0146 Efficacy and Safety of Single Dose of TS-142, a Novel and Potent Dual Orexin Receptor Antagonist, in Insomnia Patients

Introduction

TS-142 is a novel dual orexin receptor antagonist (DORA) developed for the treatment of insomnia. Here we report its pharmacokinetic profile in the healthy subjects and its efficacy and safety in patients with insomnia.

Methods

A phase1 study was conducted to clarify pharmacokinetic profile, in which various doses of TS-142 (1–30 mg) were orally administered once to thirty two healthy subjects. Subsequently, a phase 2a study utilizing polysomnography (PSG) was carried out in patients with primary insomnia, in which 5, 10, or 30 mg of TS-142, or placebo was randomly administered in a double-blind manner. Karolinska Sleepiness Scale (KSS) and Digit Symbol Substitution Test (DSST) were also examined in the morning after PSG.

Results

Following single administration of TS-142, plasma concentration of unchanged compound reached maximum within 2.50 h (median), and then eliminated rapidly, giving mean elimination half-life between 1.32 and 3.25 h. Twenty-three patients with insomnia completed the Phase2a study. Both latency to persistent sleep (LPS) and wake after sleep onset (WASO) were significantly improved with TS-142 at all doses, in comparison with placebo (-42, -42 and -45 for LPS [min] and -28, -35 and -55 for WASO [min] in 5, 10, 30 mg, respectively). KSS and DSST administered in the morning indicated no serious hangover effects. No serious adverse events were observed in these trials.

Conclusion

The phase 1 trial showed favorable pharmacokinetic profiles. The phase 2a trial demonstrated that TS-142 was efficacious in objective sleep onset and maintenance with minimal next-day residual effects. TS-142 was generally well tolerated in both studies.

Support

Taisho Pharmaceutical. Co., Ltd.

Polyglycolic acid sheet and fibrin glue for preventing esophageal stricture after endoscopic submucosal dissection: a historical control study

There have been several reports that steroid administration is effective at preventing strictures after endoscopic submucosal dissection (ESD). However, adverse events after steroid use are of great concern. We have reported that shielding with a polyglycolic acid (PGA) sheet and fibrin glue can be useful for prevention of stricture after ESD. We conducted a retrospective analysis of efficiency of shielding with a PGA sheet and fibrin glue for prevention of esophageal stricture compared with intralesional steroid injection. ESD was performed on a total of 489 lesions in 400 patients for superficial esophageal cancer from January 2012 to July 2016. Of these, 39 lesions were enrolled in the study group (PGA sheet and fibrin glue) and 31 lesions were enrolled in the control group. The incidence of postoperative stricture at 6 weeks and the number of sessions of endoscopic balloon dilatation (EBD) required to resolve any strictures were evaluated. The post-ESD stricture rate was 9.1% in the study group (3/33 patients), which was not significantly lower than the stricture rate of 10.3% in the historical control group (3/29 patients; p = 1.00). The mean number of EBD was 0.057 ± 0.24 in the study group and 1.9 ± 5.1 in the control group, which was not significant (P = 0.95). PGA sheet and fibrin glue appear to be a promising option for the prevention of esophageal stricture similar to the effect of intralesional steroid injection.

Rotatable Offner imaging system for ellipsometric measurement

To realize high spatial resolution imaging ellipsometric measurement with large field of view, we developed a rotatable Offner system with unit magnification. When the conventional Offner imaging system is tilted relative to the sample plane for the ellipsometric measurement, only a small region of plane is in focus. The rotatable Offner system developed here renders the entire object in focus through all rotations. The performance of the prototype of the Offner system and imaging ellipsometer is tested by generating maps of the ellipsometric parameters Δ and Ψ for samples such as a silicon wafer and a resolution target made of chromium film evaporated on a glass substrate.

Utility of weekly docetaxel combined with preoperative radiotherapy for locally advanced esophageal cancer from pathological analysis

Esophageal squamous cell cancer (ESCC) is a high-grade carcinoma that is treated with multidisciplinary approaches, including chemoradiotherapy (CRT) followed by surgery. Despite some success with these therapies, overall survival remains poor. In order to investigate a newer CRT regimen, we designed a comparative study to evaluate preoperative CRT using docetaxel (DOC) or 5-Fluorouracil and cisplatin (FU+CDDP [FP] therapy) for treatment of resectable ESCC. In a retrospective review of patients with resectable, locally advanced ESCC, 95 patients received preoperative CRT between 2001 and 2007. CRT was administered using either FP (n = 40) or DOC (n = 55). Pathological response and clinical outcomes were compared between the two groups. Hazard ratios and time-to-event analyses were used to assess outcomes; the ratios were controlled by multivariate logistic regression analysis of potential prognostic factors, and survival was presented with Kaplan-Meier curves. In the FP group, a significant curative effect was observed on the basis of pathological examination of postoperative lesions. However, the DOC group presented a significantly better prognosis on the basis of cumulative survival rates. Logistic regression analysis revealed that the presence of five or more lymph node metastases was an independent predictor of reduced survival. Patients with lymph node metastasis exhibited a better prognosis in the DOC group than those in the FP group. Preoperative CRT for locally advanced esophageal cancer using DOC results in similar or better long-term outcomes compared with FP-based CRT. Therefore, CRT using DOC is a promising therapy option for esophageal cancer.

[Lymph nodes dissection in esophageal cancer surgery]

Esophageal cancer has high incidence and broad distribution of lymph node metastases. Among the sites of possible lymph node metastasis, the station along the recurrent laryngeal nerve shows the highest rate of lymph node metastasis. For complete lymph nodes clearance, dissection of lymph nodes along the nerves of both sides is essential. The procedure of lymph node dissection along the recurrent laryngeal nerve is a good indicator of the whole quality of the surgery. In order to reduce the morbidity of lymph node dissection, we preserve bronchial artery and pulmonary branches of the vagal nerve. The postoperative complication rate of esophageal cancer surgery is higher comparing other gastrointestinal cancer operations. Pulmonary complication occurs in high rate, and sometimes leads to mortality. On the 2nd and 3rd postoperative day, we have to be very careful for cardiopulmonary condition of the patient. The accuracy and quality of lymph node dissection is closely related to both curability and morbidity.

Correlation between loss of Bcl-XL expression and improved prognosis in advanced esophageal cancer treated by preoperative chemoradiotherapy

We investigated the clinical significance of the apoptosis- related molecule expression of tumor cells in patients with advanced esophageal cancer treated with preoperative chemoradiotherapy (CRT). Preoperative CRT reduced Bcl-X(L) expression in a significant proportion of the group responding to CRT but not in the group resisting CRT, although Bcl-2 expression was reduced in both groups. The mean survival time of the patients with cancers that lost Bcl-X(L) following CRT was significantly longer compared to those with cancers expressing Bcl-X(L). These results suggested that CRT reduced Bcl-X(L) expression, and this decrease closely correlated with the prolonged survival of advanced esophageal cancer patients treated with preoperative CRT.

Circulating micrometastases of esophageal cancer detected by carcinoembryonic antigen mRNA reverse transcriptase-polymerase chain reaction: clinical implications

In some patients without distant metastases according to conventional preoperative investigations, relapse occurs in distant organs within a few years after radical resection of esophageal cancer. Various attempts have been made to detect micrometastases that are not found by conventional techniques. A quantitative real-time reverse-transcriptase polymerase chain reaction was used to detect messenger RNA for carcinoembryonic antigen in 147 blood samples from 49 patients scheduled for radical resection of esophageal cancer at Juntendo University Hospital between September 2003 and June 2004. The number of circulating cancer cells was assessed and the clinical significance of detecting such micrometastases was analyzed. Multivariate analysis showed that positivity of this assay was significantly associated with pT1 or pT2 disease and stage III or stage IV disease. Patients with more than 40-50 carcinoembryonic antigen mRNA copies among 10(4) normal cells on quantitative analysis had a higher recurrence rate. The number of tumor cells circulating in the blood may have more influence on the prognosis of esophageal cancer than the presence of tumor cells.

Prognostic significance of disseminated cancer cells in bone marrow in patients with squamous cell carcinoma of the esophagus using quantitative RT-PCR for CEA mRNA

20004

Background: The clinical significance of disseminated cancer cells in bone marrow has not been elucidated in esophageal cancer. The aim of this study was to evaluate the relation between quantity of disseminated cancer cells in bone marrow and clinical characteristics, including prognostic significance, in patients with squamous cell carcinoma of the esophagus using real time reverse transcriptase polymerase chain reaction (RT-PCR) for CEA (carcinoembryonic antigens) mRNA. Methods: Bone marrow samples were obtained from the 4th or 5th right rib on thoracotomy from consecutive 65 operative patients with esophageal squamous cell cancer, who received esophagectomy with lymph node dissection. After total RNA extraction, they were investigated by quantitative real time RT-PCR for CEA. We also performed qualitative analyses to confirm the results at least twice. We adopted quantitative results when qualitative analyses showed positive. Results: In bone marrow CEA mRNA was detected in 14 out of the 65 patients (21.5%). There were no significant differences in clinicopathological findings between positive and negative group for bone marrow CEA. However, after a short median follow-up of 12 months (3–19 months), 6 of 14 (42.9%) patients with positive CEA group had been dead compared to 4 out of 51 (7.8%) patients with negative CEA group. The survival time of both group showed a significant difference (p=0.0282). However, there was no relationship between the amount of cancer cells in bone marrow and patients’ survival. Conclusions: Disseminated cancer cells in bone marrow using quantitative RT-PCR for CEA mRNA may be a significant predictor for highly malignant squamous cell carcinoma of the esophagus.

No significant financial relationships to disclose.

[Comparison of right ventricular function between prevention and enlargement of pulmonary valve annulus after repair of tetralogy of Fallot; mid-term results]

Total of 41 patients with tetralogy of Fallot (TOF) who underwent intracardiac repair from 1993 to 1998 were divided into 2 groups: preservation (n = 14) or enlargement (n = 27) of the pulmonary valve annulus. The procedure was decided on the Z value of the annular size: above or under -2 SD of the standard value. Although postoperative right ventricular (RV) diastolic volume (RVEDV) and cardiothoracic ratio (CTR) were larger than the preservation group and pulmonary regurgitation (PR) existed in the enlargement group, RV pressure was decreased and central venous pressure (CVP) was low and RV contraction was preserved. The exercise capacity was also good and no significant arrhythmia was recognized. Our mid-term results showed that appropriate enlargement of the pulmonary valve annulus preserved good RV function in patients with TOF.

[Surgery for cancer of the esophagus in elderly patients]

Esophageal cancer has a fulminant biological characteristic, and shows a higher rate of lymph node metastasis than other gastrointestinal malignancies. The distribution of lymphatic spread is wide from cervical to abdominal field, and 3-field lymph node dissection is a standard procedure in esophageal cancer surgery. However, the morbidity and mortality rate following esophageal resection is higher than that of other gastrointestinal or thoracic surgery. The most serious postoperative complication of esophageal surgery in elderly patients is a pulmonary problem. In order to reduce postoperative pulmonary complications, we try to preserve bronchial artery, pulmonary branches of the vagal nerve, in addition to definite preservation of bilateral recurrent laryngeal nerve. Our survival rate and mean survival period in elderly patients with esophageal cancer was fairly good. To achieve a high survival rate and reduce postoperative morbidity and mortality in elderly patients, preoperative assessment of pulmonary function and quality control of surgical procedure is essential.

[Differences in postoperative course by preoperative left ventricular volume after closure of ventricular septal defect during early infancy]

A total of 38 early infants with ventricular septal defect (VSD) were divided into 2 groups by preoperative LVEDV. The group A (n=14, LVEDV>250% N) showed significantly longer period of intubation, cathecholamine drip, and hospitalization compared with the group B (n=28, LVEDV<250% N). At dischage, both groups showed significant lowered right ventricular (RV) pressure, but LVSF in the group A was significantly lower than that in the group B. The patients with larger left ventricular (LV) volume preoperatively were thought to be potential high-risk groups in cardiac and pulmonary function and their postoperative course was prolonged and recovery of LV function was worse. In such patients, special care is mandatory to do postoperative management and to decide timing of operation.

Flavopiridol as a radio-sensitizer for esophageal cancer cell lines

Flavopiridol is a synthetic flavone that has shown an antitumor effect against several cancers. Here, we investigated the in vitro effect of flavopiridol alone and the combined effect of low-dose flavopiridol plus radiation on esophageal squamous cell carcinoma cell lines. Esophageal squamous cell carcinoma cell lines (TE8, TE9 and KE4) were exposed to flavopiridol (0.05-400 nmol/L) for 48 h. Growth inhibition was evaluated by MTT assay, cell cycle distribution was determined by flow cytometry, and cyclin D1, Bcl-2 and Rb protein expression was detected by Western blotting. The effect of 0.05 nmol/L flavopiridol as a radio-sensitizer was determined by clonogenic assay. The IC50 was approximately 110-250 nmol/L. Exposure to 0.05 nmol/L flavopiridol for 48 h increased the G2/M population, while 300 nmol/L increased the G1 population. At a concentration of 300 nmol/L, nuclear fragmentation and chromatin condensation were observed in all three cell lines. Exposure to 300 nmol/L flavopiridol decreased the levels of cyclin D1 and Rb protein in all three cell lines and Bcl-2 protein was also decreased in TE8 and KE4 cells. Moreover, exposure to 0.05 nmol/L flavopiridol slightly decreased the levels of cyclin D1, Rb and Bcl-2 protein in KE4 cells. Flavopiridol treatment (0.05 nmol/L) enhanced the radio-sensitivity in all three cell lines. Low-dose flavopiridol augmented the response of esophageal squamous cell carcinoma cell lines to radiation. Administration of a low dose of flavopiridol could be a potent new therapeutic approach for improving the efficacy of radiotherapy against esophageal cancer.

Clinical significance of bone marrow micrometastases in esophageal cancer

Using the reverse transcriptase-polymerase chain reaction (RT-PCR), we investigated the clinical significance of bone marrow micrometastases in patients with esophageal cancer. Bone marrow samples from 57 patients with esophageal cancer, who underwent esophagotomy, were investigated by specific RT-PCR for carcinoembryonic antigens (CEA). A total of 40 out of 57 patients (70.1%) were positive for CEA mRNA in the bone marrow. Among curatively resected cases, 34 of 50 patients (68.0%) were positive for CEA. Ten of 13 T1 patients (76.9%) were positive for CEA. Although the CEA-positive rate was high, there was no significant correlation between CEA positivity and any clinical characteristics. Among the 40 CEA-positive patients, 50% have shown recurrence so far. Detection of cancer cells in the bone marrow by RT-PCR may not always correspond to the malignant potential or other characteristics of the tumor. CEA-positive 'micrometastases' might actually represent isolated circulating tumor cells without much biological significance.

[Congenital supravalvular aortic stenosis; report of a case]

We experienced a successful surgical case of extended aortoplasty by means of Doty's method (two sinus reconstruction) for congenital supravalvular aortic stenosis (SAS). Case was 12-year-old boy, who had no complaint except heart murmur. The retrograde aortography demonstrated localized stenosis just above the aortic valve, and it was an hour-glass type. The preoperative peak systolic pressure gradient between the left ventricle and ascending aorta was 56 mmHg, which was improved postoperatively. This case showed excellent results. Doty's aortoplasty was favorable method for SAS without deformity of aortic valve and coronary obstruction.

Limits on the neutrino magnetic moment using 1496 days of Super-Kamiokande-I solar neutrino data

A search for a nonzero neutrino magnetic moment has been conducted using 1496 live days of solar neutrino data from Super-Kamiokande-I. Specifically, we searched for distortions to the energy spectrum of recoil electrons arising from magnetic scattering due to a nonzero neutrino magnetic moment. In the absence of a clear signal, we found micro(nu)</=(3.6x10(-10))micro(B) at 90% C.L. by fitting to the Super-Kamiokande day-night spectra. The fitting took into account the effect of neutrino oscillation on the shapes of energy spectra. With additional information from other solar neutrino and KamLAND experiments constraining the oscillation region, a limit of micro(nu)</=(1.1x10(-10))micro(B) at 90% C.L. was obtained.

Mutation of the p53 gene predicts lymph node metastases in Japanese patients with esophageal carcinoma: DNA and immunohistochemical analyses

We evaluated the clinicopathologic significance of p53 gene mutations, including a comparison of DNA analysis and immunohistochemical examination, in Japanese patients with esophageal squamous cell carcinoma, a highly aggressive cancer. Genomic DNA isolated from 76 tumors without preoperative treatment was subjected to polymerase chain reaction and sequencing. Associations were sought between p53 mutations and clinicopathologic characteristics. Cases also were investigated immunohistochemically to detect abnormal p53 protein accumulation. Overexpression of p53 protein occurred in 51 cases (67.1%), while gene mutations in the examined exons were found in only 14 (18.4%). By multivariate analysis, p53 mutation predicted detection of eight or more lymph node metastases. Mutations of the p53 gene may not only participate in the initiation of esophageal cancer, but also may promote lymph node metastasis. Unlike gene mutations, p53 protein overexpression did not predict nodal metastasis extent.

Search for nu(e) from the sun at Super-Kamiokande-I

We present the results of a search for low energy nu(e) from the Sun using 1496 days of data from Super-Kamiokande-I. We observe no significant excess of events and set an upper limit for the conversion probability to nu(e) of the 8B solar neutrino. This conversion limit is 0.8% (90% C.L.) of the standard solar model's neutrino flux for total energy=8-20 MeV. We also set a flux limit for monochromatic nu(e) for E(nu(e))=10-17 MeV.

Successfully treated case of cervical abscess and mediastinitis due to esophageal perforation after gastrointestinal endoscopy

Perforations of the esophagus are uncommon complications of flexible gastrointestinal endoscopy. Perforations after endoscopy are likely to occur in the cervical esophagus, where fiber insertion is difficult anatomically. The diagnosis should be made as soon as possible, because mediastinitis and sepsis frequently develop following esophageal perforations. The surgical strategies are dependent on the location of the perforations and the condition of the patients. For a successful outcome, surgery is a preferred treatment for most perforation cases, and non-operative treatment, such as antibiotics, parental nutrition, and no food intake by mouth, should be applied carefully.

Search for supernova relic neutrinos at Super-Kamiokande

A search for the relic neutrinos from all past core-collapse supernovae was conducted using 1496 days of data from the Super-Kamiokande detector. This analysis looked for electron-type antineutrinos that had produced a positron with an energy greater than 18 MeV. In the absence of a signal, 90% C.L. upper limits on the total flux were set for several theoretical models; these limits ranged from 20 to 130 macro nu(e) cm(-2) s(-1). Additionally, an upper bound of 1.2 macro nu(e) cm(-2) s(-1) was set for the supernova relic neutrino flux in the energy region E(nu)>19.3 MeV.

Histopathologic effects of neoadjuvant therapies for advanced squamous cell carcinoma of the esophagus: multivariate analysis of predictive factors and p53 overexpression

In 97 patients (60, chemotherapy; 22, chemoradiotherapy; 15, radiotherapy), histopathologic effects were evaluated microscopically, and histologic response rates were compared among three neoadjuvant treatment modalities. Predictive factors for neoadjuvant therapies were analyzed by logistic regression, including the results of p53 immunohistochemical staining. In the chemoradiotherapy group, the pathologic response rate was 86.4%, and was significantly higher than that for chemotherapy (P < 0.0001) or for radiotherapy (P = 0.0031). In patients with normal p53 protein expression, the histopathologic response rate to chemotherapy was 20.0%, a higher rate than that for patients with abnormal p53 overexpression. In the chemoradiotherapy or radiotherapy group, however, the response rates were almost the same, irrespective of p53 oncoprotein status. From multivariate analysis, the neoadjuvant treatment modality itself was identified as the most powerful predictive factor for the effect. Chemoradiotherapy had the most powerful effect on advanced esophageal cancer, and p53 status did not influence the clinical outcome in this group.

Outcomes of extended lymph node dissection for squamous cell carcinoma of the thoracic esophagus

Patients with thoracic esophageal carcinoma who underwent extended lymph node (LN) dissection were studied to assess the state of LN metastasis and evaluate its outcome in terms of a prognostic benefit. Pertaining to LN metastasis, it was found that depending on the location of a primary tumor, the area of choice, in which metastasis tends to develop predominantly, showed some variation. However, irrespective of the location of the tumor, the predominant growth of positive nodes was found to locate among three fields, namely the neck, mediastinum and abdomen even in patients with a single metastatic node. This suggests that extended LN dissection including the neck, mediastinum and abdomen should be considered mandatory, if a complete removal of the tumors for carcinoma of the thoracic esophagus is to be desired. Multivariate analysis revealed importance of LN dissection as a prognostic factor. A cumulative survival rate in the patients with lymphadenectomy through right thoracotomy was statistically better than that in the patients who underwent blunt extraction of the esophagus without lymphadenectomy. Furthermore, extensiveness of LN dissection could effectively serve as a prognostic factor. Consequently, three-field LN dissection yields a prognostic benefit to improve a long term survival in patients with carcinoma of the thoracic esophagus.

[A case of convergence spasm in hysteria improved with a brief psychiatric assessment]

We report a 16-year-old female who developed double vision. The diplopia was in the horizontal plane and persisted for 3 weeks. She also complained of headache and nausea. She kept her eyes closed unless she was told to open. When eyelids were passively open, both eyes deviated inward in an adducted position. The pupil size and the reaction to light were normal. No weakness was noted in the extraocular muscles when each eye was examined individually. The rest of the neurologic examinations were normal. We thought that she had a convergence spasm. Brain CT and MRI were normal. The CSF and blood chemistries were also normal. We treated her with supportive psychotherapy and her convergence spasm disappeared. We concluded that her convergence spasm was a manifestation of conversion hysteria.

Constraints on neutrino oscillations using 1258 days of Super-Kamiokande solar neutrino data

We report the result of a search for neutrino oscillations using precise measurements of the recoil electron energy spectrum and zenith angle variations of the solar neutrino flux from 1258 days of neutrino-electron scattering data in Super-Kamiokande. The absence of significant zenith angle variation and spectrum distortion places strong constraints on neutrino mixing and mass difference in a flux-independent way. Using the Super-Kamiokande flux measurement in addition, two allowed regions at large mixing are found.

Solar 8B and hep neutrino measurements from 1258 days of Super-Kamiokande data

Solar neutrino measurements from 1258 days of data from the Super-Kamiokande detector are presented. The measurements are based on recoil electrons in the energy range 5.0-20.0 MeV. The measured solar neutrino flux is 2.32+/-0.03(stat)+0.08-0.07(syst)x10(6) cm(-2) x s(-1), which is 45.1+/-0.5(stat)+1.6-1.4(syst)% of that predicted by the BP2000 SSM. The day vs night flux asymmetry (Phi(n)-Phi(d))/Phi(average) is 0.033+/-0.022(stat)+0.013-0.012(syst). The recoil electron energy spectrum is consistent with no spectral distortion. For the hep neutrino flux, we set a 90% C.L. upper limit of 40x10(3) cm(-2) x s(-1), which is 4.3 times the BP2000 SSM prediction.

[Factors allowing continuous working of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas]

PURPOSE

Few investigations have been conducted on working, childcare and home education among female nurses (nurses) in the People's Republic of China (P.R. of China). The purpose of this study was to clarify the factors allowing continued working of female nurses.

METHODS

The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. In was distributed by the Ministry of Health in the P.R. of China and the data were collected between February and April in 1996.

RESULTS

A total of 4,284 (80.0%) questionnaires were collected. 1. About 60% of the nurses began working when they were 15 to 19 years old. The average length of service was 13.9 years. 2. Their professional position correlated directly with their years of service. 3. 4.3% of them had not continued working. 4. The nurses entrust their children to day-care institutions (61.2%) or grandparents (22.3%) during the daytime, and to the father (66.3%) or the grandparents (19.5%) during the night. 5. 17.6% of them have experienced being away from home for more than one month due to their job. 6. 66.8% of the nurses have experienced more than one month official trip, and had children under 14 years old at the time. They entrusted their children to day-care institutions (34.1%), to the father (29.2%) and grandparents (25.3%) during the official trip.

CONCLUSIONS

In summary, most nurses are employed when they are young and go on working as nurses. It is possible for them to continue their work after marriage, childbirth, and while they are bringing up their children. The high rate of working woman, sufficient nursery schools and family cooperation in housework can be pointed out as main factors that enable them to continue their work.

[Childcare and home education in families of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas]

PURPOSE

The purpose of this study was to investigate the actual conditions of childcare and home education among families of female nurses in the P. R. of China.

METHODS

The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. It was distributed by the Ministry of Health in the P. R. of China and data were collected between February and April in 1996.

RESULTS

A total of 4284 (80.0%) questionnaires were collected. 1. The age of the subjects was between 18 and 62 years old with a mean of 32.9 +/- 9.0 (SD) years 71.4% of them had husbands, whose ages were between 23 and 71 years old, the mean age being 38.3 +/- 8.4 (SD) years. The family types were 63.2% nuclear family and 33.7% extended family, with 3.1% being single. 65.1% of the subjects had children, whose mean number was 1.1 +/- 0.4 (SD). Firstborn children were 49.9% girls and 50.1% boys. 2. The most popular method of infant nutrition was breast-feeding, utilized by 60.1%. The highest rate (67.8%) was in the age group of 25 to 29 years old (P < 0.01). 3. The practice of "swaddling" (wrapping the child so as not to allow movement) was more common in the over 40 year old age group than the under 40 year old group (P < 0.01). Swaddling-practice showed significant differences by area. 4. The rates for children who helped with housework were 50.3% for girls and 46.7% for boys. 5. A number of children between 7 and 18 years old were studying English privately. 6. The greatest expectation of the subjects, for their children aged between 7 and 18 years old, was to study.

CONCLUSIONS

1. Infant nutrition showed significant differences between generations, and swaddling-practice differed with the generation and the area. 2. Although girls help their parents more than boys in Japan, boys and girls equally helped their parents in the P. R. of China. 3. Concerning the topics of private learning and parents expectations, the results were similar to those in Japan.

[Outpatient treatment for gastrointestinal tract cancer in the Department of Surgery]

Recently, outpatient cancer treatment has been rapidly increasing in order to cut medical expenditures and promote the QOL of cancer patients. However, the efficacy of outpatient cancer treatment is still uncertain. When performing outpatient cancer treatment, one must have a clear idea of the expected effect, and provide appropriate treatment so that none of the expected benefit is sacrificed for the improved convenience.

Distant enhancers stimulate the albumin promoter through complex proximal binding sites

The albumin-alpha-fetoprotein locus epitomizes the main features of transcriptional regulation of fetal and adult hepatocyte-specific genes: developmentally regulated promoters and strong distant enhancers. Full enhancer activity required only a proximal albumin-promoter region containing the TATA box, hepatic nuclear factor 1 (HNF1), and nuclear factor Y (NF-Y) sites. Deletion of the HNF1 site abrogated enhancer and promoter activity, whereas methylation of the site reduced all activity by about 3-fold. Deletion of the NF-Y site attenuated activity by about half, but much of the activity could be replaced by juxtaposition of an upstream region (designated distal element IV). Gel shift and competition analysis demonstrated that binding of architectural factors overlapped NF-Y binding. Moreover, a mutation that eliminated NF-Y binding but only minimally perturbed the surrounding region did not affect enhancer function. In plasmids with a second promoter, the enhancers simultaneously stimulated both albumin and alpha-fetoprotein promoters with minimal competition, but surprisingly some mutations in the albumin promoter attenuated expression from both promoters, whereas another uncoupled their expression. With single promoters, the function of the proximal promoter region was controlled by three parameters in the following hierarchy: HNF1 binding > local architecture > NF-Y binding, but integrated two-promoter function had a much greater dependence on NF-Y.

Pulmonary thromboembolism after surgery for esophageal cancer: its features and prophylaxis

We attempt to clarify the problems of pulmonary thromboembolism (PTE), which occurs less frequently in Japan than in the West, regarding its special perioperative management and prophylaxis for PTE after esophagectomy. We studied 26 patients with PTE following esophagectomy among 1023 patients with esophageal cancer between 1984 and 1997. The presence of embolism was confirmed by pulmonary perfusion scintigraphy. The incidence, diagnosis, and other issues of PTE were all reviewed. The incidence of PTE was 2.5%, with patients showing a biphasic early and late onset. The main symptoms were dyspnea in 19 patients and tachycardia in 17. Scintigraphy demonstrated 154 lesions, 35.7% of which were located in the left lower lobe and 25.3% in the right lower lobe. Treatment mainly consisted of the administration of heparin and urokinase. Four of the 26 patients died. Intermittent pneumatic compression (IPC) with the administration of heparin has been used in our department since 1994 to prevent PTE and this has also helped to decrease the incidence from 3.2% to 0.7%. Because the incidence of PTE following esophagectomy is higher than expected, PTE should be considered whenever hypoxemia of some unknown cause is found. Both early diagnosis and treatment are essential. It is also important to prevent PTE by the use of IPC.

Usefulness of autologous blood transfusion for avoiding allogenic transfusion and infectious complications after esophageal cancer resection

BACKGROUND

A retrospective investigation was conducted to determine whether autologous blood collection could reduce allogenic transfusion after resection of esophageal cancer and whether allogenic transfusion influenced postoperative infection.

METHODS

Patients (n = 100) who met the criteria for hemoglobin, age, body weight, and serum protein donated 800 mL of autologous blood from May 1994 to December 1997. The control group (n = 248) was selected from patients who met the same criteria and did not donate autologous blood over the 10 years before the start of autologous blood collection.

RESULTS

Only three patients (3%) from the autologous group required allogenic transfusion versus 84 patients (33.7%) from the control group. Sixteen of the 26 patients who received more than 4 units of allogenic blood contracted postoperative infections compared with 25 of 165 patients who did not (P < .0001). Autologous blood transfusion significantly increased the probability of avoiding allogenic transfusion (odds ratio, 27.58), and allogenic transfusion was significantly related to postoperative infection (odds ratio, 1.19), according to logistic regression analysis.

CONCLUSIONS

Autologous blood collection reduces the need for allogenic transfusion in patients undergoing resection of esophageal cancer, and avoidance of allogenic transfusion may reduce the risk of postoperative infection.

Esophageal cancer and right aortic arch associated with a vascular ring

We report on the problems of diagnosis and surgical technique from the standpoint of mediastinal anatomy in patients with esophageal cancer and right aortic arch associated with a vascular ring. We propose that left thoracotomy plus sternotomy is the best approach to allow visualization of the bilateral recurrent laryngeal nerves.

Cologastric fistula and colonic perforation as a complication of percutaneous endoscopic gastrostomy

Cologastric fistula has rarely been reported as a complication of percutaneous endoscopic gastrostomy (PEG). We encountered a patient in whom this problem went unrecognized for 2 years. After the initial PEG tube was changed, the second PEG tube was advanced into the colon, causing severe diarrhea. When a third PEG tube was inserted, acute peritonitis occurred because of colonic perforation. We discuss the mechanism of this complication and technical points related to its prevention.

[Therapeutic strategy for adenocarcinoma in Barrett's esophagus: a study based on a comparison with squamous cell carcinoma]

The therapeutic strategy for adenocarcinoma in Barrett's esophagus is discussed based on a comparison with squamous cell carcinoma. The pattern and range of lymph node metastasis of adenocarcinoma in Barrett's esophagus is similar to that of squamous cell carcinoma, as is the pattern of recurrence. Chemotherapy is less effective, except for some reports on paclitaxel, but chemoradiation therapy is comparable in effect. The general tendency of a better prognosis for patients with carcinoma in Barrett's esophagus is the result of several factors, such as earlier detection of the disease, lower probability of lymph node metastasis, and distal location which permits less radical curative surgical procedures without cervical and superior mediastinal lymph node dissection. In principal the therapeutic strategy for adenocarcinoma in Barrett's esophagus should be determined like that for squamous cell carcinoma, taking into account the location of the lesion and the depth of invasion.

p53 gene mutation in 150 dissected lymph nodes in a patient with esophageal cancer

For thoracic esophageal cancer, we perform extended three field lymph node dissection, and have achieved nearly 50% of overall 5-year survival. However, patients sometimes develop lymph node recurrences in spite of having no lymph node metastases found by conventional histopathologic examination. In a patient with esophageal squamous cell carcinoma, we sequenced all the p53 cDNA translated regions (exon 2-10) of primary carcinoma, and confirmed one p53 nonsense mutation in exon 10. Then we extracted genomic DNA from 150 surgically dissected lymph nodes from that patient, and performed polymerase chain reaction analysis (PCR-RFLP) to detect the same p53 mutation in the lymph nodes. PCR-RFLP analysis showed the same p53 mutation in six lymph nodes. One node was located along the right recurrent laryngeal nerve, where no positive nodes was identified by conventional histopathologic examination. The p53 mutational diagnosis of metastatic cancer may be useful in detecting minimal residual disease.

Role of bile acids in duodenal migrating motor complexes in dogs

Previous studies have suggested that enterohepatic circulation of bile acids is essential for regular cycling of duodenal migrating motor complexes (MMCs). The present study was an attempt to clarify the role of bile acids in the enterohepatic circulation system in initiating duodenal MMCs. Seven dogs underwent total external biliary diversion that resulted in the loss of MMCs originating from the duodenum. Sodium ursodeoxycholate (6 mg/kg/hr) was then given either through the portal vein or a peripheral vein, and motility of the gastrointestinal tract was serially recorded. When sodium ursodeoxycholate was given either through the portal vein or a peripheral vein during external biliary diversion, duodenal MMCs restarted. The cyclic change in plasma motilin levels during an MMC cycle as induced by sodium ursodeoxycholate was almost the same as in a normal MMC cycle. Total bile acid concentration in the portal vein changed cyclically with MMC cycles when bile flow was intact but did not change cyclically with MMC cycles restarted by intravenous bile salt infusion. Bile acid stimulation of putative receptors existing between the portal vein and intrahepatic bile ducts may be involved in initiating normal duodenal MMC cycles.

A new choleretic effect of folinic acid

BACKGROUND/AIMS

In the chemotherapy of recurrent gastric cancer with 5-fluorouracil and folinic acid, an interesting phenomenon, the reduction of jaundice and improvement of liver function, was observed. The aim of this study was to investigate the mechanism of this phenomenon, and to confirm a choleretic effect of folinic acid.

METHODOLOGY

The bile duct of anesthetized rats was catheterized, and bile was collected. Bile volume and total bile acid production following intraperitoneal administration of folinic acid were determined and compared to those of control rats.

RESULTS

Both bile volume and total bile acid production increased following intraabdominal administration of folinic acid.

CONCLUSIONS

Folinic acid has a newly described pharmacologic effect of stimulating bile acid-dependent choleresis. It is possible that folinic acid may become a new drug for the treatment of jaundice or for the improvement of overall liver function.

Changes in colonic motility in dogs after a resection of the inferior mesenteric ganglion and plexus

In a curative resection for advanced sigmoid or rectal cancer, an extensive dissection of the regional lymph nodes is generally required. This often necessitates the removal of the autonomic nerves around the inferior mesenteric artery. The present study was done in an attempt to clarify the influence of a neurectomy around the inferior mesenteric ganglion and plexus on the motility of the colon. In eight dogs, we resected the ganglion and plexus around the inferior mesenteric artery, together with an implantation of strain gauge force transducers in various parts of the colon, and 7-10 days later, colonic motility was examined. The percentage of contractile states and contractile forces increased at both the distal colon in fasting dogs, as well as at the middle colon in the late postprandial period. At the distal colon, contractile forces were noted in the early and late postprandial periods. These contractile abnormalities at the middle and distal colon may thus explain the frequent bowel movements or diarrhea often observed after extensive surgery in patients with sigmoid or rectal cancer.

Carcinosarcoma of the esophagus with metastases showing osteosarcoma: a case report and review of the literature

Carcinosarcoma of the esophagus includes both carcinomatous and sarcomatous elements. The classification and histogenesis of carcinosarcoma is controversial. In a polypoid carcinosarcoma diagnosed in a resected esophagus the sarcomatous component was composed of dense interlacing bundles of spindle-shaped cells in the submucosa. Areas with transitional features between the two components were observed. Immuno-histochemical examination showed vimentin-positive cells in the sarcomatous areas. Subsequently, obtained autopsy specimens from the lung, kidney and iliac bone showed metastatic osteosarcoma composed of an interlacing pattern of bone or osteoid components. We suspected that the sarcomatous elements in the esophagus resulted from sarcomatous transformation of carcinoma cells, and that the metastatic lesions showed differentiation of neoplastic cells to the osteosarcoma.

Differential mitogenic actions of alpha 1- and beta-adrenergic agonists on rat hepatocytes

alpha 1-Adrenergic receptor-mediated responses are overwhelming in adult rat hepatocytes. Inversely, beta-responses are predominant over alpha 1-responses in the hepatocytes that have been cultured at a low cell density (10(4) cells/cm2) for 24 h. The insulin-EGF-induced DNA synthesis in the beta-response-dominant hepatocytes was doubled by beta-agonists or cAMP-generating agents added far behind (16-20 h) the addition of insulin/EGF; i.e., immediately before the entry into the S-phase of the cell cycle. Agonists of alpha 1-adrenergic or other Ca2+, mobilising receptors added to the alpha 1-response-dominant hepatocytes increased DNA synthesis only if they were added within 1-2 h after the addition of insulin/EGF, at the early stage of G1-phase. Agonists of "non-dominant" receptors were rather antagonistic to agonists of "dominant" receptors. Thus, agonists of alpha 1-adrenergic (and other Ca2+ mobilising) receptors and agonists of beta-adrenergic (and other cAMP-generating) receptors acted as comitogens in their own particular manners in the presence of growth factors in hepatocytes in which the respective receptor functions were dominant.

[Rational extent of lymph node dissection for carcinoma of the lower third of the thoracic ESOP-hagus of T2 or T3 stage with abdominal lymph node metastasis]

We discussed the rational extent of the lymph node dissection for carcinoma of the lower third of the esophagus of T2 or T3 stage with abdominal lymph node metastasis. Lymph node metastasis developed in 89.5% of patients. Cervical lymph node metastasis was seen in 35.8%. In the cases with positive abdominal lymph node, 40.9% of the patients had cervical node metastasis. The most frequent site of the positive node in the neck is the area along the right recurrent laryngeal nerve. On the stand point of removal of metastatic lymph node, neck dissection should be required. Three-field dissection yielded better survival rate than two-field dissection but statistical significance was not obtained. When the patients have cervical lymph node metastasis, they have greater possibility of developing blood borne metastasis. However, this observation does not deny the validity of the three-field dissection. Because this dissection may help reducing nodal spread and nodal recurrence. We have to wait for accumulation of the patients to analyze the definite extent of node dissection for T2 or T3 stage of carcinoma of the lower third of the esophagus with positive abdominal lymph node.

Prognostic factors in adenocarcinoma of the gastric cardia: pathologic stage analysis and multivariate regression analysis

PURPOSE

To clarify the pathologic stages of adenocarcinoma of the gastric cardia in which the prognosis is worse than in adenocarcinoma of the middle or distal part of the stomach, and to determine prognostic factors in these stages by multivariate analysis.

PATIENTS AND METHODS

We analyzed 2,536 cases of surgically resected gastric adenocarcinoma of all pathologic stages. Four hundred seventy-two cases of gastric carcinoma, in which cumulative survival of gastric cardia was poor, were subjected to Cox regression analysis for prognostic factors, and to logistic regression analysis for factors influencing venous or lymphatic invasion.

RESULTS

The prognosis of adenocarcinoma of the gastric cardia was inferior when compared with similarly staged carcinomas of the middle or lower part of the stomach when there was invasion of proper muscle layer or subserosal layer, with no lymph node metastasis or with only adjacent (group 1) lymph nodes metastases (T2N0 or T2N1, according to the Japanese classification). In these stages, the prognostic factors were age, histologic type, venous invasion, and location of the tumor in the upper part of the stomach. Tumor location in the upper stomach was also a predictor for the presence of venous invasion.

CONCLUSION

The prognosis of adenocarcinoma of the gastric cardia is poor in patients with T2 tumors with no or few lymph node metastases. Additional treatment after surgery may be necessary to improve the survival of this population.

Quick and simple distal pancreatectomy using the GIA stapler: report of 35 cases

A method for distal pancreatectomy using the multifire GIA-80 stapler (US Surgical, Nonvalk, Connecticut, USA) is reported that is quicker, associated with reduced blood loss and a lower incidence of pancreatic fistula than with other instruments such as the TA-55 stapler (Auto Suture, Ascot, UK). When performing total gastrectomy with distal pancreatectomy and splenectomy to complete a wide lymph node dissection in patients with advanced gastric cancer, this method of pancreatectomy can be useful.

Relief of jaundice by 5-fluorouracil and folinic acid in patients with recurrent gastric cancer

The aim of this study was to evaluate the effect of 5-fluorouracil (5-FU) and folinic acid on liver function and bile production in patients with recurrent gastric cancer and jaundice. Thirteen patients were studied for liver function and hyperbilirubinaemia, and six patients were studied for bile production retrospectively, who were treated with 5-FU [700 mg m(-2)] and folinic acid [20 mg m(-2)] for 4 days. Serum total bilirubin, aspartate aminotransferase (AST), gamma-glutamyl transferase (gamma-GT) and alkaline phosphatase (ALP) concentrations all improved with treatment (P<0.0001), and bile production increased significantly (P<0.0001) following treatment. 5-FU and folinic acid can significantly improve jaundice and liver function, and promote bile production. It is possible that 5-FU and folinic acid may become a new method for the relief of jaundice in patients with gastrointestinal tract malignancies.

A role of asialoglycoproteins for plasma-membrane-induced inhibition of the switching from alpha 1 to beta subtypes in adrenergic response during primary culture of rat hepatocytes

Adrenergic responses of rat hepatocytes were studied by measuring Ins(1,4,5)P3(for the response via alpha 1-subtype receptors) and cAMP (for beta-subtype response) generation during brief incubation of cells with respective agonists. Hepatocytes from young rats with an age of 1 week displayed a very high beta response without a significant alpha 1 response. The beta response decreased and the alpha 1 response increased progressively as the age increased; the response was almost exclusively via alpha 1 receptors in hepatocytes of adult rats 9 weeks or more old. The beta response developed, again at the expense of the alpha 1 response, in hepatocytes from adult rats during the primary culture at low cell densities [(1-2.5) x 10(4) cells/cm2]. Such "alpha 1 to beta subtype switching' of adrenergic responses in vitro was totally inhibited by adding plasma membranes prepared from adult rat liver into the low-cell-density culture, but not inhibited at all by membranes from young rat liver. The inhibitory effect of adult rat liver membranes was lost when the membranes had been exposed to endoglycosidase F or beta-galactosidase but was not affected by prior treatment with sialidase. On the contrary, young rat liver membranes became inhibitory to "alpha 1 to beta subtype switching' after prior treatment with sialidase. Thus glycoproteins with unsialylated galactosyl termini on the surface of adult rat hepatocytes are likely to function as a determinant of the relative development of alpha 1/beta subtypes of adrenergic responses; the beta response is predominant in hepatocytes in the juvenile, presumably as a result of sialylation of the galactosyl termini of the functional glycoproteins.