Electrophysiological characteristics and catheter ablation of atypical fast-slow atrioventricular nodal reentrant tachycardia using an inferolateral left atrial slow pathway

Background

Understandings of subtypes of atypical atrioventricular nodal reentrant tachycardia (AVNRT) using variants of slow pathway (SP) are still growing. Inferolateral (inf-lat-) left atrial (LA) SP is a rare variant extending into an inf-lat-LA along the mitral annulus (MA).

Purpose

To characterize an unknown subtype of atypical fast-slow (F/S-) AVNRT using an inf-lat-LA-SP as a retrograde limb (inf-lat-LA-F/S-AVNRT).

Methods

This Japanese multicenter retrospective study enrolled 4 patients of inf-lat-LA-F/S-AVNRT that was characterized by the earliest site of atrial activation during tachycardia (EAA) between 3 and 6 o'clock along the MA. The diagnosis was made by an exclusion of AV reentrant tachycardia (AVRT) and atrial tachycardia (AT) according to the standard criteria and was confirmed by successful elimination of tachycardia and the inf-lat-LA-SP.

Results

Surface ECG during tachycardia revealed long RP appearance except one who had short RP due to a short conduction time across the inf-lat-LA-SP. During tachycardia, far-field LA activation preceding near-field activation of coronary sinus (CS) musculature was visible in the CS recording in 2. Retrograde conduction via the inf-lat-LA-SP with a decremental delay was consistently reproducible with ventricular stimulation in 2, 1 of whom had double atrial response, while it was always masked by the presence of a retrograde conduction via the fast pathway in 1 and a retrograde block at the lower common pathway in 1. An injection of a small dose of ATP transiently interrupted a retrograde conduction over the inf-lat-LA-SP, suggesting its ATP-sensitivity. Exclusion of AVRT was made by no resetting of tachycardia with left ventricular extrastimulus in 2 and VA dissociation during overdrive pacing of tachycardia in remaining 2. Exclusion of AT was made by V-A-V response after ventricular entrainment in 1 and termination without atrial capture by ventricular pacing in 2. Ablation of the right-sided SP was unsuccessful to eliminate the tachycardia, but ablation at or near the EAA by transseptal approach was successful to cure the tachycardia, associated with an elimination of a retrograde conduction over the inf-lat-LA-SP following a development of an accelerated junction rhythm in all. Low-frequency potentials preceding local atrial activation, consistent with a retrograde activation via the inf-lat-LA-SP were detected along the MA medial to the EAA in 1.

Conclusions

Differential diagnosis of tachycardia with the EAA in the inf-lat-LA and especially long RP appearance should include inf-lat-LA-F/S-AVNRT. Presumed arrhythmogenic substrate of the inf-lat-LA-SP seemed to be consistent with the remnant of embryogenic AV ring tissue in the electropharmacological and locational characteristics. Successful elimination of this AVNRT can be obtained by ablation of the inf-lat-LA-SP, but not of the right-sided SP.

Funding Acknowledgement

Type of funding sources: None.

Fast-slow atrioventricular nodal reentrant tachycardia phenotype mimicking the slow-slow type

Background

Fast-slow (F/S-) atrioventricular (AV) nodal reentrant tachycardia (AVNRT) is characterized by a short atrio-His (AH) interval and the earliest site of atrial activation (EAA) in the proximal coronary sinus (EAA-CS), while slow-slow (S/S-) AVNRT presents a long AH interval and EAA-CS. Those intracardiac appearances are initial indicators for making a diagnosis.

Purpose

To identify an unknown phenotype of F/S-AVNRT.

Methods

Among 46 consecutive patients with F/S-AVNRT, 6 patients (1 man, age 59±9) had an apparent but not typical (pseudo-) S/S-AVNRT during an electrophysiologic study. In 2 patients, pseudo-S/S-AVNRT was clinically documented.

Results

In all 6 patients, the diagnosis of F/S-AVNRT was made by an exclusion of atrial tachycardia with findings of 1) a V-A-V response following ventricular entrainment or 2) termination without atrial capture by ventricular pacing, and an exclusion of AV reentrant tachycardia with a ventriculoatrial dissociation during an initial (so-called QRS transition) zone of ventricular entrainment. An initial A-A-V activation sequence on atrial induction of F/S-AVNRT observed in 1 patient and Wenckebach-type AV block during ongoing F/S-AVNRT developing in 3 patients suggested the presence of the lower common pathway (LCP). Like the typical S/S-AVNRT, pseudo-S/S-AVNRT was induced with atrial stimulation after a jump in the AH interval or double ventricular response. However, in all patients, the pseudo-S/S-AVNRT transited to F/S-AVNRT following AV block in a single cycle and/or pseudo-S/S-AVNRT transited from spontaneously or triggered by atrial contractions. Importantly, on these transitions, the atrial cycle length (CL) and EAA-CS remained unchanged, that is, the atrial CL of S/S-AVNRT was almost identical to that of F/S-AVNRT, suggesting that the essential circuit of both tachycardias was identical. Actually, both tachycardias were cured by ablation at a single site in the traditional slow pathway (SP). Collectively, the pseudo-S/S-AVNRT was diagnosed as another phenotype of F/S-AVNRT accompanied by sustained antegrade conduction via another bystander (likely the left-sided or superior) SP breaking through the His bundle owing to the repetitive antegrade block at the LCP occurring by linking phenomenon, thus representing a long AH interval during the ongoing F/S-AVNRT. When the antegrade conduction is blocked at the bystander SP during the pseudo-S/S-AVNRT, releasing the linking phenomenon, the subsequent antegrade conduction reach the His-bundle via the fast pathway, thus returning to F/S-AVNRT.

Conclusions

An unknown, but not rare F/S-AVNRT phenotype exists that apparently mimics the typical S/S-AVNRT and is also an unknown subtype of apparent S/S-AVNRT. The presence of this pseudo-S/S-AVNRT suggests the limitation of classifying types of AVNRT based on AH and HA intervals during tachycardia. Understandings of this phenotype can advance a diagnosis of atypical AVNRT with multiple phenotypes.

Funding Acknowledgement

Type of funding sources: None.

Multicenter prospective trial of total gastrectomy versus proximal gastrectomy for upper third cT1 gastric cancer

BACKGROUND

The appropriate surgical procedure for patients with upper third early gastric cancer is controversial. We compared total gastrectomy (TG) with proximal gastrectomy (PG) in this patient population.

METHODS

A multicenter, non-randomized trial was conducted, with patients treated with PG or TG. We compared short- and long-term outcomes between these procedures.

RESULTS

Between 2009 and 2014, we enrolled 254 patients from 22 institutions; data from 252 were included in the analysis. These 252 patients were assigned to either the PG (n = 159) or TG (n = 93) group. Percentage of body weight loss (%BWL) at 1 year after surgery, i.e., the primary endpoint, in the PG group was significantly less than that of the TG group (- 12.8% versus - 16.9%; p = 0.0001). For short-term outcomes, operation time was significantly shorter for PG than TG (252 min versus 303 min; p < 0.0001), but there were no group-dependent differences in blood loss and postoperative complications. For long-term outcomes, incidence of reflux esophagitis in the PG group was significantly higher than that of the TG group (14.5% versus 5.4%; p = 0.02), while there were no differences in the incidence of anastomotic stenosis between the two (5.7% versus 5.4%; p = 0.92). Overall patient survival rates were similar between the two groups (3-year survival rates: 96% versus 92% in the PG and TG groups, respectively; p = 0.49).

CONCLUSIONS

Patients who underwent PG were better able to control weight loss without worsening the prognosis, relative to those in the TG group. Optimization of a reconstruction method to reduce reflux in PG patients will be important.

Health guidance for prevention of lifestyle-related diseases using health-related mobile applications

Issue

Lifestyle modifications are essential for the prevention of lifestyle-related diseases such as hypertension, hyperlipidaemia, and type 2 diabetes. Healthcare providers in Japan are required to use information and communications technologies (ICT), such as health-related mobile applications (mHealth apps), in health guidance.

Description of the Problem

To understand the results of and issues in health guidance, two searches were conducted to identify the domains of health guidance provided using ICT. We searched the PubMed and Japan Medical Abstracts Society databases to identify articles published from 2000-2018. The first search identified frameworks of health guidance provided using ICT. The second search identified primary studies about using mHealth apps published between 2000 and 2018. The sample comprised 22 unique programs from 38 primary studies. The following research questions were explored: 1) What is the purpose of using the mHealth app?

2) Is there a significant difference in the effect of using the mHealth app instead of face-to-face communication?

Results

The mHealth app was used to enhance convenience and to improve or modify lifestyle. The latter included self-monitoring, typing health information, providing knowledge, sharing information, providing encouragement and praise, and correction of action plans. Some positive effects were observed, including compensating for insufficient information, enhancing self-management, and improving degrees of satisfaction of users. Only two programs did not report a significant difference in the effect of using the mHealth app as compared to face-to-face communication.

Lessons

This review showed that the frequency of typing information about diet and exercise appeared to be related to the prevention of primary lifestyle-related diseases and the improvement of self-management behaviour.

Key messages

Use of the mHealth app for providing health guidance might enhance continuous support for self-monitoring and self-management behaviour. Use the mHealth app for providing encouragement and praise might promote a smooth conversation, which in turn would facilitate appropriate self-management behaviour.

Novel screening system revealed that intracellular cholesterol trafficking can be a good target for colon cancer prevention

In conventional research methods for cancer prevention, cell proliferation and apoptosis have been intensively targeted rather than the protection of normal or benign tumor cells from malignant transformation. In this study, we aimed to identify candidate colon cancer chemopreventive drugs based on the transcriptional activities of TCF/LEF, NF-κB and NRF2, that play important roles in the process of malignant transformation. We screened a “validated library” consisting of 1280 approved drugs to identify hit compounds that decreased TCF/LEF and NF-κB transcriptional activity and increased NRF2 transcriptional activity. Based on the evaluation of these 3 transcriptional activities, 8 compounds were identified as candidate chemopreventive drugs for colorectal cancer. One of those, itraconazole, is a clinically used anti-fungal drug and was examined in the Min mouse model of familial adenomatous polyposis. Treatment with itraconazole significantly suppressed intestinal polyp formation and the effects of itraconazole on transcriptional activities may be exerted partly through inhibition of intracellular cholesterol trafficking. This screen represents one of the first attempts to identify chemopreventive agents using integrated criteria consisting of the inhibition of TCF/LEF, NF-κB and induction of NRF2 transcriptional activity.

Effects of mirogabalin, a novel ligand for the α₂δ subunit of voltage-gated calcium channels, on N-type calcium channel currents of rat dorsal root ganglion culture neurons

Mirogabalin, which is a novel ligand for the α₂δ subunit of voltage-gated calcium channels, is being developed for treating neuropathic pain including diabetic peripheral neuropathy and postherpetic neuralgia. Mirogabalin possesses unique α₂δ subunit binding characteristics and has potent and long-lasting analgesic effects in neuropathic pain models. In the present study, we investigated the effects of mirogabalin on N-type calcium channel currents of the rat dorsal root ganglion (DRG) culture neurons using the whole-cell patch clamp technique. Small or medium DRG neurons were isolated from Sprague-Dawley rats and were incubated for 20 to 24 h with mirogabalin or pregabalin. The DRG neurons were depolarised from a holding potential of -40 mV to +40 mV in steps of 10 mV for 220 ms, and elicited N-type calcium channel currents were recorded. The N-type calcium channel currents were verified by sensitivity to ω-conotoxin GVIA, a selective N-type calcium channel blocker. Mirogabalin inhibited the calcium channel currents of rat DRG neurons at 50 μM, and pregabalin inhibited them at 200 μM. Mirogabalin and pregabalin showed significant differences in the peak current densities at depolarisation to -20 and -10 mV when compared with that shown by the vehicle control. In conclusion, mirogabalin inhibits N-type calcium channel currents in rat DRG culture neurons. The potent and long-lasting analgesic effects of mirogabalin are thought to be associated with its potent and selective binding to α₂δ-1 subunits and following functional inhibition of calcium channel currents.

Inhibition of NF-kappaB transcriptional activity enhances fucoxanthinol-induced apoptosis in colorectal cancer cells

Background

Evidence from epidemiological and experimental studies has shown that the etiology of colorectal cancer (CRC) is related to lifestyle, mainly diet. At the same time, there are many foods and beverages that have been shown to provide protection against CRC. We turned our attention to a traditional Japanese food, brown algae, that contains carotenoids and various functional polyphenols, especially fucoxanthin (FX) and fucoxanthinol (FxOH).

Results

Both FX and FxOH treatments induced apoptosis in a dose-dependent and time-dependent manner as detected by annexin V / propidium iodide and the presence of a subG1 population in human colon cancer HCT116 cells. This apoptotic effect of FxOH was stronger than that of FX. We also found that nuclear factor-kappa B (NF-κB) transcriptional activity was significantly increased by treatment with ≥5 μM FxOH. Thus, we cotreated the cells with FxOH plus NF-κB inhibitor, and the results demonstrated that this cotreatment strongly enhanced the induction of apoptosis compared with the effects of FxOH or NF-κB inhibitor treatment alone and resulted in X-linked inhibitor of apoptosis (IAP) downregulation.

Conclusions

This study suggested that FxOH is a more potent apoptosis-inducing agent than FX and that its induction of apoptosis is enhanced by inhibiting NF-κB transcriptional activity via suppression of IAP family genes.

Three-dimensional shaping technique for coil placement using the steam-shaped microcatheter for ruptured blood blister-like aneurysm

Treatment of blood blister-like aneurysm (BBA) is a challenge due to its unfavourable morphology, small size and the friable neck of BBA. In the management of ruptured BBA, coil placement can be achieved by stent-assisted coil embolisation. We propose to incorporate a new technique using a steam-shaped microcatheter to improve safety. A 59-year-old woman was transferred to our hospital and diagnosed with subarachnoid haemorrhage (SAH) due to a ruptured BBA of the left internal carotid artery (ICA) at the C2 portion. For coil embolisation, we selected the aneurysm sac using a three-dimensional shaping technique and the jailing method. Post-embolisation angiography revealed complete occlusion of the aneurysmal sac. For safe treatment and stability of BBA, the shape of the catheter tip and the distal portion of the microcatheter are two important factors to consider. The proposed technique could help resolve the problem of catheter shaping in the treatment of BBA.

Functional characterization of recombinant snake venom rhodocytin: rhodocytin mutant blocks CLEC-2/podoplanin-dependent platelet aggregation and lung metastasis

Essentials We generated recombinant rhodocytin that could aggregate platelets via CLEC-2. Recombinant wild-type rhodocytin formed heterooctamer with four α- and β-subunits. Asp 4 in α-subunit of rhodocytin was required for binding to CLEC-2. Inhibitory mutant of rhodocytin blocked podoplanin-dependent hematogenous metastasis.

SUMMARY

Background Rhodocytin, a disulfide-linked heterodimeric C-type lectin from Calloselasma rhodostoma consisting of α-subunits and β-subunits, induces platelet aggregation through C-type lectin-like receptor 2 (CLEC-2). CLEC-2 is a physiological binding partner of podoplanin (PDPN), which is expressed on some tumor cell types, and is involved in tumor cell-induced platelet aggregation and tumor metastasis. Thus, modified rhodocytin may be a possible source of anti-CLEC-2 drugs for both antiplatelet and antimetastasis therapy. However, its molecular function has not been well characterized, because of the lack of recombinant rhodocytin that induces platelet aggregation. Objective To produce recombinant rhodocytin, in order to verify its function with mutagenesis, and to develop an anti-CLEC-2 drug based on the findings. Methods We used Chinese hamster ovary cells to express recombinant rhodocytin (wild-type [WT] and mutant), which was analyzed for induction/inhibition of platelet aggregation with light transmission aggregometry, the formation of multimers with blue native PAGE, and binding to CLEC-2 with flow cytometry. Finally, we investigated whether mutant rhodocytin could suppress PDPN-induced metastasis in an experimental lung metastasis mouse model. Results Functional WT] rhodocytin (αWTβWT) was obtained by coexpression of both subunits. Asp4 in α-subunits of rhodocytin was required for CLEC-2 binding. αWTβWT formed a heterooctamer similarly to native rhodocytin. Moreover, an inhibitory mutant of rhodocytin (αWTβK53A/R56A), forming a heterotetramer, bound to CLEC-2 without inducing platelet aggregation, and blocked CLEC-2-PDPN interaction-dependent platelet aggregation and experimental lung metastasis. Conclusion These findings provide molecular characterization information on rhodocytin, and suggest that mutant rhodocytin could be used as a therapeutic agent to target CLEC-2.

Optimisation of antithrombin resistance assay as a practical clinical laboratory test: Development of prothrombin activator using factors Xa/Va and automation of assay

INTRODUCTION

Antithrombin resistance (ATR) is a novel thrombotic risk in abnormal prothrombins. A manual ATR assay using Oxyuranus scutellatus (Ox) venom as a prothrombin activator was established for detecting antithrombin-resistant prothrombin. However, this assay was limited because of Ox snake venom availability and its throughput capacity. Here, we have improved the ATR assay using bovine factors Xa and Va (FXa/Va) as prothrombin activators and have optimised assay conditions for an automated instrument (ACL TOP 500).

METHODS

Diluted plasma was incubated with a prothrombin activator mix (phospholipids, CaCl₂ , and bovine FXa/Va), followed by inactivation with antithrombin for 10, 20 and 30 minutes. We added a chromogenic substrate S-2238, and assessed changes in absorbance/min at 405 nm. We also adapted assay conditions for ACL TOP 500.

RESULTS

Optimum conditions for FXa/Va treatment were 6.25% phospholipids, 5 mM CaCL₂ , 0.01 μg/mL FXa and 0.1 μg/mL FVa. ATR assay kinetics with the FXa/Va activator was comparable with that with the Ox activator in heterozygous reconstituted plasma with the recombinant wild-type or antithrombin-resistant prothrombin. Using ACL TOP 500, optimum conditions for the FXa/Va treatment were 10.0% phospholipids, 5 mM CaCl₂ , 0.02 μg/mL FXa and 0.2 μg/mL FVa. The automated ATR assay with the FXa/Va activator demonstrated good detectability for antithrombin-resistant prothrombin in plasma from a heterozygous carrier with prothrombin Yukuhashi or Belgrade.

CONCLUSION

We optimised the ATR assay with the FXa/Va activator and adapted the assay for ACL TOP 500; the assay showed the ability to clearly detect antithrombin-resistant prothrombin in manual and automated procedures.

Chemopreventive effects of a low-side-effect antibiotic drug, erythromycin, on mouse intestinal tumors

It is important to establish effective methods for preventing colorectal cancer because the number of colorectal cancer deaths is increasing. Erythromycin one of the macrolide antibiotics, has been shown to exert pleiotropic effects, such as anti-inflammatory and anti-oxidative effects, on mammalian cells. In the present study, we aimed to evaluate the preventive effects of erythromycin on intestinal carcinogenesis. We first confirmed that erythromycin suppresses the transcriptional activity of nuclear factor-κB and activator protein-1 and the expression of its downstream targets, interleukin-6 and cyclooxygenase-2 in human colon cancer cells. Next, we fed 5-week-old male Apc mutant Min mice with diets containing 500 ppm erythromycin for 15 weeks. Erythromycin treatment significantly reduced the number of proximal intestinal polyps to 70.9% of the untreated control value. Moreover, erythromycin reduced the levels of interleukin-6 and cyclooxygenase-2 mRNA expression in intestinal polyps. Although the levels of hepatic NADPH oxidase mRNA were decreased, erythromycin treatment did not affect the levels of oxidative stress markers, reactive carbonyl species, in the liver of Min mice. Our results suggest that erythromycin suppresses intestinal polyp development in Min mice, in part by attenuating local inflammation, and indicate that erythromycin is useful as a chemopreventive agent.

Preventive Effects of Heat-Killed Enterococcus faecalis Strain EC-12 on Mouse Intestinal Tumor Development

Establishing effective methods for preventing colorectal cancer by so-called “functional foods” is important because the global burden of colorectal cancer is increasing. Enterococcus faecalis strain EC-12 (EC-12), which belongs to the family of lactic acid bacteria, has been shown to exert pleiotropic effects, such as anti-allergy and anti-infectious effects, on mammalian cells. In the present study, we aimed to evaluate the preventive effects of heat-killed EC-12 on intestinal carcinogenesis. We fed 5-week-old male and female Apc mutant Min mice diets containing 50 or 100 ppm heat-killed EC-12 for 8 weeks. In the 50 ppm treated group, there was 4.3% decrease in the number of polyps in males vs. 30.9% in females, and significant reduction was only achieved in the proximal small intestine of female mice. A similar reduction was observed in the 100 ppm treated group. Moreover, heat-killed EC-12 tended to reduce the levels of c-Myc and cyclin D1 mRNA expression in intestinal polyps. Next, we confirmed that heat-killed EC-12 suppressed the transcriptional activity of the T-cell factor/lymphoid enhancer factor, a transcriptional factor involved in cyclin D1 mRNA expression in intestinal polyps. Our results suggest that heat-killed EC-12 very weakly suppresses intestinal polyp development in Min mice, in part by attenuating β-catenin signaling, and this implies that heat-killed EC-12 could be used as a “functional food”.

C-type lectin-like receptor 2 promotes hematogenous tumor metastasis and prothrombotic state in tumor-bearing mice

Essentials The role of C-type lectin-like receptor-2 (CLEC-2) in cancer progression is unclear. CLEC-2-depleted mouse model is generated by using a rat anti-mouse CLEC-2 monoclonal antibody. CLEC-2 depletion inhibits hematogenous tumor metastasis of podoplanin-expressing B16F10 cells. CLEC-2 depletion prolongs cancer survival by suppressing thrombosis and inflammation.

SUMMARY

Background C-type lectin-like receptor 2 (CLEC-2) is a platelet activation receptor of sialoglycoprotein podoplanin, which is expressed on the surface of certain types of tumor cells. CLEC-2-podoplanin interactions facilitate hematogenous tumor metastasis. However, direct evidence of the role of CLEC-2 in hematogenous metastasis and cancer progression is lacking. Objective and methods We generated immunological CLEC-2-depleted mice by using anti-mouse CLEC-2 monoclonal antibody 2A2B10 and investigated whether CLEC-2 promoted hematogenous tumor metastasis and tumor growth and exacerbated the prognosis of mice bearing podoplanin-expressing B16F10 melanoma cells. Results Our results showed that hematogenous metastasis was significantly inhibited in CLEC-2-depleted mice. B16F10 cells co-cultured with wild-type platelets, but not with CLEC-2-deficient platelets, showed increased proliferation. However, B16F10 cell proliferation was not inhibited in CLEC-2-depleted mice. Histological analysis showed that thrombus formation in tumor vessels was significantly inhibited and functional vessel density was significantly increased in CLEC-2-depleted mice. These data suggest that CLEC-2 deficiency may inhibit thrombus formation in tumor vessels and increase the density of functional vessels, thus improving oxygen and nutrient supply to tumors, indirectly promoting tumor proliferation. Furthermore, the overall survival of CLEC-2-depleted mice was significantly prolonged, which may be due to the suppression of thrombus formation in the lungs and subsequent inhibition of systemic inflammation and cachexia. Conclusions These data provide a rationale for the targeted inhibition of CLEC-2 as a new strategy for preventing hematogenous tumor metastasis and for inhibiting cancer-related thromboembolism.

Multicenter randomized phase II study of cisplatin and fluorouracil plus docetaxel (DCF) compared with cisplatin and fluorouracil plus Adriamycin (ACF) as preoperative chemotherapy for resectable esophageal squamous cell carcinoma (OGSG1003)

BACKGROUND

This phase II trial evaluated the efficacy of cisplatin and fluorouracil (CF)-based combination neoadjuvant chemotherapy on the outcome of patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC). We compared the recurrence-free survival (RFS) associated with CF plus Adriamycin (ACF) with that associated with CF plus docetaxel (DCF) to select an alternative regimen in a new phase III trial investigating the optimal neoadjuvant treatment of patients with ESCC.

PATIENTS AND METHODS

Patients with resectable advanced ESCC were randomly assigned to either ACF (Adriamycin 35 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 7 days) every 4 weeks or DCF (docetaxel 70 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 5 days) every 3 weeks. Surgery was scheduled after completion of two cycles of chemotherapy. The primary end point was RFS, analyzed by the intention-to-treat.

RESULTS

Between October 2011 and October 2013, 162 patients at 10 institutions were enrolled in the study, all of whom were eligible and randomly assigned to the two groups (81 to the ACF group and 81 to the DCF group). The R0 resection rates for the ACF and DCF groups were equivalent (95.9% versus 96.2%, P = 0.93). The 2-year RFS and overall survival rates for DCF versus ACF were 64.1% versus 42.9% (hazard ratio 0.53, 95% confidence interval 0.33-0.83, P = 0.0057) and 78.6% versus 65.4% (P = 0.08), respectively.

CONCLUSION

Compared with ACF, DCF chemotherapy was associated with prolonged RFS for patients with resectable advanced ESCC. Thus, DCF chemotherapy has potential as a standard neoadjuvant therapy for resectable ESCC.

CLINICAL TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry of Japan (identification number UMIN000004555/000004616).

The real impact of telaprevir dosage on the antiviral and side effects of telaprevir, pegylated interferon and ribavirin therapy for chronic hepatitis C patients with HCV genotype 1

Triple therapy with telaprevir, pegylated interferon and ribavirin has been reported to improve antiviral efficacy but have potentially severe adverse effects in patients with chronic hepatitis C. To avoid the severe effects of telaprevir, lowering the dose has been suggested. However, impact of dosage changes on antiviral and adverse effects remains unclear. One hundred and sixty-six Japanese patients with HCV genotype 1 were treated with triple therapy. The drug exposure of each medication was calculated by averaging the dose actually taken. The overall SVR rate was 82%. The telaprevir discontinuation rate was 26%. The factors associated with discontinuation were an older age (≥65 y.o.) and a higher average dose during treatment. The telaprevir discontinuation rates were 42%, 25% and 14% in patients at ≥35, 25-35 and <25 mg/kg/day of telaprevir and 58% in older patients at ≥35 mg/kg/day of TVR. The factors associated with SVR were treatment-naïve, relapse to previous treatment, higher average telaprevir dose during treatment and completion of treatment. The SVR rate was higher, at 91%, in patients at 25-35 mg/kg/day of telaprevir than the 71% and 78% observed in those at <25 and ≥35 mg/kg/day of drug. In Japanese patients, a mean telaprevir dose of 25-35 mg/kg/day during treatment can augment its efficacy in triple therapy for patients with HCV genotype 1.

Risk factors for hepatocellular carcinoma in hepatitis C patients with normal alanine aminotransferase treated with pegylated interferon and ribavirin

Pegylated interferon (Peg-IFN) plus ribavirin combination therapy is effective in patients with hepatitis C virus (HCV) infection and normal alanine aminotransferase levels (NALT). However, it remains unclear whether the risk of hepatocellular carcinoma (HCC) incidence is actually reduced in virological responders. In this study, HCC incidence was examined for 809 patients with NALT (ALT ≤ 40 IU/mL) treated with Peg-IFN alpha-2b and ribavirin for a mean observation period of 36.2 ± 16.5 months. The risk factors for HCC incidence were analysed by Kaplan-Meier method and Cox proportional hazards model. On multivariate analysis among NALT patients, the risk of HCC incidence was significantly reduced in patients with sustained virological response (SVR) or relapse compared with those showing nonresponse (NR) (SVR vs NR, hazard ratio (HR): 0.16, P = 0.009, relapse vs NR, HR: 0.11, P = 0.037). Other risk factors were older age (≥65 years vs <60 years, HR: 6.0, P = 0.032, 60-64 vs <60 years, HR: 3.2, P = 0.212) and male gender (HR: 3.9, P = 0.031). Among 176 patients with PNALT (ALT ≤ 30 IU/mL), only one patient developed HCC and no significant risk factors associated with HCC development were found. In conclusion, antiviral therapy for NALT patients with HCV infection can lower the HCC incidence in responders, particularly for aged and male patients. The indication of antiviral therapy for PNALT (ALT ≤ 30 IU/mL) patients should be carefully determined.

Extremely high levels of C-reactive protein in patients with acute lupus serositis

Abstract We present the cases of two patients (19- and 40-year-old women) with systemic lupus erythematosus (SLE) who showed marked elevation of C-reactive protein (CRP). In both patients, pleural and/or peritoneal effusions were caused by lupus serositis. Methylprednisolone pulse therapy was effective in improving the serositis and normalizing CRP. Although it is generally considered that the CRP response is relatively weak in lupus patients, these cases suggest that a strong CRP response can occur in a subset of SLE.

Differences in the locations and modes of labral tearing between dysplastic hips and those with femoroacetabular impingement

We investigated differences in the location and mode of labral tears between dysplastic hips and hips with femoroacetabular impingement (FAI). We also investigated the relationship between labral tear and adjacent cartilage damage. We retrospectively studied 72 symptomatic hips (in 68 patients: 19 men and 49 women) with radiological evidence of dysplasia or FAI on high-resolution CT arthrography. The incidence and location of labral tears and modes of tear associated with the base of the labrum (Mode 1) or body of the labrum (Mode 2) were compared among FAI, mildly dysplastic and severely dysplastic hips. The locations predominantly involved with labral tears were different in FAI and mild dysplastic hips (anterior and anterosuperior zones) and in severely dysplastic hips (anterosuperior and superior zones) around the acetabulum. Significant differences were observed in the prevalence of Mode 1 versus Mode 2 tears in FAI hips (72% (n = 13) vs 28% (n = 5)) and severe dysplastic hips (25% (n = 2) vs 75% (n = 6)). The frequency of cartilage damage adjacent to Mode 1 tears was significantly higher (42% (n = 14)) than that adjacent to Mode 2 tears (14% (n = 3)).

Hip pathology is significantly related to the locations and modes of labral tears. Mode 1 tears may be a risk factor for the development of adjacent acetabular cartilage damage.

Cite this article: Bone Joint J 2013;95-B:1320–5.

Anti-influenza viral effects of novel nuclear export inhibitors from Valerianae Radix and Alpinia galanga

Many pathogenic viruses, such as the influenza virus and the Human Immunodeficiency Virus (HIV)-1, are a threat to humans, thus leading to thousands of deaths annually. The development of antiviral drugs is urgent, and it is an essential strategy for the suppression of these infectious diseases. However, regardless of the rapid emergence of many infectious diseases, the development of novel antiviral drugs has been slow, except for the case of the AIDS. In addition, several viruses can easily mutate and escape the inhibitory activity of anti-viral drugs. It was already well-established that HIV escapes from anti-viral drug effects because of the lack of proofreading activity in its reverse transcriptase. It is known that the influenza virus, which is resistant to Tamiflu, is already spread all over the world. Viruses utilize the host cell environment and cellular factors to propagate. Therefore, the development of novel drugs which inhibit viral protein-host protein interactions or cellular functions appear to be good candidates. The influenza virus is unique in replicating in host nuclei, and we therefore focused on the nuclear export processes for the development of anti-influenza viral drugs. We previously reported that leptomycin B (LMB), which inhibited the nuclear export processes via the nuclear export signal (NES) inhibited the nuclear export of influenza viral RNP (vRNP), and resulted in the inhibition of influenza viral propagation. We herein examined novel CRM1 inhibitors, valtrate from Valerianae Radix, and 1'-acetoxychavicol acetate (ACA) from Alpinia galanga as potent inhibitors for the influenza virus replication.

Resection of the second portion of the duodenum sacrificing the minor papilla but preserving the pancreas for a recurrent duodenal adenocarcinoma: report of a case

Duodenal adenocarcinoma is a relatively rare malignancy and pancreaticoduodenectomy would be a standard procedure to achieve curative resection. We report a case of resection of the 2nd portion of the duodenum with nodal dissection preserving the pancreas. The patient was a 75-year-old man with right-sided paresis suffering from early cancer in the 2nd portion of the duodenum. Despite 3 times of endoscopic mucosal resections, mucosal local recurrence was found. The depth of the tumour involvement continued to be limited within the mucosal layer. We performed segmental duodenal resection with nodal dissection sacrificing the minor papilla, while preserving the pancreas and the major papilla. The pathological diagnosis was primary intramucosal adenocarcinoma; the surgical margin was negative for cancer and there was no nodal metastasis. This procedure can be an alternative to pancreaticoduodenectomy in patients with earlystage adenocarcinoma in the 2nd portion of the duodenum when the major papilla can be spared, especially in high-risk patients.

Three-dimensional patterns of early acetabular cartilage damage in hip dysplasia; a high-resolutional CT arthrography study

OBJECTIVE

The purpose of this study was to examine the three-dimensional (3D) progression patterns of early acetabular cartilage damage in hip dysplasia using high-resolutional computed tomography (CT) arthrography.

DESIGN

Thirty-two dysplastic hips of 26 Japanese symptomatic females including 21 hips in pre-stage of osteoarthritis (Kellgren-Lawrence (K-L) grade 0; mean patient age, 32.0 years) and 11 hips in early stage of osteoarthritis (K-L grade 1 or 2; mean patient age, 32.8 years) were examined. Isotropic high-resolutional CT arthrography with an image resolution of 0.5 mm in any orthogonal direction was performed. A 3D acetabular cartilage model was generated and we evaluated distribution of cartilage thickness in 12 zones after dividing the weight-bearing area of the hip joint in radial and lateral/medial directions.

RESULTS

In pre-stage of osteoarthritis, significant differences in cartilage thickness were observed between the lateral and medial zones in all radial regions, most prominently in the antero-superior region. In early stage of osteoarthritis, no significant differences in cartilage thickness were observed, except in the most posterior region. The lateral-medial (LM) ratio was defined as cartilage thickness in the lateral zone divided by that in the medial zone, and hips with the LM ratio in the antero-superior region of <1.4 had significantly more extensive involvement of labral tears than hips with the LM ratio of ≥1.4.

CONCLUSIONS

In hip dysplasia, acetabular cartilage damage was probably occurred in the antero-superior lateral area. The LM ratio may be a sensitive index to quantify early cartilage damage associated with extent of labral disorders.

Severe liver dysfunction possibly caused by the combination of interferon beta-1b therapy and melilot (sweet clover) supplement

WHAT IS KNOWN AND OBJECTIVE

We report a case of severe liver dysfunction exacerbated after interferon beta (IFNB)-1b injection in a patient with multiple sclerosis (MS) who had been taking a melilot (sweet clover) supplement. Although IFNB-1b therapy for MS can cause mild liver dysfunction, severe hepatotoxicity attributable to supplement use has been reported.

CASE SUMMARY

A 23-year-old Japanese woman taking a melilot supplement containing coumarin at 10 mg/day for 3 years was admitted to our hospital to receive IFNB-1b therapy for MS. Fourteen days after subcutaneous injection of IFNB-1b every other day, her aspartate transaminase (AST) and alanine aminotransferase (ALT) levels were elevated at 235 and 681 IU/L, respectively. After the discontinuation of IFNB-1b therapy and supplement intake, AST and ALT returned to normal levels. Later, she started receiving an intramuscular injection of IFNB-1a weekly without supplement intake. She was able to continue IFNB-1a therapy this time, showing a slight elevation of AST level at 61 IU/L.

WHAT IS NEW AND CONCLUSION

The combination of IFNB-1b therapy and melilot supplement intake may cause severe liver dysfunction in patients with MS. Given the doubtful value of the supplement, we suggest that it should be avoided by patients receiving interferon therapy.

Standardization of perioperative management on hepato-biliary-pancreatic surgery

Japan-China Joint Medical Workshop (2012) on standardization of perioperative management on hepato-biliary-pancreatic surgery was held by the Center for Medical Standards Research, IRCA-BSSA Group in Japan on April 15-16, 2012. Experts in the fields of surgery, anesthesia, pharmacy, and public health from 21 health institutions from Japan and China presented their research achievements and shared their medical experience of perioperative management on hepato-biliary-pancreatic surgery, which should facilitate building of guidelines for hepatocellular carcinoma and be expected to promote standardized management of liver cancer in Asia.

Thrombotic microangiopathy after living-donor liver transplantation

Thrombotic microangiopathy (TMA) is an infrequent but severe life-threatening disorder in solid organ transplant recipients. Few studies of TMA in living donor liver transplant (LDLT) recipients, however, have been reported. We investigated the clinical characteristics and prognostic factors of TMA after LDLT. Among 393 adult LDLT recipients, 30 patients (7.6%) were identified to have TMA. The 1-, 3- and 5-year survival rates of these patients were lower (60.6%, 52.5% and 47.7%, respectively) than those of patients without TMA (93.0%, 89.0% and 87.3%, respectively). Multivariate analysis confirmed that reduced administration of fresh frozen plasma and sensitization against HLA are closely related with TMA (odds ratio [OR]: 2.6 and 16.1, respectively). However, a review of the cases revealed that individual responses to treatment varied considerably and the main etiologies were difficult to determine. A comparison of the clinical factors suggested that late onset (>30 days), poor response to treatment and delayed diagnosis and/or treatment are associated with a poor outcome. Because the prevention of TMA in LDLT patients is difficult, early diagnosis and initiation of intensive therapies may be crucial to improve the prognosis.

Phase II trial of preoperative S-1 plus cisplatin followed by surgery for initially unresectable locally advanced gastric cancer

BACKGROUND

The aim of this study was to evaluate the efficacy and feasibility of preoperative chemotherapy with S-1 plus cisplatin in patients with initially unresectable locally advanced gastric cancer.

METHODS

We enrolled patients with initially unresectable locally advanced gastric cancer because of severe lymph node metastases or invasion of adjacent structures. Preoperative chemotherapy consisted of S-1 at 80 mg/m(2) divided in two daily doses for 21 days and cisplatin at 60 mg/m(2) intravenously on day 8, repeated every 35 days. If a tumor decreased in size, patients received 1 or 2 more courses. Surgery involved radical resection with D2 lymphadenectomy.

RESULTS

Between December 2000 and December 2007, 27 patients were enrolled on the study. No CR was obtained, but PR was seen in 17 cases, and the response rate was 63.0%. Thirteen patients (48.1%) had R0 resections. There were no treatment related deaths. The median overall survival time (MST) and the 3-year overall survival (OS) of all patients were 31.4 months and 31.0%, respectively. Among the 13 patients who underwent curative resection, the median disease-free survival (DFS) and the 3-year DFS were 17.4 months and 23.1%, respectively. The MST and the 3-year OS were 50.1 months and 53.8%, respectively. The most common site of initial recurrence after the R0 resection was the para-aortic lymph nodes.

CONCLUSIONS

Preoperative S-1 plus cisplatin can be safely delivered to patients undergoing radical gastrectomy. This regimen is promising as neoadjuvant chemotherapy for resectable gastric cancer. For initially unresectable locally advanced gastric cancer, new trials using more effective regimens along with extended lymph node dissection are necessary.

Bioassay technique using seed shrimps for comparative studies regarding the aquatic acute lethality of biodegradable lubricants

To evaluate the environmental load resulting from the spillage of biodegradable lubricants in aquatic systems, a comparative acute lethality test wherein an oil-water interfacial area could be examined was considered. In this study, oleic acid was employed as a model biodegradable lubricant. Measurements of the pH value and dissolved oxygen (DO) level of water during the exposure tests indicate that water degradation depends on the oil-water interfacial area, exposure duration, and water temperature. Furthermore, 72 h acute lethality tests were performed using two types of freshwater ostracods (seed shrimps) as test organisms: the large species Stenocypris hislopi and the small species Cypretta seurati. The longevity of the small species, which was physically more active, was strongly affected by water pollution. During the exposure test, the DO in water was significantly consumed by the degradation of the lubricant floating on it. Water exposed to a lubricant containing copper (Cu) demonstrated strong toxicity even after the recovery of the pH value and DO level by aging. The decrease in the DO level of water and increase in the concentration of metal compounds are dominant factors responsible for the mortality of aquatic organisms.