative Surveillance Protocol after Thoracoscopic Esophagectomy Focusing on Symptoms in Patients with Esophageal Cancer

BACKGROUND

The optimal postoperative surveillance protocol after esophagectomy for patients with esophageal cancer has still not been established. We investigated the risk factors for recurrence of esophageal cancer to devise an appropriate surveillance protocol. We focused on the appearance and worsening of symptoms to determine if additional imaging examinations should be performed.

STUDY DESIGN

We enrolled 416 patients with esophageal and esophagogastric junctional cancer who had undergone thoracoscopic esophagectomy at Tokai University Hospital. Outpatient visits for the patients are usually scheduled at least 4 times per year with CT imaging and blood biochemical examination. We evaluated the time to recurrence after esophagectomy, especially the correlation of this parameter with the appearance and worsening of symptoms during the postoperative outpatient follow-up.

RESULTS

Of the 416 patients, recurrence occurred in 127 patients (30.5%). The median time to recurrence was 6 months after esophagectomy; recurrence occurred within 24 months in 112 patients (88%), and 51 of these patients (40%) developed some new symptom(s) (symptomatic group) before the diagnosis of recurrence. The number of patients who developed recurrence within 6 months was significantly higher in the symptomatic group compared with that in the asymptomatic group (66.7% vs 46.0%, p = 0.02). The overall survival in the symptomatic group was significantly shorter than that in the asymptomatic group (p < 0.001).

CONCLUSIONS

We advocate an effective surveillance protocol depending on the appearance and worsening of symptoms to diagnose recurrence of esophageal cancer; we recommend routine imaging examinations every 6 months and clinical outpatient follow-up at even shorter intervals for the first 24 months after esophagectomy.

Usefulness of three-dimensional thoracoscope for prone position thoracoscopic esophagectomy improves mediastinal lymph node dissection and prognosis for esophageal cancer

OBJECTIVES

This study aimed to assess the superiority of 3D flexible thoracoscope against 2D thoracoscope for lymph node dissection (LND) and prognosis for prone-position thoracoscopic esophagectomy (TE) in esophageal cancer.

METHODS

Three hundred and sixty-seven esophageal cancer patients who underwent prone-position TE with 3-field LND between 2009 and 2018 were evaluated. 2D and 3D thoracoscope was used in 182 (2D group) and 185 cases (3D group), respectively. Short-term surgical outcomes, numbers of retrieved mediastinal lymph node (LN), and rates of LN recurrence were compared. Risk factors for mediastinal LN recurrence and long-time prognosis were also evaluated.

RESULTS

No differences in postoperative complications were observed between the groups. The numbers of retrieved mediastinal LN were significantly higher, and the rates of LN recurrence were significantly lower in the 3D group compared to 2D group. Use of 2D thoracoscope was a significant independent factor of middle mediastinal LN recurrence by multivariable analysis. Survival was compared by cox regression analysis, and the 3D group had a significantly better prognosis than the 2D group.

CONCLUSIONS

Prone position TE using 3D thoracoscope may improve the accuracy of mediastinal LND and prognosis without increasing postoperative complications for esophageal cancer.

Current status and future perspectives for the treatment of resectable locally advanced esophagogastric junction cancer: A narrative review

Incidence rates for esophagogastric junction cancer are rising rapidly worldwide possibly due to the economic development and demographic changes. Therefore, increased attention has been paid to the prevention, diagnosis, and the treatment of esophagogastric junction cancer. Although there are discrepancies in the treatment strategy between Asian and Western countries, surgery remains the mainstay of treatment for esophagogastric junction cancer. Recent developments of perioperative multidisciplinary treatment may lead to better therapeutic effect, higher complete resection rate, and better control of the residual diseases, thus result in prolonged prognosis. In this review, we will focus on the treatment of locally advanced resectable esophagogastric junction cancer, and discuss the current status and future perspectives of the perioperative treatment including chemotherapy, radiation therapy, and immunotherapy, as well as the surgical strategy. Better understanding of the latest treatment strategy and future overlook may enable to standardize and individualize the treatment for esophagogastric junction cancer, thus leading to better prognosis for those patients.

Usefulness of skeletal muscle measurement by computed tomography in patients with esophageal cancer: changes in skeletal muscle mass due to neoadjuvant therapy and the effect on the prognosis

PURPOSE

This analysis was performed to clarify the usefulness of skeletal muscle measurements using computed tomography (CT) in patients with esophageal cancer and the effect of treatment-induced changes in the skeletal muscle mass on the prognosis.

METHODS

Ninety-seven male patients who underwent thoracoscopic esophagectomy for esophageal squamous cell carcinoma were included in the study. The preoperative CT images were analyzed retrospectively.

RESULTS

In a survival analysis performed according to the preoperative data of skeletal muscle, the low-skeletal muscle index (l-SMI) group had a poorer outcome than the normal skeletal muscle index (n-SMI) group in terms of both the overall survival (OS) and the relapse-free survival (RFS) (OS: P < 0.01, RFS: P = 0.01). In the multivariate analysis for the OS, preoperative l-SMI was an independent predictor (hazard ratio: 3.68, 95% confidence interval 1.32-10.2, P = 0.01). In patients who underwent neoadjuvant therapy (NAT), the SMI was significantly reduced after NAT (P < 0.01). The preoperative skeletal muscle area on CT was strongly correlated with the results of a bioelectrical impedance analysis (BIA) (ρ = 0.77, P < 0.01).

CONCLUSIONS

A decreased preoperative skeletal muscle mass was associated with a poor outcome. In patients who underwent NAT, the SMI was significantly reduced after NAT. An analysis of the skeletal muscle mass using CT images was found to be useful for providing data that corresponded with BIA data.

Thoracoscopic esophagectomy for stenosis of thoracic esophagus due to acute esophageal necrosis associated with alcoholic ketoacidosis

Acute esophageal necrosis (AEN) is a rare disease characterized by the appearance of diffuse black mucosa on upper gastrointestinal endoscopy; the condition often progresses to esophageal stenosis in the chronic phase. A 70-year-old man was admitted to a neighborhood hospital with the diagnosis of alcoholic ketoacidosis and an upper gastrointestinal endoscopy performed to investigate the symptom of esophageal tightness revealed AEN. The patient developed esophageal stenosis with scarring in the chronic phase and was referred to our hospital for surgery 6 months after the diagnosis of AEN. We performed thoracoscopic esophagectomy with the patient in the prone position. Although the esophagus was thickened and strong adhesions were present around the esophagus due to inflammation, we were able to complete the surgical procedure thoracoscopically. In patients presenting with benign esophageal stenosis developing after AEN, thoracoscopic esophagectomy may be a useful treatment option, even in the presence of severe fibrosis.

Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review

Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.

Internal hernia caused by bridge formation between the medial and lateral segments of the liver: a case report

Background

Despite numerous reports on ischemic bowel obstruction caused by internal hernia, no case presentation has been reported of an internal hernia caused by a bridge formed between the medial and lateral zones of the liver. Herein, we report the first case of ischemic bowel obstruction caused by a hepatic bridge.

Case presentation

A 24-year-old man complaining of abdominal pain was referred to our hospital and admitted. Computed tomography showed formation of a closed loop of small bowel with a hernia orifice near the hilar region, and poor contrast of the prolapsed small bowel. We suspected ischemic bowel obstruction caused by an internal hernia with a fissure of the greater omentum as the hernia orifice, and performed emergency surgery. Laparoscopic observation revealed that the medial and lateral segments of the liver formed a bridge on the dorsal side at the liver portal, and that the small intestine was ischemic in the gap created between the bridge and the medial and lateral liver segments. A Meckel’s diverticulum was also invaginated in the gap. The bridge was dissected out and the hernia orifice was opened to release the bowel obstruction. The small bowel was preserved and the Meckel’s diverticulum was resected. The patient’s postoperative course was uneventful.

Conclusions

We experienced a case of ischemic bowel obstruction caused by hepatic bridge formation, which was successfully treated by laparoscopic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02294-x.

Does synchronous early head and neck cancer with esophageal cancer need treatment after preoperative chemotherapy?

OBJECTIVE

Treatment options for patients with resectable thoracic esophageal squamous cell cancer (ESCC) and synchronous head and neck cancer (HNC) are unclear. Little has been reported about the effects of chemotherapy on early HNC. The aim of this study was to investigate the treatment outcomes of resectable thoracic ESCC with synchronous early HNC.

METHODS

We retrospectively reviewed 37 patients undergoing esophagectomy for thoracic ESCC with synchronous early HNC from January 2008 to December 2018.

RESULTS

Among 37 patients who had synchronous early HNC, 27 patients received preoperative therapy for ESCC before HNC treatment, and 16 of 27 patients achieved a complete response for HNC by preoperative chemotherapy. Fifteen of 16 patients did not receive additional treatment, and regional recurrence of HNC was not observed. In one other case, an oral excision was performed, but no cancer cell remnants were found pathologically. No significant difference in overall survival and disease-free survival was observed between 15 patients with follow-up and 22 patients with surgery or radiation.

CONCLUSION

Our results indicate that early HNC with comorbid ESCC could be followed up without additional treatment if preoperative chemotherapy is successful.

Small bowel obstruction caused by a true ileo-ileal knot: a rare case successfully treated by prior ligation of mesenteric vessels

Background

Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation.

Case presentation

An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home.

Conclusion

We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure.

Indocyanine green fluorescence imaging for evaluating blood flow in the reconstructed conduit after esophageal cancer surgery

We investigated the effectiveness of indocyanine green (ICG) fluorescence blood flow imaging of the gastric conduit to evaluate anastomotic leakage after esophagectomy. We identified 19 articles using the PRISMA standard for systematic reviews. The more recent studies reported attempts at objective quantification of ICG fluorescence imaging, rather than qualitative assessment. Anastomotic leakage after esophagectomy occurred in 0-33% of the patients who underwent ICG fluorescence imaging. According to the six studies that compared the incidence of anastomotic leakage in the ICG group and the control group, it ranged from 0 to 18.3% in the ICG group and from 0 to 25.2% in the control group, respectively. Overall, the incidence of anastomotic leakage in the ICG group (8.4%) was lower than that in the control group (18.5%). Although the incidence of anastomotic leakage was as high as 43.1% in patients who did not undergo any intraoperative intervention for poor blood flow, it was only 24% in patients who underwent intraoperative intervention. This systematic review revealed that ICG fluorescence imaging may be a crucial adjunctive tool for reducing anastomotic leakage after esophagectomy, suggesting that it should be performed during esophageal reconstruction.

Adhesion Strength of Al/Epoxy Resin Interface over a Wide Range of Loading Rates

This study evaluated the interfacial adhesive strength between aluminium alloy and epoxy resin (Al/epoxy resin) over a wide range of strain rates (loading rates). We conducted three types of tests with different loading rate, i.e., a quasi-static tensile test for the range of lower loading rate, a Split Hopkinson Bar (SHB) for the range of middle loading rate, and Laser Shock Adhesion Test (LaSAT) for the range of higher loading rate. LaSAT is a unique test of adhesion evaluation, since laser induced shock wave is employed to lead interfacial fracture. In parallel, finite element method (FEM) is conducted in order to calculate stress distribution at the interface during LaSAT. As a result, it was found that the interface between the aluminium alloy and the epoxy resin interface shows significant loading rate dependency of the adhesion strength and this tendency is very similar to that of bulk epoxy materials.

Progress in Multimodal Treatment for Advanced Esophageal Squamous Cell Carcinoma: Results of Multi-Institutional Trials Conducted in Japan

In Japan, the therapeutic strategies adopted for esophageal carcinoma are based on the results of multi-institutional trials conducted by the Japan Esophageal Oncology Group (JEOG), a subgroup of the Japan Clinical Oncology Group (JCOG). Owing to the differences in the proportion of patients with squamous cell carcinoma among all patients with esophageal carcinoma, chemotherapeutic drugs available, and surgical procedures employed, the therapeutic strategies adopted in Asian countries, especially Japan, are often different from those in Western countries. The emphasis in respect of postoperative adjuvant therapy for patients with advanced esophageal squamous cell carcinoma (ESCC) shifted from postoperative radiotherapy in the 1980s to postoperative chemotherapy in the 1990s. In the 2000s, the optimal timing of administration of perioperative adjuvant chemotherapy returned from the postoperative adjuvant setting to the preoperative neoadjuvant setting. Recently, the JEOG commenced a three-arm randomized controlled trial of neoadjuvant therapies (cisplatin + 5-fluorouracil (CF) vs. CF + docetaxel (DCF) vs. CF + radiation therapy (41.4 Gy) (CRT)) for localized advanced ESCC, and patient recruitment has been completed. Salvage and conversion surgeries for ESCC have been developed in Japan, and the JEOG has conducted phase I/II trials to confirm the feasibility and safety of such aggressive surgeries. At present, the JEOG is conducting several trials for patients with resectable and unresectable ESCC, according to the tumor stage. Herein, we present a review of the JEOG trials conducted for advanced ESCC.

Extra-gastrointestinal stromal tumor arising in the lesser omentum with a platelet-derived growth factor receptor alpha (PDGFRA) mutation: a case report and literature review

BACKGROUND

Gastrointestinal stromal tumors (GIST) arising from sites other than the gastrointestinal (GI) tract, termed extra-gastrointestinal stromal tumors (EGIST), are rare. Among EGIST, those with platelet-derived growth factor receptor alpha (PDGFRA) mutations are even rarer, with only a few cases reported. About 80% of GIST has KIT mutations, and 10% of GIST have PDGFRA mutations, which commonly affect the TK2 domain (exon 18). Among the exon 18 mutations, the D842V substitution is limited to gastric GIST. In EGIST, the degree of KIT and PDGFRA mutations varies on where the location of the tumor is, and it is suggested that omental EGIST is similar to gastric GIST. Adjuvant imatinib therapy is recommended for high-risk GIST; however, it is known that imatinib is less effective against GIST with a PDGFRA D842V mutation.

CASE PRESENTATION

A 75-year-old man was referred to our hospital with an extrinsic tumor of the lesser curvature of the gastric body. Intraoperative findings showed a tumor located outside of the lesser omentum with no connection between the tumor and the gastric wall. The tumor was subsequently resected. Pathological examination indicated a GIST arising in the lesser omentum measuring 70 mm in its longer dimension. Because the tumor had a PDGFRA mutation (D842V substitution), imatinib was suspected to lack efficacy to the tumor. Thus, although the tumor was considered clinically to have a high risk of recurrence, adjuvant imatinib therapy was not indicated. The patient has been free of recurrence for 29 months since the surgery.

CONCLUSION

We described a case of EGIST with a PDGFRA mutation arising in the lesser omentum. And we reviewed 57 cases of omental EGIST and showed that the clinicopathological characteristics and mutation status in omental EGIST were very similar to gastric GIST. In particular, PDGFAR D842V mutation rate in omental EGIST seemed as high as that in gastric GIST. These results suggested that omental EGIST is strongly related to gastric GIST, so the behavior of omental EGIST might be akin to gastric GIST. However, further studies are required to determine the prognosis and the necessity of adjuvant therapy for EGIST with a PDGFRA mutation.

Early and midterm results of minimally invasive aortic and mitral valve surgery via right mini-thoracotomy

OBJECTIVES

There are few reports regarding minimally invasive aortic valve replacement concomitant with mitral valve surgery (MIAMVS). The aim of this study was to evaluate early and midterm MIAMVS results.

METHODS

We reviewed the medical records of 21 consecutive patients (nine females, 43%) who underwent MIAMVS through a right mini-thoracotomy from December 2014 to April 2017. Mean patient age was 73 ± 7.4 years and four (19%) were New York Heart Association Class III or IV. Aortic stenosis and mitral valve insufficiency were the most common pathologies. All patients were followed for a mean period of 30 ± 8.5 months.

RESULTS

The types of surgery consisted of aortic valve replacement with mitral valve repair in 11 (52%) patients, and replacement of both aortic and mitral valves in 10 (48%), while a tricuspid valve repair, was performed in four. No conversion to a full sternotomy was necessary in any of the cases. Postoperatively, the median intensive care unit and hospital stays were 4.7 and 11.8 days, respectively, with no in-hospital mortality. Following the initial treatment, all 21 patients were followed for a mean period of 30 ± 8.5 months (14-45 months). All patients returned to NYHA Class I or II following the procedure. During the follow-up period, there was no need for a heart valve reoperation for any of the patients and none showed recurrent mitral regurgitation (>mild), though one died from respiratory failure caused by pneumonia.

CONCLUSIONS

MIAMVS can be performed via a right mini-thoracotomy, with acceptable early and midterm results expected. This may be a feasible alternative to the standard median sternotomy approach.

Nanostructured titanium phosphates prepared via hydrothermal reaction and their electrochemical Li- and Na-ion intercalation properties

A series of titanium phosphates with various morphologies are fabricated via a simple hydrothermal reaction of TiO₂ in H₃PO₄ aq.

Glucose-6-Phosphate Dehydrogenase in the Pentose Phosphate Pathway Is Localized in Vanadocytes of the Vanadium-Rich Ascidian, Ascidia sydneiensis samea

Ascidians are sessile marine animals known to accumulate high levels of vanadium selectively in vanadium-containing blood cells (vanadocytes). Almost all the vanadium accumulated in the vacuoles of vanadocytes is reduced to the +3 oxidation state via the +4 oxidation state, although vanadium is dissolved in the +5 oxidation state in sea water. Some of the reducing agents that participate in the reduction have been proposed. By chemical study, vanadium in the +5 oxidation state was reported to be reduced to the +4 oxidation state in the presence of NADPH. The present study revealed the existence of glucose-6-phosphodehydrogenase (G6PDH), the first enzyme to produce NADPH in the pentose phosphate pathway, in vanadocytes of a vanadium-rich ascidian. The results suggested that G6PDH conjugates the reduction of vanadium from the +5 through to the +4 oxidation state in vanadocytes of ascidians.

Benzoate catalysis in the hydrolysis of endo-5-[4'(5')imidazolyl]-bicyclo[2.2.1]hept-endo- 2-yl trans-cinnamate: Implications for the charge-transfer mechanism of catalysis by serine proteases

The acceleration, by a factor of 2500, of the hydrolysis of endo-5-[4'(5')imidazolyl]bicyclo[2.2.1]hept-endo- 2-yl trans-cinnamate by 0.5 M sodium benzoate in 42 mol% dioxane in water can be explained without resort to operation of a "charge-relay" mechanism similar to that often postulated to account for the enzymatic activity of serine proteases. The degree of ionization of 4-methylimidazole and of sodium benzoate in 42 mol% dioxane in water at 60 degrees C have been measured by NMR spectroscopy.

13C enrichment of extracellular neurotransmitter glutamate in rat brain--combined mass spectrometry and NMR studies of neurotransmitter turnover and uptake into glia in vivo

13C-enrichment analysis of glutamate in the extracellular fluid (GLU(ECF): 2-3 microM) by gas-chromatography/mass-spectrometry (GCMS) was combined with in vivo NMR observation of whole-brain GLU (approximately10 mM) to study neurotransmitter uptake. Brain GLU C5 was 13C-enriched by intravenous [2,5-13C]glucose infusion. GLU(ECF) was collected by microdialysis from the cortico-striatal region of awake rats. The 13C-enrichment of basal dialysate GLU C5 during 0.75-1.25 hr of infusion was 0.263 +/- 0.01, very close to the enrichment of whole-brain GLU C5. The result strongly suggests that dialysate GLU consists predominantly of neurotransmitter GLU. For selective 13C-enrichment of neurotransmitter GLU, the whole-brain 13C-enrichment was followed by [12C]glucose infusion to chase 13C from the small glial GLU pool. This leaves [5-13C]GLU mainly in the large neuronal metabolic pool and the vesicular neurotransmitter pool. The uptake of synaptic [5-13C]GLU(ECF) into glia and metabolism to glutamine (GLN) were monitored in vivo by NMR observation of [5-13C,15N]GLN formed during 15NH4Ac infusion. The rate of GLN synthesis, derived from neurotransmitter GLU(ECF) (which provided 80-90% of the substrate) was 6.4 +/- 0.44 micromol/g/hr. Hence, the observed rate represents a reasonable estimate for the rate of glial uptake of GLU(ECF), a process that is crucial for protecting the brain from GLU excitotoxicity.

The first in vivo observation of (13)C-(15)N coupling in mammalian brain

[5-(13)C,(15)N]Glutamine, with (1)J((13)C-(15)N) of 16 Hz, was observed in vivo in the brain of spontaneously breathing rats by (13)C MRS at 4.7 T. The brain [5-(13)C]glutamine peak consisted of the doublet from [5-(13)C,(15)N]glutamine and the center [5-(13)C,(14)N]glutamine peak, resulting in an apparent triplet with a separation of 8 Hz. The time course of formation of brain [5-(13)C,(15)N]glutamine was monitored in vivo with a time resolution of 20-35 min. This [5-(13)C,(15)N]glutamine was formed by glial uptake of released neurotransmitter [5-(13)C]glutamate and its reaction with (15)NH(3) catalyzed by the glia-specific glutamine synthetase. The neurotransmitter glutamate C5 was selectively (13)C-enriched by intravenous [2,5-(13)C]glucose infusion to (13)C-label whole-brain glutamate C5, followed by [(12)C]glucose infusion to chase (13)C from the small and rapidly turning-over glial glutamate pool, leaving (13)C mainly in the neurotransmitter [5-(13)C]glutamate pool, which is sequestered in vesicles until release. Hence, the observed [5-(13)C,(15)N]glutamine arises from a coupling between (13)C of neuronal origin and (15)N of glial origin. Measurement of the rate of brain [5-(13)C,(15)N]glutamine formation provides a novel noninvasive method of studying the kinetics of neurotransmitter uptake into glia in vivo, a process that is crucial for protecting the brain from glutamate excitotoxicity.

Syntheses, structures, stability, and insulin-like activities of peroxovanadium(V) complexes with a heteroligand

Several peroxovanadium(V) complexes were prepared with a tripodal or a quasi-tripodal tetradentate ligand. The structures of K(2)[VO(O(2))(nta)].2H(2)O and K[VO(O(2))(DL-cmhist)].H(2)O have been determined by X-ray crystallography (nta, nitrilotriacetate; cmhist, N-carboxymethylhistidinate). The structure of Cs[VO(O(2))(pda)].2H(2)O (pda, N-pyridylmethyliminodiacetate) has been estimated to be similar to that of K[VO(O(2))(DL-cmhist)].H(2)O. Each complex anion in these compounds adopts a distorted pentagonal bipyramidal structure, which is typical for heptacoordinate oxoperoxovanadium(V) complexes. The peroxide ion binds in a side-on fashion to the vanadium(V) center in the pentagonal plane. The peroxide anion in the cmhist complex dissociates rather easily in an acidic solution (pH approximately 3), while that in the other complexes stays intact under similar conditions. The in vitro insulin mimetic effect of the peroxovanadium(V) complexes has been evaluated by the inhibitory effect on free fatty acid (FFA) release in isolated rat adipocytes treated with epinephrine. The cmhist complex is effective, while the others are almost totally ineffective.

Subunit C of the vacuolar-type ATPase from the vanadium-rich ascidian Ascidia sydneiensis samea rescued the pH sensitivity of yeast vma5 mutants

A vanadium-accumulating ascidian, Ascidia sydneiensis samea, expresses vacuolar-type H(+)-ATPases (V-ATPases) on the vacuole membrane of the vanadium-containing blood cells known as vanadocytes. Previously, we showed that the contents of their vacuoles are extremely acidic and that a V-ATPase-specific inhibitor, bafilomycin A(1), neutralized the contents of the vacuoles. To understand the function of V-ATPase in vanadocytes, we isolated complementary DNA encoding subunit C of V-ATPase from vanadocytes because this subunit has been known to be responsible for the assembly of V-ATPases and to regulate the ATPase activity of V-ATPases. The cloned cDNA was 1443 nucleotides in length, and encoded a putative 384 amino acid protein. By expressing the ascidian cDNA for subunit C under the control of a galactose-inducible promoter, the pH-sensitive phenotype of the corresponding vma5 mutant of a budding yeast was rescued. This result showed that the ascidian cDNA for subunit C functioned in yeast cells.

Exclusive expression of transketolase in the vanadocytes of the vanadium-rich ascidian, Ascidia sydneiensis samea

Ascidians, especially those belonging to the Ascidiidae, are known to accumulate extremely high levels of vanadium in vanadocytes, one type of blood (coelomic) cell. Vanadium, which exists in the +5 oxidation state in seawater, is accumulated in the vanadocytes and reduced to the +3 oxidation state. We have been trying to characterize all of the polypeptides specific to vanadocytes and to specify the proteins that participate in the accumulation and reduction of vanadium. To date, we have localized three enzymes in vanadocytes: 6-phosphogluconate dehydrogenase (6-PGDH: EC 1.1.1.44), glucose-6-phosphate dehydrogenase (G6PDH: EC 1.1.1.49), and glycogen phosphorylase (GP: EC 2.4.1.1), all of which are involved in the pentose phosphate pathway. In the current study, we cloned a cDNA for transketolase, an essential and rate-limiting enzyme in the non-oxidative part of the pentose phosphate pathway, from vanadocytes. The cDNA encoded a protein of 624 amino acids, which showed 61.8% identity to the human adult-type transketolase gene product. By immunocytochemistry and immunoblot analyses, the transketolase was revealed to be a protein that was expressed only in vanadocytes and not in any of the more than ten other types of blood cell. This finding, taken together with the localized expression of the other three enzymes, strongly supports the hypothesis that the pentose phosphate pathway functions exclusively in vanadocytes.

[{Pt]

Prolonged evacuation of [{Pt(CO)(3)}(2)](2+) (1), the first homoleptic, dinuclear, cationic platinum(I) carbonyl complex, results in reversible disproportionation. Complex 1 was formed by dissolution of PtO(2) in concentrated H(2)SO(4) under an atmosphere of CO [Eq. (a)], and completely characterized by NMR ((13)C, (195)Pt), IR, and Raman spectroscopy.

In vivo detection of (15)N-coupled protons in rat brain by ISIS localization and multiple-quantum editing

Three-dimensional image-selected in vivo spectroscopy (ISIS) was combined with phase-cycled (1)H-(15)N heteronuclear multiple-quantum coherence (HMQC) transfer NMR for localized selective observation of protons J-coupled to (15)N in phantoms and in vivo. The ISIS-HMQC sequence, supplemented by jump-return water suppression, permitted localized selective observation of 2-5 micromol of [(15)N(indole)]tryptophan, a precursor of the neurotransmitter serotonin, through the (15)N-coupled proton in 20-40 min of acquisition in vitro at 4.7 T. In vivo, the amide proton of [5-(15)N]glutamine was selectively observed in the brain of spontaneously breathing (15)NH(4)(+)-infused rats, using a volume probe with homogeneous (1)H and (15)N fields. Signal recovery after three-dimensional localization was 72-82% in phantoms and 59 +/- 4% in vivo. The result demonstrates that localized selective observation of (15)N-coupled protons, with complete cancellation of all other protons except water, can be achieved in spontaneously breathing animals by the ISIS-HMQC sequence. This sequence performs both volume selection and heteronuclear editing through an addition/subtraction scheme and predicts the highest intrinsic sensitivity for detection of (15)N-coupled protons in the selected volume. The advantages and limitations of this method for in vivo application are compared to those of other localized editing techniques currently in use for non-exchanging protons.

Localized 15N NMR spectroscopy of rat brain by ISIS

Three-dimensional image-selected in vivo spectroscopy (ISIS), combined with proton-decoupled nuclear-Overhauser-enhanced 15N nuclear magnetic resonance (NMR), was used to localize [15N]metabolites, observed by a head coil, to the brain in rats. In spontaneously breathing anesthetized rats given intravenous [15N]ammonium acetate infusion, brain [5-15N]glutamine was observed in the localized spectrum with a v1/2 of 5 Hz in 19-28 min at 4.7 T, while the signal from blood [15N]urea was eliminated by the localization process. In rats given [15N]leucine infusion, the peak representing predominantly (89%) brain [15N]glutamate was observed, with elimination of the signal from muscle [15N]alanine. In vivo peak areas of the brain [15N]metabolites in the localized spectra were proportional to their concentrations. The advantages and limitations of localization by ISIS using a volume coil with a homogeneous B1 field are compared with those of localization by a surface coil for in vivo 15N NMR study of neurotransmitters in the brain.

A new insulin-mimetic vanadyl complex, (N-pyridylmethylaspartate)oxovanadium(IV) with VO(N2O2) coordination mode, and evaluation of its effect on uptake of D-glucose by Ehrlich ascites tumour cells

Because it has been confirmed that the vanadyl(IV) ion and its complexes act as insulin mimetics, a new organic vanadyl complex, (N-pyridylmethylaspartate)oxovanadium (VOPASP) with VO(N2O2) coordination mode, was prepared. Development of a simple and rapid in-vitro assay is needed for recognition of potent insulin-mimetic complexes. Treatment of Ehrlich ascites tumour cells with 2-deoxyglucose in the presence of vanadyl sulphate, or other vanadyl complexes with the same coordination mode (VOPASP, bis(picolinate)oxovanadium (VOPA) and bis(6-methyl picolinate)oxovanadium (VOMPA)), in the presence of 2-deoxy-D-[1-3H]glucose ([3H]deoxyglucose), resulted in concentration-dependent uptake of 2-deoxyglucose by the cells. The responses of the cells to the vanadyl complexes were reflected, in part, by results obtained from the free fatty acid-releasing assay using rat adipocytes. These results show that the in-vitro assay with Ehrlich ascites tumour cells provides an accurate and rapid assessment of glucose uptake by the cells. The assay is proposed as a means of predicting the insulin-mimetic activity of the vanadyl complexes and for studying the mechanism of action of the complexes.

6-Phosphogluconate dehydrogenase is a 45-kDa antigen recognized by S4D5, a monoclonal antibody specific to vanadocytes in the vanadium-rich ascidian Ascidia sydneiensis samea

We previously prepared a monoclonal antibody, S4D5, specific to vanadocytes, vanadium-containing blood cells, in the vanadium-rich ascidian Ascidia sydneiensis samea. Here, we demonstrate that a 45-kDa antigen recognized by S4D5 is 6-phosphogluconate dehydrogenase (6-PGDH), an enzyme of the pentose phosphate pathway, based on cDNA isolation of RNA samples from blood cells of the ascidian. Western blot analysis confirmed an abundance of 6-PGDH protein in the vanadocytes and localization of 6-PGDH in the soluble extract of the blood cells. Soluble protein exhibited a correspondingly high level of 6-PGDH enzymatic activity. Ascidians are known to selectively accumulate high levels of vanadium in vanadocytes, and the highest recorded concentration of accumulated vanadium is 350 mM, which is 10(7) times the concentration in sea water. Almost all vanadium ions are reduced to the +3 oxidation state via the +4 oxidation state in vanadocytes, indicating that reducing agents must participate in the accumulation. On the other hand, vanadium ions in the +5 oxidation state are reduced to the +4 oxidation state by the presence of NADPH in vitro. Together, these observations suggest that NADPH produced in the pentose phosphate pathway may conjugate the reduction of vanadium from the +5 oxidation state through the +4 oxidation state in vanadocytes of ascidians.

Rate of glutamate synthesis from leucine in rat brain measured in vivo by 15N NMR

The rate of glutamate synthesis from leucine by the branched-chain aminotransferase was measured in rat brain in vivo at steady state. The rats were fed exclusively by intravenous infusion of a nutrient solution containing [15N]leucine. The rate of glutamate synthesis from leucine, determined from the rate of increase of brain [15N]glutamate measured by 15N NMR and the 15N enrichments of brain and blood leucine analyzed by gas chromatography-mass spectrometry, was 0.7-1.8 micromol/g/h at a steady-state brain leucine concentration of 0.25 micromol/g. A comparison of the observed fractional 15N enrichments of brain leucine (0.42 +/- 0.03) and glutamate (0.21 +/- 0.015) showed that leucine provides approximately 50% of glutamate nitrogen under our experimental condition. From the observed rate (0.7-1.8 micromol/g) and the known Km of the branched-chain aminotransferase for leucine (1.2 mM), the rate of glutamate synthesis from leucine at physiological brain leucine concentration (0.11 micromol/g) was estimated to be 0.35-0.9 micromol/g/h, with leucine providing approximately 25% of glutamate nitrogen. The results strongly suggest that plasma leucine from dietary source, transported into the brain, is an important external source of nitrogen for replenishment of brain glutamate in vivo. Implications of the results for treatment of maple-syrup urine disease patients with leucine-restricted diet are discussed.

Glial alkalinization detected in vivo by 1H-15N heteronuclear multiple-quantum coherence-transfer NMR in severely hyperammonemic rat

Brain [5-15N] glutamine amide protons were selectively observed in vivo by 1H-15N heteronuclear multiple-quantum coherence-transfer NMR in spontaneously breathing, severely hyperammonemic rats during intravenous [15N]ammonium acetate infusion and the subsequent recovery period. The linewidth of brain [5-15N]-glutamine amide proton Hz increased from 36 +/- 2 Hz at 3.4 h to 58 +/- 6 Hz after 5.7 h of infusion, a net increase of 22 +/- 6 Hz. Concomitantly, brain ammonia concentration increased from 1.7 to 3.5 +/- 0.2 mumol/g and the rat progressed from grade III to grade IV encephalopathy. On recovery to grade III and decrease of brain ammonia concentration to 1.3 mumol/g, the linewidth returned to 37 +/- 2 Hz. In aqueous solution, [5-15N]glutamine amide proton Hz underwent a 17-Hz linebroadening when pH was raised from 7.1 to 7.5 at 37 degrees C, due to the increased rate of base-catalyzed exchange with water proton. Hence, linebroadening is a sensitive measure of changing intracellular pH. The 22-Hz linebroadening observed in vivo in severely hyperammonemic grade IV rats strongly suggests that the intracellular pH increases from 7.1 to about 7.4-7.5 in astrocytes where glutamine is synthesized and mainly stored. Probable mechanisms for the ammonia-induced alkalinization and decreased intraglial buffering capacity, as well as implications of the result for pathogenesis of hepatic encephalopathy, are discussed.

Severity of hyperammonemic encephalopathy correlates with brain ammonia level and saturation of glutamine synthetase in vivo

Correlation among in vivo glutamine synthetase (GS) activity, brain ammonia and glutamine concentrations, and severity of encephalopathy was examined in hyperammonemic rats to obtain quantitative information on the capacity of GS to control these metabolites implicated in the etiology of hepatic encephalopathy. Awake rats were observed for neurobehavioral impairments after ammonium acetate infusion to attain a steady-state blood ammonia concentration of 0.9 (group A) or 1.3 mumol/g (group B). As encephalopathy progressed from grade III to IV, brain ammonia concentration increased from 1.9 to 3.3 mumol/g and then decreased to 1.3 mumol/g on recovery to grade III. In contrast, brain glutamine concentration was 26, 23, and 21 mumol/g, respectively. NH(4+)-infused rats pretreated with L-methionine DL-sulfoximine reached grade IV when brain ammonia and glutamine concentrations were 3.0 and 5.5 mumol/g, respectively; severity of encephalopathy correlates with brain ammonia, but not glutamine. In vivo GS activity, measured by NMR, was 6.8 +/- 0.7 mumol/h/g for group A and 6.2 +/- 0.6 mumol/h/g for group B. Hence, the in vivo activity, shown previously to increase with blood ammonia over a range of 0.4-0.64 mumol/g, approaches saturation at blood ammonia > 0.9 mumol/g. This is likely to be the major cause of the observed accumulation of brain ammonia and the onset of grade IV encephalopathy.

[Effects of pulmonary rehabilitation in patients with chronic respiratory failure]

To evaluate the effects of pulmonary rehabilitation in patients with chronic respiratory failure, 43 patients with stable chronic respiratory failure were enrolled in a pulmonary rehabilitation program. The program included education, instruction in diaphragmatic breathing, respiratory muscle training, and exercise training (walking and riding a stationary bicycle). Patients were divided into 2 groups by the lowest SpO2 during a 12-minute-walk test done before rehabilitation: lowest SpO2 < 90% (Group A, 32 patients) and lowest SpO2 > or = 90% (Group B, 11 patients). In group A, SpO2 during exercise training was maintained over 90% by O2 inhalation, by load reduction, or by maintaining a slower walking speed. During 2 months of rehabilitation, the distance walked in 12 minutes and the maximum distance walked with an SpO2 > or = 90% significantly increased in both groups, but PaO2, VC, and FEV1 increased only in group A. In group A, the patients with chronic obstructive pulmonary disease had significant increases in PaO2, VC, and FEV1, but those with old tuberculosis sequelae had significant increases in PaO2 only. Pulmonary rehabilitation in patients with chronic respiratory failure may not only increase exercise tolerance but may also improve arterial oxygenation and pulmonary function.

Steady-state in vivo glutamate dehydrogenase activity in rat brain measured by 15N NMR

The in vivo activity of glutamate dehydrogenase (GDH) in the direction of reductive amination was measured in rat brain at steady-state concentrations of brain ammonia and glutamate after intravenous infusion of the substrate 15NH4+. The in vivo rate was determined from the steady-state fractional 15N enrichment of brain ammonia, measured by selective observation of 15NH4+ protons in brain extract by 1H-15N heteronuclear multiple-quantum coherence transfer NMR, and the rate of increase of brain [15N]glutamate and [2-15N]glutamine measured by 15N NMR. The in vivo GDH activity was 0.76-1.17 mumol/h/g, and 1.1-1.2 mumol/h/g at 1.0 +/- 0.17 mumol/g. Comparison of the observed in vivo GDH activity with the in vivo rates of glutamine synthesis and of phosphate-activated glutaminase suggests that, under mild hyperammonemia, GDH-catalyzed de novo synthesis can provide a minimum of 19% of the glutamate pool that is recycled from neurons to astrocytes through the glutamate-glutamine cycle.

Dependence of in vivo glutamine synthetase activity on ammonia concentration in rat brain studied by 1H - 15N heteronuclear multiple-quantum coherence-transfer NMR

The dependence of the in vivo rate of glutamine synthesis on the substrate ammonia concentration was studied in rat brain by 1H-15N heteronuclear multiple-quantum coherence-transfer NMR in combination with biochemical techniques. In vivo rates were measured at various steady-state blood and brain ammonia concentrations within the ranges 0.4-0.55 mumol/g and 0.86-0.98 mumol/g respectively, after low-rate intravenous 15NH4+ infusion (isotope chase). The rate of glutamine synthesis at steady state was determined from the change in brain [5-15N]glutamine levels during isotope chase, observed selectively through the amide proton by NMR, and 15N enrichments of brain glutamine and of blood and brain ammonia measured byN gas chromatography-MS. The in vivo rate (v) was 3.3-4.5 mumol/h per g of brain at blood ammonia concentrations (s) of 0.40-0.55 mumol/g. A linear increase of 1/v with 1/s permitted estimation of the in vivo glutamine synthetase (GS) activity at a physiological blood ammonia concentration to be 0.4-2.1 mumol/h per g. The observed ammonia-dependence strongly suggests that, under physiological conditions, in vivo GS activity is kinetically limited by sub-optimal in situ concentrations of ammonia as well as glutamate and ATP. Comparison of the observed in vivo GS activity with the reported in vivo rates of glutaminase and of gamma-aminobutyrate (GABA) synthesis suggests that, under mildly hyperammonaemic conditions, glutamine is synthesized at a sufficiently high rate to serve as a precursor of GABA, but glutaminase-catalysed hydrolysis of glutamine is too slow to be the sole provider of glutamate used for GABA synthesis.

Selective, in vivo observation of [5-15N]glutamine amide protons in rat brain by 1H-15N heteronuclear multiple-quantum-coherence transfer NMR

The amide protons of [5-15N]glutamine were selectively observed in vivo in the brains of anesthetized, spontaneously breathing rats after intravenous 15NH4+ infusion by 1H-15N heteronuclear multiple-quantum-coherence (HMQC) transfer NMR at 200 MHz for 1H. The peak intensity of the upfield amide proton was proportional to brain [5-15N]glutamine concentration. The 15N-decoupled amide-proton signal was observed in vivo in 2 min of acquisition at a brain [5-15N]glutamine concentration of 7.7 +/- 0.4 mumol/g, in < 8 min at 4.35 +/- 0.15 mumol/g, and in 17-34 min at 2.0 +/- 0.1 mumol/g. 1H signals not coupled to 15N were suppressed by phase cycling. The result suggests that 1H-15N HMQC will be useful for kinetic study of glutamine synthesis in rat brain in vivo at physiological concentrations of brain ammonia.

In vivo activity of glutaminase in the brain of hyperammonaemic rats measured by 15N nuclear magnetic resonance

The in vivo activity of phosphate-activated glutaminase (PAG) was measured in the brain of hyperammonaemic rat by 15N n.m.r. Brain glutamine was 15N-enriched by intravenous infusion of 15NH4+ until the concentration of [5-15N]glutamine reached 6.1 mumol/g. Further glutamine synthesis was inhibited by intraperitoneal injection of methionine-DL-sulphoximine, an inhibitor of glutamine synthetase, and the infusate was changed to 14NH4+ during observation of decrease in brain [5-15N]glutamine due to PAG and other glutamine utilization pathways. Progressive decrease in brain [5-15N]glutamine, PAG-catalysed production of 15NH4+ and its subsequent assimilation into glutamate by glutamate dehydrogenase were monitored in vivo by 15N n.m.r. Brain [5-15N]glutamine (15N enrichment of 0.35-0.50) decreased at a rate of 1.2 mumol/h per g of brain. The in vivo PAG activity, determined from the observed rate and the quantity of 15NH4+ produced and subsequently assimilated into glutamate and aspartate, was 0.9-1.3 mumol/h per g. This activity is less than 1.1% of the reported activity in vitro measured in rat brain homogenate at a 10 mM concentration of the activator Pi. Inhibition by ammonia (brain level 1.4 mumol/g) alone does not account for the observed low activity in vivo. The result strongly suggests that, in intact brain, PAG activity is maintained at a low level by a suboptimal in situ concentration of Pi and the strong inhibitory effect of glutamate. The observed PAG activity in vivo is lower than the reported in vivo activity of glutamate decarboxylase which converts glutamate into gamma-aminobutyrate (GABA). The result suggests that PAG-catalysed hydrolysis of glutamine is not the sole provider of glutamate used for GABA synthesis.

[Effects of inhaled furosemide after indomethacin premedication on bronchial hyperresponsiveness in patients with chronic congestive heart failure]

We studied the effects of inhaled furosemide (40 mg) on bronchial responsiveness to acetylcholine (ACh) in patients with chronic congestive heart failure who had been premedicated with indomethacin (75 mg/day) for five days. The measurement of bronchial responsiveness was performed by inhaling doses of ACh and calculating the provocative concentration of ACh needed to cause a 20% fall in FEV1.0 (PC20-ACh). Inhaled furosemide (N = 11) had no effect on resting pulmonary function but did cause a significant increase in the median value of PC20-ACh, from 7.58 to 11.9 mg/ml (p < 0.01). Irrespective of premedication with indomethacin, inhaled furosemide reduces bronchial hyperresponsiveness to ACh in patients with chronic congestive heart failure. Therefore, we speculate that the mechanism of bronchial hyperresponsiveness noticed in our patients is not related to prostaglandins such as PGE2 or PGI2.