[A Case of Rectal Cancer with Bladder Invasion Performed with Robot-Assisted Low Anterior Resection after TNT]

A 73-year-old woman was admitted with a chief complaint of weight loss. Colonoscopy revealed rectal cancer. After the placement of a colonic stent, the patient was referred to our department. Computed tomography, magnetic resonance imaging, and cystoscopy indicated extensive invasion of the bladder. Since total pelvic exenteration was necessary at the first diagnosis, total neoadjuvant therapy(TNT)was conducted. The diagnosis after TNT was ycT4bycN0ycM0. Low anterior resection with partial resection of the bladder and a diverting ileostomy were performed. The patient was discharged on the 16th day post-surgery with a good postoperative course. The pathological examination revealed a complete response, ypT0ypN0.

[A Case of Locally Advanced Rectal Cancer Treated Successfully with TNT]

Local control is important in the treatment of locally advanced rectal cancer(LARC). In Western countries, the standard therapy for LARC is preoperative chemoradiotherapy(CRT)followed by total mesorectal excision. Recently, addition of intensive chemotherapy to CRT known as total neoadjuvant therapy(TNT)is increasing. We herein report a 69-year-old woman who developed LARC(cT3N3M0, cStage Ⅲc). She was diagnosed as clinical complete response after TNT, and she chose"watch and wait". She did not have a recurrence for 16 months.

Predicting Overall Survival Using Preoperative Nutritional and Inflammation Status for Colorectal Cancer

AIM

It has been shown that nutritional status and inflammation correlate with survival in patients with various cancer types. In this study, we evaluated several kinds of nutritional and inflammation parameters in preoperative blood samples and constructed new risk model predicting survival in patients with colorectal cancer.

PATIENTS AND METHODS

We retrospectively examined 286 patients with stage I-III colorectal cancer who had undergone curative resection at Teikyo University Hospital. The association between overall survival (OS) and nutritional status and inflammation factors were examined using Kaplan-Meier curves and log-rank tests.

RESULTS

Serum albumin, cholesterol and C-reactive protein concentration, neutrophil count and platelet count were shown to be correlated with OS. We constructed a new risk model (nutrition inflammation status, NIS) using these factors, and compared it with other nutrition and inflammation models.

CONCLUSION

NIS was useful as a new model for predicting OS in patients undergoing curative resection for colorectal cancer, compared with known models.

[A Case of SM Carcinoma of the Sigmoid Colon with Distant Metastasis in the Early Stage after Endoscopic MucosalResection]

INTRODUCTION

We report a case of submucosal(SM)adenocarcinoma of the sigmoid colon which developed distant metastasis 3 months after endoscopic mucosal resection(EMR).

CASE

54-year-old, male. Colonoscopy, which was performed due to positive fecal occult blood test, revealed 18 mm Isp sigmoid polyp. EMR was performed with en bloc resection. Pathological examination revealed adenocarcinoma(tub>por>sig), pT1b, Ly1c, V1a, pHM0, and pVM1. Therefore, laparoscopic sigmoidectomy(D2 dissection)was performed. Postoperative pathological examination revealed pT1b, pN2b(10/11), PN1b, pPM0, pDM0, pStage Ⅲb. Distant nodal involvement were found on computed tomography 3 months after EMR, although systemic chemotherapy(mFOLFOX6 plus panitumumab 18 courses and FOLFIRI plus bevacizumab 4 courses)was performed, the patient died of liver failure caused by liver metastasis 21 months after EMR.

CONCLUSION

We present a case of T1 sigmoid adenocarcinoma which developed distant metastasis 3 months after EMR with literature review.

Impact of Colon Cancer Location on the Prognostic Significance of Nutritional Indexes and Inflammatory Markers

BACKGROUND/AIM

The prognosis of colorectal cancer is reported to differ depending on the tumor site, and clinical differences depending on the site of occurrence have gained attention. The aim was to compare nutrition index and inflammatory markers according to the site of colon cancer.

PATIENTS AND METHODS

We retrospectively analyzed 272 cases of stage I-III colon cancer (55% males, 45% females). The clinical characteristics, nutrition index and inflammatory markers were compared between patients with right colon cancer (RCC, n=119) and those with left colon cancer (LCC, n=153), and the relapse-free survival was then compared.

RESULTS

RCC was associated with older age (p=0.03), female gender (p=0.003), higher T stage (p=0.01), elevated platelet/lymphocyte ratio (PLR) (p=0.009), and elevated CONUT score (p=0.028). The prognostic values differed between RCC and LCC (RCC: CONUT score, p=0.04, LCC: PLR, p=0.02).

CONCLUSION

RCC was associated with an elevated CONUT score and PLR. In RCC, the CONUT score was an independent recurrence factor, and in LCC, the PLR was an independent recurrence factor.

Impact of Fluoropyrimidine and Oxaliplatin-based Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer

BACKGROUND/AIM

To evaluate the benefits of the addition of oxaliplatin (OX) to fluoropyrimidine (FP)-based neoadjuvant chemoradiotherapy (CRT) for patients with locally advanced rectal cancers (LARCs).

PATIENTS AND METHODS

We performed retrospective analyses comparing the pathological complete response (pCR) rate, overall survival (OS), recurrence-free survival (RFS), and local recurrence-free survival (LRFS) between FP-based and FP+OX-based CRT groups and for patients who had completed the CRT.

RESULTS

One hundred patients were included in the analyses: the pCR rate, OS, RFS, and LRFS were similar between these groups. The FP+OX group showed significantly more frequent incompleteness of the CRT compared to the FP group (p=0.049). Among the patients who had completed the CRT, the FP+OX group demonstrated significantly improved LRFS compared to the FP group (p=0.048).

CONCLUSION

The addition of OX to an FP regimen in neoadjuvant CRT for LARC may reduce local recurrence in patients who have achieved good compliance to CRT.

Impact of subdivision of pathological stage I colorectal cancer

AIM

Stage II-IV colorectal cancers are subdivided according to TNM categories. However, stage I cases are a single category, despite the inclusion of both T1 and T2 cases, which may have different outcomes. The aim of this study was to evaluate the usefulness of subdividing stage I colorectal cancers by T category.

METHODS

From 1984 to 2015, 844 patients with stage I colorectal cancer (T1: 446, T2: 398) underwent colorectal resection with lymph node dissection at three hospitals. The long-term survival and recurrence rates were compared between T1 and T2. A Cox regression analysis was used to evaluate the risk factors associated with cancer recurrence.

RESULTS

A comparison of the T1 and T2 groups revealed significant differences in 5-year overall (95.9% vs 91.4%, P = .008), recurrence-free (94.8% vs 87.1%, P = .0007), and cancer-specific survival (97.6% vs 93.6%, P = .004), and in the overall (2.5% vs 6.8%, P = .003), local (0.2% vs 1.5%, P = .04), and lymph node recurrence rates (0.2% vs 1.5%, P = .04). All local and lymph node recurrences were associated with lower rectal cancer, and this difference was significant. The Cox multivariate analysis identified male sex (P = .01, hazard ratio: 4.00, 95% confidence interval: 1.38-11.55), T2 (P = .02, hazard ratio: 2.98, 95% confidence interval: 1.17-7.60), and venous invasion (P = .03, hazard ratio: 2.38, 95% confidence interval: 1.12-5.10) as risk factors for recurrence.

CONCLUSIONS

The subdivision of stage I colorectal cancer according to T category clearly reflected the long-term outcomes.

Ulcerative colitis that developed during radiotherapy for prostate cancer, deteriorated rapidly and required emergency surgery

Background

Although there are reports linking ulcerative colitis (UC) to prostate cancer (PC), those reports are of PC patients who were previously diagnosed with UC. There are no reports of the development of UC during radiotherapy. Here we describe the first case of a patient who developed UC during radiotherapy for PC. The UC progressed rapidly and required emergency surgery.

Case presentation

A 61-year-old Japanese man underwent a prostate biopsy at another hospital due to a high prostate-specific antigen level and was diagnosed with PC. Goserelin and bicalutamide treatment was initiated in 2019, and intensity-modulated radiotherapy (total of 60 Gy/20 Fr) was administered in 2020. Diarrhea began during the radiotherapy and bleeding began post-radiotherapy. He was admitted to another hospital 14 days after the end of the radiotherapy, and colonoscopy revealed a deep ulcer in the colon, which led to the suspicion of UC. He was transferred to our hospital, and colonoscopy showed a widespread map-like ulcer, pseudopolyposis, and very easy bleeding in the colon. We diagnosed severe UC, and it worsened rapidly with uncontrollable bleeding, which we considered an indication for surgery. Emergency surgery (a total colectomy and ileostomy creation) was performed. The specimens confirmed an extensively spreading ulcer throughout the colon. The pathological report was UC in the active phase. The postoperative course was good.

Conclusions

When a patient exhibits diarrhea while undergoing radiotherapy for PC, clinicians should be aware of the possibility of UC in addition to radiation colitis, and colonoscopy should be considered.

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

Background

Small bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.

Case presentation

When this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.

Conclusion

Clinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

The pretreatment Controlling Nutritional Status (CONUT) score is an independent prognostic factor in patients undergoing resection for colorectal cancer

The Controlling Nutritional Status (CONUT) score is a marker of nutrition and is associated with poor survival in various kinds of cancers. However, no reports have yet compared risk factors for colorectal cancer recurrence using a nutritional index. We assessed the predictive value of the CONUT score compared with the modified Glasgow Prognostic Score (mGPS) and Prognostic Nutritional Index (PNI) in colorectal cancer (CRC) patients. We performed a retrospective cohort study of the medical records of 336 consecutive patients with stage I-I I I CRC who underwent curative resection at a single institution in 2012–2017. Univariate and multivariate analyses were conducted to identify prognostic factors associated with relapse-free survival (RFS) and overall survival (OS). The low CONUT score group exhibited higher RFS and longer OS compared to the high CONUT score group (82.2% vs. 63.3%, p = 0.002 and 95.5% and 86.2%, p = 0.005, respectively). The Akaike’s information criterion values of each index for RFS and OS were superior in CONUT score (723.71 and 315.46, respectively) compared to those of PNI (726.95 and 316.52) and mGPS (728.15 and 318.07, respectively). The CONUT score was found to be a good predictor of RFS and OS in patients with resectable CRC.

The cooling mechanism of minuscule ribbed surfaces

One reason human beings wear stockings is to warm their legs. Ordinary textile materials are thermally insulative, which prevents body’s heat from dissipating. In contrary to this common sense, it was discovered that some knitted stockings made up of them permanently promote heat release and cool body. This non-intuitive phenomenon emerges when micro-size yarns are knitted to form wide spacing between neighboring yarns. However, the reason why they cool body was unclear because conventional principles of cooling garments cannot account for it. Here, in the basis of fluid-solid conjugate heat transfer analysis of natural convection, we have clarified the cooling mechanism originates from relative relationship between their geometric structure, a periodic alignment of minuscule ribs, and thermal boundary layer. Our novel finding revealed that sufficiently small ribs on the surface are exposed to steep temperature gradient within thermal boundary layer. Thereby, thermal conduction via ribs is enhanced complementarily as they are separated to guide cooler flow onto the surface. Our study provides a general insight into understanding permanent cooling mechanism on micro-size ribbed surfaces in contrast to conventional theory for heat sink, which is applicable not only to other clothes, but also to artificial devices or natural structures.

Adsorptive Granulocyte and Monocyte Apheresis Is Effective in Ulcerative Colitis Patients Both with and without Concomitant Prednisolone

Background

The number of ulcerative colitis (UC) patients is increasing in Japan and other countries. Selective depletion of myeloid lineage leucocytes by adsorptive granulocyte and monocyte apheresis (GMA) with an Adacolumn (JIMRO, Takasaki, Japan) was introduced as a nonpharmacologic treatment strategy in UC patients in 2000. GMA has been reported to be effective in clinical trials; however, the effect of concomitant prednisolone (PSL) on GMA needs to be clarified.

Methods

Thirty-nine patients with active UC were treated with GMA at our institute between June 2009 and September 2018. All patients received GMA therapy once or twice a week with the Adacolumn. Conventional medication was to be continued during the whole GMA treatment course. The clinical response was retrospectively evaluated.

Results

According to the partial Mayo score, remission was 33.3%, significant efficacy 25.6%, effective 25.6%, and no response 15.4%. The average partial Mayo score was 6.2 ± 1.4 at entry and significantly declined to 1.8 ± 1.8 after GMA sessions (p < 0.0001). The average number of bowel movements was 9.5 ± 5.6 at entry and significantly declined to 3.0 ± 2.8 after GMA sessions (p < 0.0001). In a comparison between the group treated with concomitant PSL and the group without PSL, the change in partial Mayo score or the number of bowel movements from entry to after GMA sessions was not significantly different. Among 24 patients treated by GMA with concomitant PSL, 75% (18/24) became steroid free.

Conclusions

The effect of GMA with concomitant PSL and that of GMA without PSL were not different, and GMA was effective irrespective of PSL administration. The present study showed that GMA had efficacy and led many UC patients treated by PSL to be steroid free with no safety concern in the real world, although there is the possibility of recruitment bias due to the retrospective nature of the study.

Successful surgical management of mesenteric inflammatory veno-occlusive disease

BACKGROUND

The term "mesenteric inflammatory veno-occlusive disease (MIVOD)" is used to describe an ischemic injury resulting from phlebitis or venulitis that affects the bowel or mesentery in the absence of arteritis. MIVOD is difficult to diagnose because of its rarity and frequent confusion with other diseases. The incidence and etiology of MIVOD remain unclear; only a few cases have been reported. We describe a case of the successful surgical management of a patient with MIVOD with characteristic images.

CASE PRESENTATION

A 65-year-old Japanese man visited a hospital with the chief complaint of abdominal pain in January 2018. CT showed edema and thickening of the intestinal wall from the descending colon to the rectum. The patient was admitted to the hospital. Suspected diagnoses were enteritis, ulcerative colitis, amyloidosis, vasculitis, malignant lymphoma, and venous thrombus, but no definitive diagnosis was obtained. The patient was transferred to our hospital for the treatment of stenosis (located from the descending colon to the rectum) and bowel obstruction. An emergency transverse colostomy was performed. The sigmoid colon and mesentery were too rigid and edematous to resect. Colonic hemorrhage occurred 2 weeks after the surgery. With radiology intervention, coiling for the arteriovenous fistula in the descending colon was performed, and hemostasis was obtained. A colonoscopy at 6 months post-surgery showed neither ulceration nor stenosis in the rectum, indicating that the rectum could be preserved in the next surgery. However, severe stenosis in the descending and sigmoid colon remained unchanged. Ten months after the transverse colostomy, we performed a subtotal colectomy and ileorectal anastomosis, and an ileostomy was created. The sigmoid colon and mesentery were not so rigid compared to the first surgery's findings, and we were able to resect intestine and mesentery. Histopathology revealed phlebitis and venulitis, fibrinoid necrosis, and normal arteries, meeting the diagnostic criteria for MIVOD. Postoperatively, the patient showed no recurrence for 8 months.

CONCLUSION

Clinicians should consider MIVOD when examining a patient with intestinal ischemia. When MIVOD is suspected, the patient is indicated for surgery based on an accurate diagnosis and good prognosis.

Plasma exosomal microRNA-125b as a monitoring biomarker of resistance to mFOLFOX6-based chemotherapy in advanced and recurrent colorectal cancer patients

Liquid biomarkers for the early detection of resistance to chemotherapy are important for improving prognosis. This study investigated the usefulness of plasma exosomal microRNA-125b (ex-miRNA-125b) for the early detection of resistance to modified fluorouracil, leucovorin and oxaliplatin (mFOLFOX6)-based first-line chemotherapy in patients with advanced or recurrent (advanced/recurrent) colorectal cancer (CRC). First, ex-miRNAs associated with resistance to mFOLFOX6-based chemotherapy were profiled via miRNA microarray analysis. In this analysis, ex-miR-125b exhibited the greatest upregulation in patients with progressive disease (PD) compared with the findings for patients with stable disease (SD) and healthy controls. Next, another 55 patients with advanced/recurrent CRC who received mFOLFOX6-based first-line chemotherapy underwent a validation study of ex-miR-125b. Blood samples were collected before and during treatment until tumor progression. Ex-miRNA levels were measured via TaqMan microRNA assays. Patients with CRC had significantly higher ex-miR-125b levels than healthy controls. In patients with partial responses, ex-miR-125b levels at the Response Evaluation Criteria in Solid Tumors (RECIST) judgment point were significantly lower than those measured before treatment. In patients with SD, ex-miR-125b levels did not differ before and during treatment. In patients with PD, ex-miR-125b levels at the RECIST judgment point were significantly higher than those measured before treatment. These changes in ex-miR-125b levels were significantly different between groups even 1 month after the initiation of chemotherapy. Progression-free survival (PFS) was significantly worse in patients with high baseline ex-miR-125b levels than in those with low levels. In the Cox analysis, baseline ex-miR-125b levels and KRAS mutation were indicated to be independent prognostic factors for PFS. The present results suggest that plasma ex-miR-125b levels may be useful for the early detection of resistance to mFOLFOX6-based first-line chemotherapy. Furthermore, ex-miR-125b before chemotherapy is a predictive biomarker for PFS in patients with advanced/recurrent CRC.

A case of intussusception developed at the site of ileocolic anastomosis after laparoscopic right hemicolectomy

BACKGROUND

Intussusception is a relatively common condition seen in children. In comparison, adult intussusception is rare and usually occurs as a complication in patients with organic diseases. It is responsible for 1% of all bowel obstructions, in most of intussusceptions a malignant tumor is involved. Herein, we present an extremely unusual case of intussusception that occurred as a complication at the site of a functional end-to-end anastomosis.

CASE PRESENTATION

A 57-year-old female patient was diagnosed with tumors in the ascending and descending colon and was referred to our department. Laparoscopic hemicolectomy and laparoscopic descending colectomy were performed. The mechanical intestinal obstruction occurred on the 9th day postoperatively, and computed tomography scan revealed intussusception at the site of the ileocolic anastomosis. Endoscopic reduction was attempted, but the procedure was challenging. Surgery was then performed and revealed that the site of ileocolic anastomosis firmly adhered to the side wall and right retroperitoneum. However, the intestine in the oral side of the anastomosis was not fixed. Examination of the anastomotic site revealed that the ileum had passed through the anastomosis and prolapsed into the transverse colon. The ileocolic anastomosis was resected. End-to-end anastomosis was performed, and surgery was then completed. No neoplastic lesions were observed in the resected tissue of the lead point of intussusception. The postoperative clinical course was favorable, and the patient was discharged on the 11th day after the second round of surgery.

CONCLUSIONS

There are no reports the anastomosis is involved as part of the intussception, as observed in the present case. Intussusception should thus be considered as one of the causes of postoperative mechanical intestinal obstruction.

A rare case of perivascular epithelioid cell tumor (PEComa) of the greater omentum

Background

A tumor composed exclusively or predominantly of human melanin black 45 (HMB45)-positive epithelioid cells is called a perivascular epithelioid cell tumor (PEComa). We report a very rare case of a PEComa of the greater omentum.

Case presentation

MRI conducted to examine the orthopedic disease of the patients, a 49-year-old Japanese woman, also identified a tumor in her pelvis. A CT scan revealed a tumor mass on the right side of the pelvic floor and clear nutrient vessels originating from the splenic and celiac arteries. An omental primary tumor or accessory spleen was thus suspected, and tumor resection was performed. The tumor was a light brown solid tumor with a smooth margin, measuring 5.2 × 3.8 × 3.5 cm. Histopathologically, the tumor was composed mainly of spindle and epithelioid cells, and large and small blood vessel formation was observed. In the immunohistochemical staining, tumor cells were positive for human melanin black 45 (HMB-45) and Melan-A and partially positive for alpha-smooth muscle actin. The final diagnosis was PEComa of the greater omentum.

Conclusions

Although omental PEComa is very rare, it should be considered as a differential disease of an omental primary tumor.

Effects of a high-fat diet on superoxide anion generation and membrane fluidity in liver mitochondria in rats

Background

Obesity is a primary factor of lifestyle-related diseases, and the age of its onset has decreased. The reactive oxygen species (ROS), the superoxide anion, is generated in the mitochondrial electron transport chain and the damage it induces in cells may be a contributing factor to obesity-related lifestyle diseases. In the present study, the influence of the ingestion of a high-fat diet (HFD) on superoxide anion generation in rat liver mitochondria (Mt) and membrane fluidity was investigated.

Methods

Male Wistar rats were fed a normal diet (ND, n = 6) or HFD (n = 6). Liver Mt were isolated and oxygen consumption, superoxide anion production (the adrenaline method), and membrane fluidity (the spin label method) were measured.

Results

After 11 weeks, body weights and abdominal circumferences were higher in the HFD group than in the ND group. Mt oxygen consumption was higher in the HFD group than in the ND group. Superoxide anion production was significantly lower in the HFD group than in the ND group, while no significant changes were observed in membrane fluidity.

Conclusion

Although rats developed diet-induced obesity, it did not reach the level of disease development. The promotion of lipid metabolism appeared to reduce superoxide anion production, but did not influence membrane fluidity. While superoxide anion damages cells as an oxidative stress, ROS and superoxide dismutase are essential signaling molecules in the body. The present results suggest that the continuous ingestion of a HFD impairs Mt and induces disease development.

Absorptive anti-adhesion barrier for the prevention of bowel obstruction after laparoscopic colorectal cancer surgery

Objectives: The protective efficacy of an absorptive adhesion prevention product (Seprafilm^Ⓡ) against bowel obstruction (BO) during open surgery was demonstrated in a large-scale randomized controlled clinical trial in Europe and America. However, the efficacy of Seprafilm against BO in laparoscopic surgery remains uncertain. The objective of this study was to clarify the protective efficacy of Seprafilm against BO after laparoscopic surgery for colorectal cancer. Methods: From 2009 to 2016, 1328 laparoscopic colorectal resections were performed for colorectal cancer. From 2009, Seprafilm was used for preventing BO in laparoscopic colorectal surgery. The incidence of BO and short-term results were compared between the Seprafilm and non-Seprafilm groups after propensity score matching. Results: Propensity scoring generated 270 matched patients per group for the comparisons between the Seprafilm and non-Seprafilm groups. The two groups showed no significant differences regarding patients' backgrounds. Among all patients, 73.1% (19/26) of BO occurred within 30 days after the surgery. Significantly lower incidences of all grade (2.6% vs. 7.0%; p = 0.016) and grade 2 + 3a (1.5% vs. 5.2%; p = 0.017) BO were observed in the Seprafilm group than in the non-Seprafilm group; no significant difference regarding grade 3b BO (1.1% vs. 1.9%; p = 0.476) was found. A significant difference in BO within 30 days was also noted between the two groups (1.9% vs. 5.2%, p = 0.036). There were no significant differences between the groups regarding anastomotic leakage and deep surgical site infection. Conclusions: Seprafilm was useful for preventing BO, requiring decompression therapy of the bowel, after laparoscopic colorectal surgery without increasing adverse events.

Combined electric and pressure cuff pain stimuli for assessing conditioning pain modulation (CPM)

Aims

Traditionally, conditioning pain modulation (CPM) can be assessed by applying a test stimulus (TS) before and after application of a conditioning stimulus (CS), which is normally applied extra-segmental. Currently, no studies have attempted to apply the TS and CS to the same site using different stimuli modalities. The aim of this study was to evaluate electrical TS and cuff pressure CS applied to the same experimental site for studying CPM.

Methods

20 male volunteers participated in this study, which consisted of stimulations applied by a cuff-algometer (NociTech and Aalborg University, Denmark) and current stimulator (Digitimer DS5, UK), through two Ag/AgCl electrodes (Ambu® Neuroline 700, Denmark). The cuff was wrapped around the lower leg and stimulation electrodes were placed under the cuff and to the same location on the contralateral leg. Electrical TS were applied to the non-dominant leg with or without cuff pressure CS on the dominant (CS1) or the same (non-dominant) leg (CS2, electrode under cuff). The subjects were instructed to rate the electrical evoked pain intensity on a 10-cm continuous visual analog scale (VAS, “0” represented “no pain”, and “10” represented “maximal pain”). The pain detection threshold (PDT) was defined as “1” on the VAS scale.

Results

There was no significant deference in PDT for neither CS1 nor CS2. A median split subanalysis on CPM-responders versus CPM-nonresponders to the TS + CS1 combination. Using this grouping, there was significant increase in PDT when comparing TS to TS + CS1 or TS + CS2 (4.0 mA vs 5.6 mA; P < 0.05, 4.0 mA vs 5.1 mA; P < 0.05).

Conclusions

The study indicates that CPM can be evoked in a subgroup of subjects by applying the electrical test stimulus and cuff pressure conditioning stimuli to the same experimental site.

Circulating Exosomal MicroRNA-21 as a Biomarker in Each Tumor Stage of Colorectal Cancer

OBJECTIVE

We clarified the predictive and prognostic value of circulating plasma exosomal microRNA-21 (miR-21) in each TNM stage of colorectal cancer (CRC) patients.

METHODS

The microRNA (miRNA) profiles of the plasma exosomes, primary tumor tissues, and liver metastasis tissues from the same CRC patients were examined using a microarray. For validation analysis, the plasma exosome samples from 326 CRC patients were measured by TaqMan miRNA assays.

RESULTS

In the miRNA microarray analyses, miR-21 showed the highest upregulation in exosomes, primary tumor tissues, and liver metastasis tissues. Significant correlations were demonstrated between exosomal miR-21 and tissue miR-21 levels. As for the relationship to the pathological condition, exosomal miR-21 showed a significant association with liver metastasis and TNM stage. The overall survival (OS) rates and disease-free survival (DFS) rates in high-exosomal-miR-21 patients were significantly worse than those in low-miR-21 patients. Exosomal miR-21 levels were an independent prognostic factor for OS and DFS in CRC patients with TNM stage II or III, and for OS in patients with TNM stage IV.

CONCLUSION

Plasma exosomal miR-21 levels are a useful biomarker for the prediction of recurrence and poor prognosis in CRC patients with TNM stage II, III, or IV.

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy (LAC) in elderly colorectal cancer patients with open colectomy (OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups.

RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC (mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss (mean difference = -93.3738, 95%CI: -132.3437 to -54.4039, P < 0.0001), overall morbidity (OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection (OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus (OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications (OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes (median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival (mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival (mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes (mean difference = -0.1360, 95%CI: -4.0553-3.7833, P = 0.9458).

CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.

A case of IgG4-related disease coexisted with rectal cancer

A 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. Colonoscopic findings were intermittent nodular lesions with redness which were atypical to primary rectal cancer. Endoscopic retrograde cholangiopancreatography showed narrowing of the bilateral intrahepatic bile duct. However, the findings were improved 1 month later. Blood biochemistry showed high level of serum IgG4 up to 1140 mg/dl. The patient matched to comprehensive diagnostic criteria for IgG4-related disease as a possible diagnostic case. Laparoscopic low anterior resection with creation of ileostomy was performed for rectal cancer. Histological findings revealed cancer cells spread horizontally at submucosal layer and subserosal layer. There was marked infiltration of the plasma cells and lymphocytes at tumor stroma, and more than half of the plasma cells were positive for IgG4. After surgery, the level of serum IgG4 was decreased to 597 mg/dl. Although the association with IgG4-related disease and colorectal disease is unclear, the tumor progression was atypical for rectal cancer. Some report that the disease may rise up the risk of a malignant disease. It is necessary to perform systemic examination keeping in mind for concurrence of malignancy.

Clinical significance of microRNA-21 as a biomarker in each Dukes' stage of colorectal cancer

The potential value of microRNAs (miRNAs) as prognostic biomarkers are of interest. It is known that microRNA-21 (miR-21) is implicated in the promotion, proliferation and progression of several types of human cancers. However, the prognostic significance of miR-21 in each tumor stage of colorectal cancer (CRC) remains elusive. The objective of this study was to clarify the prognostic value of miR-21 for CRC patients at each tumor stage. The expression levels of miR-21 in the tumor tissues and normal adjacent tumor tissues of 306 CRC patients were determined by TaqMan microRNA assays. In order to clarify the miRNA profile in CRC tissues, miRNA arrays were examined. In this analysis, miR-21, miR-224, miR-96, miR-31 and miR-155 showed marked upregulation, and miR-21 showed the highest level. Upon comparison of clinicopathological factors, miR-21 expression showed significant association with depth of invasion, lymphatic and venous invasion, liver metastasis and Dukes' stage. In the Kaplan-Meier survival curve analysis of all patients, overall survival (OS) and disease-free survival (DFS) rates of the patients with high miR-21 expression were significantly worse than these rates in patients with low miR-21 expression. In the Kaplan-Meier analysis of each tumor stage, the DFS of patients with high miR-21 expression was significantly worse than patients with low miR-21 levels in Dukes' stage A tumors. In Dukes' stage B and C, patients with high miR-21 expression showed a significantly worse OS and DFS than patients with low miR-21 expression. In Dukes' stage D, patients with high miR-21 expression showed a significantly worse OS than patients with low miR-21 expression. In the Cox multivariate analysis, it was shown that miR-21 expressions in CRC tissues is an independent prognostic factor in Dukes' stage B, C and D. In conclusion, miR-21 expression may be a valuable biomarker for prediction of poor prognosis in CRC patients with Dukes' stage B, C and D.

Total hip arthroplasty with bone graft for acetabular protrusion in rheumatoid arthritis

Abstract Twenty-five hips in 19 rheumatoid arthritis (RA) patients with protrusio acetabuli were followed up, both clinically and radiographically, for more than 9 years after total hip arthroplasty (THA), that was performed with a bone graft to reinforce the medial acetabular wall. Radiographs were taken preoperatively and every 6 months postoperatively. Clinical assessments of pain, gait, and range of motion of the hips were obtained preoperatively and every year postoperatively using the Japanese Orthopaedic Association hip-scoring system. Radiographs showed that bony union had occurred in all cases. Six acetabular components were loose, but no femoral components became loose during the 9-year period. The clinical evaluation showed that relief of pain was very significant. The range of motion of the hip joints also improved from 12 points to 16.6 points after 9 years. Walking ability improved, but is becoming worse as time goes by. The radiographic results were compared with the results of a THA group with RA that had not had a bone graft. The rate of loosening of the THA without a bone graft was significantly higher than that of THA with a bone graft. We concluded that bone grafting for protrusio acetabuli was a very useful procedure.

Influence of Carbonate Ions on Europium Sorption onto Iron-Oxides

The sorption behavior of europium onto two iron-oxides, goethite and magnetite, focused on the effect of carbonate species concentration was investigated in 0.01 M NaClO4 solution by the batch method over a pH range of 4 to 11. It was found that sorption of europium was enhanced in the higher concentration solution of carbonate species for both materials. The zeta-potential of goethite in the solutions including sodium bicarbonate was also measured to estimate the effect of sorbed carbonate species. Our experimental results and model calculation suggest that the production of surface carboxylic group FeOCOO by the sorption of carbonate species lowered the zeta-potential and enhanced europium sorption.

Strengthening tuberculosis patient referral mechanisms among health facilities in Punjab, Pakistan

OBJECTIVE

To describe approaches to strengthen existing tuberculosis (TB) patient referral mechanisms in Punjab, Pakistan.

METHODS

A descriptive intervention study was conducted through medical chart review. All new smearpositive pulmonary TB patients diagnosed at Gulab Devi Hospital, Lahore, who were referred to any of the primary health care (PHC) units in Punjab Province, were enrolled from January to September 2009. TB coordinators at the referral unit maintained an electronic TB referral/transfer register (e-TRTR) as their key referral monitoring tool.

RESULTS

Of 444 new smear-positive pulmonary TB patients enrolled in the study, 181 (41%) confirmed that they had arrived and were registered at the receiving PHC units, and another 17 (4%) had gone to other health facilities. Of the 181 access-confirmed patients at the receiving PHC units, seven were confirmed by postal mail, 49 by district TB coordinators, and the remaining 125 only through direct phone calls made by Provincial TB Programme staff.

CONCLUSION

The present study indicates that utilisation of a referral register (e-TRTR), appointment of a responsible person for patient referral at the hospital, close monitoring of the referral by telephone and communication with responsible TB coordinators bring about a considerable improvement in the TB patient referral mechanism.

Corrosion of Radioactive, Crushed Waste Glass

The corrosion experiments of crushed, radioactive waste glass at Studsvik within phase V of the JSS Project are described. The experiments were performed with high S/V ratios (1100 and 4000 m−1) which resulted in silica saturation already after the shortest reaction time studied (91 d).Thee long term leach rate of the soluble elements is about 10−3 g.m d−1, both in the presence and absence of bentonite. In the presence of bentonite + magnetite the leach rate is higher, about 0.007 g.m1.d−2. The release rate to the solution of Cs is one order of magnitude lower and that of Pu-238 + Am-241 three orders of magnitude lower than the release rate of the soluble elements Mo and B. Most of the Pu-238 and Am-241 fraction, found in the solution, is present as colloids.

Modeling of Neptunium(V) Sorption Behavior onto Iron-Containing Minerals

Sorption behaviors of neptunium (V) on naturally-occurring magnetite (Fe3O4) and goethite (α-FeOOH) in 0.1M NaN03electrolyte solution under aerobic conditions were interpreted using the surface complexation model (SCM). The surface properties of these materials were experimentally investigated by C02-free potentiometric titration, and SCM parameters for the constant capacitance model, such as protonation/deprotonation constants of the surface hydroxyl group, were determined. The number of negatively charged sorption sites of goethite rapidly increased with the increase of the bulk solution pH compared with that of magnetite and this tendency was similar to the pH dependence of neptunium sorption. This implies that the neptunyl cation, NpO2+, plays a dominant role in possible sorption reactions. Assuming that the dominant surface complex is XO-NpO2, modeling by means of SCM was carried out, and the results were found to agree with experimental data.

Uranium(VI) Uptake by Synthetic Calcium Silicate Hydrates

The immobilization of U(VI) by C-S-H phases under conditions relevant for the cementitious near field of a repository for radioactive waste has been investigated. C-S-H phases have been synthesized using two different procedures: the “direct reaction” method and the “solution reaction” method.

The stabilities of alkaline solutions of U(VI) (presence of precipitates or colloidal material) were studied prior to sorption and co-precipitation tests in order to determine the experimental U(VI) solubility limits. These U(VI) solubility limits were compared with the U(VI) solubilities obtained from thermodynamic speciation calculations assuming the presence of combinations of different solid U(VI) phases. The solid phase controlling U(VI) solubility in the present experiments was found to be CaUO4(s).

The U(VI) uptake kinetics and sorption isotherms on C-S-H phases with different C:S ratios were determined under various chemical conditions; e.g., sorption and co-precipitation experiments and different pH’s. U(VI) was found to sorb fast and very strongly on C-S-H phases with distribution ratios (Rd values) ranging in value between 103 L kg-1 and 106 L kg-1. Both sorption and co-precipitation experiments resulted in Rd values which were very similar, thus indicating that no additional sorption sites for U(VI) were generated in the co-precipitation process. Furthermore, C-S-H synthesis procedures did not have a significant influence on U(VI) uptake. The U(VI) sorption isotherms were found to be non-linear, and further, increasing Ca concentrations resulted in increasing U(VI) uptake. The latter observation suggests that U(VI) uptake is controlled by a solubility-limiting process, while the former observation further indicates that pure Ca-uranate is not the solubility-limiting phase. It is proposed that a solid solution containing Ca and could control U(VI) uptake by C-S-H phases.

Reserpine causes biphasic nociceptive sensitivity alteration in conjunction with brain biogenic amine tones in rats

The present study investigated the precise relationship between brain biogenic amine (dopamine, noradrenaline, and serotonin) tones and nociception. Nociceptive sensitivities to multimodal (muscle pressure, tactile, cold, and heat) stimuli were assessed in acute phase (up to 24 h after reserpine or tetrabenazine injection) and chronic phase (on day 2 or later) in rats. A single injection of reserpine (3 mg/kg s.c.) significantly decreased biogenic amines in the spinal cord (SC), thalamus (THA), and prefrontal cortex (PFC) in both acute and chronic phases, but significantly increased a dopamine metabolite 3,4-dihydroxyphenylacetic acid (DOPAC) in the SC and a serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the SC and THA in acute phase. The content of all biogenic amine metabolites was at low level in chronic phase. Animals exhibited hypersensitivities to tactile and heat stimuli and hyposensitivity to muscle pressure stimulus in acute phase. In chronic phase, they manifested hypersensitivities to all modes of stimuli. Tetrabenazine (20 mg/kg i.p.) significantly decreased brain biogenic amines for a short time, although it did not significantly affect the nociceptive sensitivities. In conclusion, a single injection of reserpine causes a biphasic alteration of nociceptive sensitivities, which is in conjunction with the dynamic change of brain biogenic amine tones, in rats. Cold and heat hypersensitivities in addition to mechanical ones are induced by the reserpine treatment. Sustained modification of brain biogenic amine tones would be critical to induce a robust change in nociceptive sensitivities based on the different effects between reserpine and tetrabenazine.

Magnetic excitations in the spin-1 anisotropic Heisenberg antiferromagnetic chain system NiCl(2)-4SC(NH(2))(2)

NiCl(2)-4SC(NH(2))(2) (DTN) is a quantum S=1 chain system with strong easy-pane anisotropy and a new candidate for the Bose-Einstein condensation of the spin degrees of freedom. ESR studies of magnetic excitations in DTN in fields up to 25 T are presented. Based on analysis of the single-magnon excitation mode in the high-field spin-polarized phase and previous experimental results [Phys. Rev. Lett. 96, 077204 (2006)10.1103/PhysRevLett.96.077204], a revised set of spin-Hamiltonian parameters is obtained. Our results yield D=8.9 K, J(c) = 2.2 K, and J(a,b) = 0.18 K for the anisotropy, intrachain, and interchain exchange interactions, respectively. These values are used to calculate the antiferromagnetic phase boundary, magnetization, and the frequency-field dependence of two-magnon bound-state excitations predicted by theory and observed in DTN for the first time. Excellent quantitative agreement with experimental data is obtained.

EXAFS study of U(VI) uptake by calcium silicate hydrates

Among the different cement minerals, calcium silicate hydrates (C-S-H) are the prime candidates for heavy metal binding because of their abundance and appropriate structure. Immobilization processes of heavy metals by cementitious materials, and in particular C-S-H phases, thus play an important role in multibarrier concepts developed worldwide for the safe disposal of hazardous and radioactive wastes. In this study, the uptake of U(VI) by C-S-H has been investigated using X-ray absorption fine structure (XAFS) spectroscopy. C-S-H phases were synthesized using two different procedures: One is based on the mixing of CaO and SiO2 solids ("direct reaction" method); for the other one starting solutions of Ca and Si are used ("solution reaction" method). XAFS investigations were carried out on samples doped with U(VI). U(VI) was either sorbed onto previously precipitated C-S-H phases (sorption samples) or added during C-S-H synthesis (coprecipitation samples). The coordination environment of U(VI) in the sorption samples was found to be independent of the procedure used for C-S-H synthesis. A split equatorial oxygen shell (Oeq1: R=2.23-2.27 A; Oeq2: R=2.36-2.45 A), neighboring silicon atoms at short (R=3.07-3.11 A) and long (R=3.71-3.77 A) distances, and neighboring Ca atoms (R=3.77-3.81 and 4.15-4.29 A) were observed for all the samples. The structural parameters resemble those reported for uranophane. The coordination environment of U(VI) in the coprecipitation samples depends on the method used for C-S-H synthesis, and further, the spectra differ from those determined for the sorption samples. UU backscattering contributions were observed in the samples prepared using the direct reaction method, whereas no split equatorial shell appeared in the samples prepared using the solution reaction method.

[Utility of the perfusion-assist for beating heart coronary artery bypass surgery]

During off-pump coronary artery bypass surgery, concern remains about the possible myocardial injury associated with the transient occlusion and stabilization of the target vessels. To try to minimize myocardial ischemia and achieve hemodynamic stability, we utilized a coronary perfusion catheter combined with the perfusion-assisted direct coronary artery bypass system that enables active and modified coronary perfusion of the target vessel throughout the duration of multiple grafting (modified PADCAB). In the series of 10 patients, perfusion of the target coronary systems averaged 2,072.8 +/- 649.7 ml over 92.9 +/- 26.1 minutes under a constant infusion pressure of 120 mmHg. Nitroglycerin (100 micrograms/l of flow) was delivered directly into the coronary arteries as an additive in all patients. Hemodynamic instability was notably absent in all cases, even in cases that required difficult anastomosis with a relatively long time for the anastomosis. There were no perioperative complications and no detectable myocardial damage (i.e., impairment of myocardial wall motion indicated by echocardiography findings or by > 0.25 ng/ml of troponin-T release compared to the preoperative level) in this series of patients.

The adhesion molecules, l-selectin and sialyl lewis x, relate to the formation of the follicular dendritic cell-lymphocyte cluster in the mantle zone

The follicular dendritic cell (FDC)-lymphocyte cluster is rich in the follicular light zone of the secondary lymphoid follicles (LFs). Although, the mantle zone (MZ) also has FDC-lymphocyte cluster, it has not known about what kind of adhesion molecules relates to cluster formation. In the present study, we investigated whether the adhesion molecules, L-selectin (CD62L) and sialyl Lewis x (CD15s) can mediate the formation of the cluster in human tonsillar LFs. The MZ only expressed both the adhesion molecules in the secondary LF. Isolated FDC-lymphocyte clusters were composed of CD62L(+) lymphocytes and CD15s(+) FDCs. Stamper-Woodruff binding assay revealed that the binding of IgD(+) lymphocytes was significantly inhibited by pretreatment with anti-CD62L antibody or with anti-CD15s antibody. These results indicate that CD62L on MZ lymphocytes and CD15s on FDCs may play a role of the cluster formation, unlike the clusters in the other parts of LFs.

Effect of skin pressure by clothing on small bowel transit time

We examined the effect of increased skin pressure from tight clothing on small bowel transit time by means of the breath hydrogen test, using milk that contained lactulose as an additional indigestible disaccharide, which is used as a test meal after overnight fasting. In this experiment, we measured the small bowel transit time from 9 healthy and non-constipated female subjects with two different skin pressures that were applied by loose-fitting experimental garment or an additional tight-fitting girdle on two consecutive days. The skin pressure of the latter condition was 8-9 mmHg higher than that of the former one on the participants' waist, abdomen and hip region. The experimental order of the two skin pressure conditions was counterbalanced. As a result, the small bowel transit time obtained with and without girdle did not differ significantly (165.0 +/- 26.0 minutes for less skin pressure condition and 173.3 +/- 26.8 minutes for more skin pressure condition, n = 9, p = 0.43). This result indicated that the skin pressure from clothing has no effect on the passage rate of food through the small intestine.