Prediction of anesthetic torsadogenicity using a human ventricular cell model

This simulation study was designed to predict the torsadogenicity of sevoflurane and propofol in healthy control, as well as type 1 and type 2 long QT syndrome (LQT1 and LQT2, respectively), using the O'Hara-Rudy dynamic model. LQT1 and LQT2 models were simulated by decreasing the conductances of slowly and rapidly activating delayed rectifier K+ currents (IKs and IKr, respectively) by 50%, respectively. Action potential duration at 50% repolarization level (APD50) and diastolic intracellular Ca2+ concentration were measured in epicardial cell during administration of sevoflurane (1 ~ 5%) and propofol (1 ~ 10 μM). Torsadogenicity can be predicted from the relationship between APD50 and diastolic intracellular Ca2+ concentration, which is classified by the decision boundary. Whereas the relationships in control and LQT1 models were distributed on nontorsadogenic side in the presence of sevoflurane at all tested concentrations, those in LQT2 models were shifted to torsadogenic side by concentrations of ≥ 2%. In all three models, propofol shifted the relationships in a direction away from the decision boundary on nontorsadogenic side. Our findings suggest that sevoflurane, but not propofol, exerts torsadogenicity in patients with reduced IKr, such as LQT2 patients. Caution should be paid to the occurrence of arrhythmia during sevoflurane anesthesia in patients with reduced IKr.

Time-, spin-, and angle-resolved photoemission spectroscopy with a 1-MHz 10.7-eV pulse laser

We describe a setup of time-, spin-, and angle-resolved photoemission spectroscopy (tr-SARPES) employing a 10.7 eV (λ = 115.6 nm) pulse laser at a 1 MHz repetition rate as a probe photon source. This equipment effectively combines the technologies of a high-power Yb:fiber laser, ultraviolet-driven harmonic generation in Xe gas, and a SARPES apparatus equipped with very-low-energy-electron-diffraction spin detectors. A high repetition rate (1 MHz) of the probe laser allows experiments with the photoemission space-charge effects significantly reduced, despite a high flux of 1013 photons/s on the sample. The relatively high photon energy (10.7 eV) also brings the capability of observing a wide momentum range that covers the entire Brillouin zone of many materials while ensuring high momentum resolution. The experimental setup overcomes the low efficiency of spin-resolved measurements, which gets even more severe for the pump-probed unoccupied states, and affords the opportunity to investigate ultrafast electron and spin dynamics of modern quantum materials with energy and time resolutions of 25 meV and 360 fs, respectively.

Severe Calcification of Femoral Arteries Causes Tourniquet Failure Accompanied by Massive Bleeding

Tourniquet failure is attributed to inadequate tourniquet pressure, inadequate exsanguination, failure to compress medullary vessels within the bone, and incompressible calcified arteries. We herein report a case of massive bleeding using a properly functioning tourniquet in a patient who had bilateral calcified femoral arteries. When incompressible calcified arteries are present, the inflated tourniquet cuff fails to adequately compress the underlying artery, yet acts as an efficient venous tourniquet, which leads to an increase in bleeding. It is therefore critical to preoperatively confirm the effectiveness of the tourniquet in arterial occlusion in patients with severe arterial calcification.

Propofol, an Anesthetic Agent, Inhibits HCN Channels through the Allosteric Modulation of the cAMP-Dependent Gating Mechanism

Propofol is a broadly used intravenous anesthetic agent that can cause cardiovascular effects, including bradycardia and asystole. A possible mechanism for these effects is slowing cardiac pacemaker activity due to inhibition of the hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels. However, it remains unclear how propofol affects the allosteric nature of the voltage- and cAMP-dependent gating mechanism in HCN channels. To address this aim, we investigated the effect of propofol on HCN channels (HCN4 and HCN2) in heterologous expression systems using a whole-cell patch clamp technique. The extracellular application of propofol substantially suppressed the maximum current at clinical concentrations. This was accompanied by a hyperpolarizing shift in the voltage dependence of channel opening. These effects were significantly attenuated by intracellular loading of cAMP, even after considering the current modification by cAMP in opposite directions. The differential degree of propofol effects in the presence and absence of cAMP was rationalized by an allosteric gating model for HCN channels, where we assumed that propofol affects allosteric couplings between the pore, voltage-sensor, and cyclic nucleotide-binding domain (CNBD). The model predicted that propofol enhanced autoinhibition of pore opening by unliganded CNBD, which was relieved by the activation of CNBD by cAMP. Taken together, these findings reveal that propofol acts as an allosteric modulator of cAMP-dependent gating in HCN channels, which may help us to better understand the clinical action of this anesthetic drug.

Citizen seismology helps decipher the 2021 Haiti earthquake

The August 14, Mw7.2, Nippes earthquake in Haiti occurred within the same fault zone as its devastating, Mw7.0, 2010 predecessor but struck the country when field access was limited by insecurity and conventional seismometers from the national network were inoperative. A network of citizen seismometers installed in 2019 provided near-field data critical to rapidly understand the mechanism of the mainshock and monitor its aftershock sequence. Their real-time data define two aftershock clusters that coincide with two areas of coseismic slip derived from inversions of conventional seismological and geodetic data. Machine learning applied to data from the citizen seismometer closest to the mainshock allows us to forecast aftershocks as accurately as with the network-derived catalog. This shows the utility of citizen science contributing to the understanding of a major earthquake.

A Pure Acute Subdural Hematoma Presenting with a Diploic Arteriovenous Fistula: Case Report and Literature Review

Objective

We report a case of pure acute subdural hematoma (SDH) caused by a diploic arteriovenous fistula (AVF) and it is a first case report as far as we researched it.

Case Presentation

A 19-year-old man was admitted as an emergency to our hospital with headache and nausea. CT scan on hospital admission showed a right acute SDH. Because there was no history of head trauma, MRI, MRA, and DSA were performed to identify a source of bleeding. DSA disclosed an AVF. The shunt was located between a frontotemporal branch of the middle meningeal artery (MMA) and a diploic vein, and its shunting point formed an aneurysmal sac, which was considered to have ruptured. Endovascular treatment was administered rather than surgical treatment to prevent re-bleeding because the patient was conscious and alert, CT showed a small SDH, and the left MMA near the shunting point was accessible for catheterization. A diluted mixture of 25% n-butyl-2-cyanoacrilate was injected into a left frontoparietal branch just before the shunting point and the shunt, including the aneurysmal sac, was obliterated. The patient's postoperative course was uneventful and he was discharged without neurological deficits.

Conclusion

We experienced a patient with a pure acute SDH caused by diploic AVF. In patients with non-traumatic acute SDH, DSA is recommended to determine its underlying cause. Our review of published reports yielded few instances of non-traumatic pure acute SDH in young people. Possible causative factors should be investigated promptly and appropriate treatment provided immediately.

Endometrial epithelial-mesenchymal transition (EMT) by menstruation-related inflammatory factors during hypoxia

Endometriosis is characterised by inflammation and fibrotic changes. Our previous study using a mouse model showed that proinflammatory factors present in peritoneal haemorrhage exacerbated inflammation in endometriosis-like grafts, at least in part through the activation of prostaglandin (PG) E2 receptor and protease-activated receptor (PAR). In addition, hypoxia is a well-known inducer of fibrosis that may be associated with epithelial-mesenchymal transition (EMT). However, the complex molecular interactions between hypoxia and proinflammatory menstruation-related factors, PGE2 and thrombin, a PAR1 agonist, on EMT in endometriosis have not been fully characterised. To explore the effects of hypoxia and proinflammatory factors on EMT-like changes in endometrial cells, we determined the effects of PGE2 and thrombin (P/T) on EMT marker expression and cell migration in three dimensional cultured human endometrial epithelial cells (EECs) and endometrial stromal cells (ESCs). Treatment of EECs with P/T under hypoxia stimulated cell migration, increased the expression of mesenchymal N-cadherin, vimentin and C-X-C chemokine receptor type 4 (CXCR4), and reduced the expression of epithelial E-cadherin. Furthermore, treatment with C-X-C motif chemokine ligand 12 (CXCL12), a ligand for CXCR4, increased EMT marker expression and cell migration. In ESCs, P/T or oestrogen treatment under hypoxic conditions increased the expression and secretion of CXCL12. Taken together, our data show that hypoxic and proinflammatory stimuli induce EMT, cell migration and inflammation in EECs, which was increased by CXCL12 derived from ESCs. These data imply that inflammatory mediators in retrograde menstrual fluid contribute to ectopic endometrial EMT and migration in the presence of peritoneal hypoxia.

Elevation of propofol sensitivity of cardiac IKs channel by KCNE1 polymorphism D85N

BACKGROUND AND PURPOSE

The slowly activating delayed rectifier K⁺ channel (I_Ks ), composed of pore-forming KCNQ1 α-subunits and ancillary KCNE1 β-subunits, regulates ventricular repolarization in human heart. Propofol, at clinically used concentrations, modestly inhibits the intact (wild-type) I_Ks channels and is therefore unlikely to appreciably prolong QT interval in ECG during anaesthesia. However, little information is available concerning the inhibitory effect of propofol on I_Ks channel associated with its gene variants implicated in QT prolongation. The KCNE1 single nucleotide polymorphism leading to D85N is associated with drug-induced QT prolongation and therefore regarded as a clinically important genetic variant. This study examined whether KCNE1-D85N affects the sensitivity of I_Ks to inhibition by propofol.

EXPERIMENTAL APPROACH

Whole-cell patch-clamp and immunostaining experiments were conducted in HEK293 cells and/or mouse cardiomyocyte-derived HL-1 cells, transfected with wild-type KCNQ1, wild-type or variant KCNE1 cDNAs.

KEY RESULTS

Propofol inhibited KCNQ1/KCNE1-D85N current more potently than KCNQ1/KCNE1 current in HEK293 cells and HL-1 cells. Immunostaining experiments in HEK293 cells revealed that pretreatment with propofol (10 μM) did not appreciably affect cell membrane expression of KCNQ1 and KCNE1 proteins in KCNQ1/KCNE1 and KCNQ1/KCNE1-D85N channels.

CONCLUSION AND IMPLICATIONS

The KCNE1 polymorphism D85N significantly elevates the sensitivity of I_Ks to inhibition by propofol. This study detects a functionally important role of KCNE1-D85N polymorphism in conferring genetic susceptibility to propofol-induced QT prolongation and further suggests the possibility that the inhibitory action of anaesthetics on ionic currents becomes exaggerated in patients carrying variants in genes encoding ion channels.

Positive Inotropic Effects of ATP Released via the Maxi-Anion Channel in Langendorff-Perfused Mouse Hearts Subjected to Ischemia-Reperfusion

The organic anion transporter SLCO2A1 constitutes an essential core component of the ATP-conductive large-conductance anion (Maxi-Cl) channel. Our previous experiments using Langendorff-perfused mouse hearts showed that the Maxi-Cl channel contributes largely to the release of ATP into the coronary effluent observed during 10-min reperfusion following a short period (6 min) of oxygen-glucose deprivation. The present study examined the effect of endogenous ATP released via Maxi-Cl channels on the left ventricular contractile function of Langendorff-perfused mouse hearts, using a fluid-filled balloon connected to a pressure transducer. After the initial 30-min stabilization period, the heart was then perfused with oxygen-glucose-deprived Tyrode solution for 6 min, which was followed by a 10-min perfusion with oxygenated normal Tyrode solution in the absence and presence of an ATP-hydrolyzing enzyme, apyrase, and/or an adenosine A1 receptor antagonist, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX). In the absence of apyrase and DPCPX, the left ventricular developed pressure (LVDP) decreased from a baseline value of 72.3 ± 7.1 to 57.5 ± 5.5 mmHg (n = 4) at the end of 6-min perfusion with oxygen-glucose-deprived Tyrode solution, which was followed by a transient increase to 108.5 ± 16.5 mmHg during subsequent perfusion with oxygenated normal Tyrode solution. However, in the presence of apyrase and DPCPX, the LVDP decreased to the same degree during 6-min perfusion with oxygen-glucose-deprived Tyrode solution, but failed to exhibit a transient increase during a subsequent perfusion with oxygenated normal Tyrode solution. These results strongly suggest that endogenous ATP released through Maxi-Cl channels contributes to the development of transient positive inotropy observed during reperfusion after short-period hypoxia/ischemia in the heart.

Prognostic value of hybrid cardiac perfusion SPECT/CT for patients with coronary artery disease after coronary artery bypass grafting

Introduction

Patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) occasionally experience recurrent myocardial ischemia. Because of their severe CAD and its complicated hemodynamics, conventional cardiac perfusion SPECT often cannot reveal the severity and prognosis solely. Hybrid cardiac SPECT/CT imaging simultaneously shows myocardial ischemia distribution, coronary artery lesion distribution, and their relationship, and this modality may enable detailed interpretation and risk stratification for such patients.

Aim

This study aimed to assess the prognostic value of hybrid cardiac SPECT/CT for patients with CAD and suspected myocardial ischemia after CABG.

Methods

A total of 201 consecutive patients, registered between April 2016 and September 2018, with suspected recurrent angina pectoris after CABG requiring examinations for myocardial ischemia were included in this study. Among these, 135 patients who underwent cardiac perfusion SPECT, cardiac CT, and hybrid cardiac SPECT/CT imaging were analyzed. In the SPECT-only analysis, SDS was calculated, and the patients were divided into none-to-mild (SDS <4) and moderate-to-severe ischemia (SDS ≥4) groups. In the SPECT/CT analysis, the patients were divided into a matched group (SPECT reversible accumulation defects [SDS ≥2] along coronary arteries with significant lesions) and an unmatched group (accumulation defects not coincided with coronary artery territories or no significant stenoses in the corresponding coronary arteries). All patients were observed from the time of these tests for the occurrence of major adverse cardiac events (MACE), and the prognostic performances of these analyses were compared.

Results

In the SPECT-only analysis, 62 were in the none-to-mild group and 73 were in the moderate-to-severe group. In the SPECT/CT analysis, 61 were in the matched group and 74 were in the unmatched group. Within the follow-up period of 29±8 months, 15 patients experienced MACE. The patients' prognoses were clearly stratified by hybrid SPECT/CT analysis (matched: 13/61, 21.3% vs. unmatched: 2/74, 2.7%) compared with SPECT-only analysis (moderate-to-severe: 11/73, 15.0% vs. none-to-mild: 4/62, 6.5%). The hybrid cardiac SPECT/CT analysis was more strongly associated with the occurrence of MACE compared with SPECT-only analysis (p=0.008 vs. p=0.04, respectively).

Conclusions

Hybrid cardiac SPECT/CT imaging can have higher prognostic value compared with stand-alone cardiac perfusion SPECT for patients with CAD after CABG.

Funding Acknowledgement

Type of funding source: None

Open-channel blocking action of volatile anaesthetics desflurane and sevoflurane on human voltage-gated Kv 1.5 channel

BACKGROUND AND PURPOSE

Volatile anaesthetics have been shown to differentially modulate mammalian Shaker-related voltage-gated potassium (K_v 1.x) channels. This study was designed to investigate molecular and cellular mechanisms underlying the modulatory effects of desflurane or sevoflurane on human K_v 1.5 (hK_v 1.5) channels.

EXPERIMENTAL APPROACH

Thirteen single-point mutations were constructed within pore domain of hK_v 1.5 channel using site-directed mutagenesis. The effects of desflurane or sevoflurane on heterologously expressed wild-type and mutant hK_v 1.5 channels were examined by whole-cell patch-clamp technique. A computer simulation was conducted to predict the docking pose of desflurane or sevoflurane within hK_v 1.5 channel.

KEY RESULTS

Both desflurane and sevoflurane increased hK_v 1.5 current at mild depolarizations but decreased it at strong depolarizations, indicating that these anaesthetics produce both stimulatory and inhibitory actions on hK_v 1.5 channels. The inhibitory effect of desflurane or sevoflurane on hK_v 1.5 channels arose primarily from its open-channel blocking action. The inhibitory action of desflurane or sevoflurane on hK_v 1.5 channels was significantly attenuated in T480A, V505A, and I508A mutant channels, compared with wild-type channel. Computational docking simulation predicted that desflurane or sevoflurane resides within the inner cavity of channel pore and has contact with Thr479, Thr480, Val505, and Ile508.

CONCLUSION AND IMPLICATIONS

Desflurane and sevoflurane exert an open-channel blocking action on hK_v 1.5 channels by functionally interacting with specific amino acids located within the channel pore. This study thus identifies a novel molecular basis mediating inhibitory modulation of hK_v 1.5 channels by desflurane and sevoflurane.

[Ruptured Dissecting Aneurysm of M2 Portion of the Middle Cerebral Artery:A Case Report]

A 71-year-old woman presented with a sudden onset of headache and vomiting. Computed tomography(CT)showed diffuse subarachnoid hemorrhage(SAH)that was more severe on the right side. Three-dimensional CT angiography and right carotid angiography(CAG)demonstrated 2-mm microaneurysms at the middle cerebral artery(MCA)bifurcation and anterior communicating artery, with slight narrowing and dilatation of the M2 inferior trunk. Each microaneurysm was smooth, making it difficult to identify the bleeding source. Thus, surgery was postponed at the acute stage, and further investigation was planned. Repeated CAG was diagnostically unsuccessful, finding no source of the bleeding. On day 45 after the onset, exploratory craniotomy was performed to confirm the cause of the SAH. During the operation, both microaneurysms were found to be unruptured. However, the distal portion of the M2 inferior trunk was dark purplish and red and enlarged in a fusiform shape, suggesting a dissecting aneurysm. Residue of the SAH observed near the enlarged vessel identified it as the bleeding source. The enlarged vessel was wrapped with Bemsheets, and the Bemsheets was clipped to secure it. A dissecting aneurysm of the distal MCA is rare, as is the onset of bleeding. Based on a review of the literature related to dissecting aneurysms of the distal MCA, we recommend exploratory craniotomy if CT demonstrates laterality of the sylvian fissure on the SAH and CAG reveals stenosis or occlusion of the distal MCA in cases of SAH for which no bleeding source is detected.

Hyperkalemia caused by rapid red cell transfusion and the potassium absorption filter

We report a case of transient hyperkalemia during hysterectomy after cesarean section, due to preoperatively undiagnosed placenta accreta that caused unforeseen massive hemorrhage and required rapid red cell transfusion. Hyperkalemia-induced by rapid red cell transfusion is a well-known severe complication of transfusion; however, in patients with sudden massive hemorrhage, rapid red cell transfusion is necessary to save their life. In such cases, it is extremely important to monitor serum potassium levels. For an emergency situation, a system should be developed to ensure sufficient preparation for immediate transfusion and laboratory tests. Furthermore, sufficient stock of preparations to treat hyperkalemia, such as calcium preparations, diuretics, glucose, and insulin is required. Moreover, a transfusion filter that absorbs potassium has been developed and is now available for clinical use in Japan. The filter is easy to use and beneficial, and should be prepared when it is available.

Tuberculosis Caused by Mycobacterium orygis in Dairy Cattle and Captured Monkeys in Bangladesh: a New Scenario of Tuberculosis in South Asia

Mycobacterium orygis, commonly known as the oryx bacillus and a newly proposed Mycobacterium tuberculosis complex subspecies, was isolated from 18 cattle in a dairy farm and two captured rhesus monkeys in a zoo in Bangladesh. All the infected animals had tuberculosis lesions in their lungs, suggesting transmission and infection with M. orygis by an airborne route. The 20 isolates were analysed using a range of conventional and molecular typing methods, and RD-deletion typing and sequencing of selected genes confirmed the isolates as M. orygis. Multiple-locus variable-number tandem repeat analysis (MLVA) allowed the isolates to be divided into three clusters based on the relatedness of their MLVA profiles. The two monkey isolates shared the same MLVA pattern with 15 of the cattle isolates, whereas the remaining three cattle isolates had different patterns, even though the latter animals had been kept in the same dairy farm. The diversity observed among isolates may suggest the bacteria have been established in this area for a long period. This study along with other recent findings that report the detection of M. orygis from animals as well as humans originating from South Asia potentially indicate endemic distribution of M. orygis in South Asia.

Hip fracture incidence in Japan: Estimates of new patients in 2012 and 25-year trends

We estimated the number of hip fracture patients in 2012 in Japan and investigated the trends in incidence during a 25-year period from 1987 to 2012. Despite the increasing number of patients, the incidence of hip fracture in both men and women aged 70-79 years showed the possibility of decline.

INTRODUCTION

The objectives of this study were to estimate the number of hip fracture patients in 2012, to investigate the trends in incidence during a 25-year period from 1987 to 2012, and to determine the regional differences in Japan.

METHODS

Data were collected through a nationwide survey based on hospitals by a mail-in survey. Hip fracture incidences by sex and age and standardized incidence ratios by region were calculated.

RESULTS

The estimated numbers of new hip fracture patients in 2012 were 175,700 in total (95 % CI 170,300-181,100), 37,600 (36,600-38,600) for men and 138,100 (134,300-141,900) for women. The incidence rates in both men and women aged 70-79 years were the lowest in the 20-year period from 1992 to 2012. The incidence was higher in western areas of Japan than that in eastern areas in both men and women; however, the difference in the incidence of hip fracture between western and eastern areas is becoming smaller.

CONCLUSIONS

Despite the increasing number of new patients, the incidence of hip fracture in both men and women aged 70-79 years showed the possibility of decline. The exact reasons for this are unknown, but various drugs for improving bone mineral density or preventing hip fracture might have influenced the results. A decrease in the differences in nutrient intake levels might explain some of the change in regional differences in Japan.

Rare complication characterized by late-onset transient neurological symptoms without hyperperfusion after carotid artery stenting: A report of three cases

We experienced a rare complication after carotid artery stenting (CAS) characterized by transient neurological symptoms with no evidence of distal emboli or hyperperfusion. Using neuroimaging, we investigated the pathogenesis of the complication that occurred after CAS in three patients who developed neurological symptoms over a period of ten hours after CAS and improved within two days. None of the three patients showed signs of fresh infarctions on diffusion-weighted imaging or hyperperfusion on single-photon emission computed tomography. However, high signal intensity was observed in the leptomeningeal zone of the cerebral hemisphere on the stent side in all three patients and in the leptomeningeal zone of the contralateral anterior cerebral artery territory in one patient. These areas were assessed using fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging without gadolinium administration. The high signal intensity in the leptomeningeal zone disappeared as the symptoms improved. Based on the transient nature of the neurological disorders and the normalization of FLAIR imaging findings in these patients, the pathogenesis of this complication might have been vasogenic edema due to vasoparalysis of the local vessels caused by the hemodynamic changes occurring after CAS.

[A case of ganglioglioma extended to the lateral ventricle and associated with neurofibromatosis type 1]

We encountered a rare case of intraventricular ganglioglioma associated with neurofibromatosis type 1. A 42-year-old woman presented with a feeling of heaviness of the head and dizziness. She was diagnosed with neurofibromatosis type 1 because she had multiple subcutaneous neurofibromas and café au lait spots. On admission, she deteriorated slightly(Japan Coma Scale 1)and suffered from cognitive dysfunction and right hemiparesis. A computed tomography(CT)scan showed that she had an obstructed hydrocephalus with a long and circular mass lesion, 2cm in diameter, in the anterior horn of the left lateral ventricle. The mass showed low signal intensity(SI)on the T1-weighted image(WI), heterogeneous high SI on the T2-WI, and dense enhancement on a Gd-DTPA contrast MRI, extending from the head of the left caudate nucleus to the lateral ventricle. The patient underwent an urgent operation via an anterior transcallosal approach because of an obstructed hydrocephalus. The tumor was removed in its entirety, including its origin at the caudate head. The pathological diagnosis was a ganglioglioma grade 1 according with the classification of the World Health Organization. Here we describe this case and discuss the rare association between gangliogliomas and neurofibromatosis type 1.

Randomized clinical trial: rikkunshito in the treatment of functional dyspepsia--a multicenter, double-blind, randomized, placebo-controlled study

BACKGROUND

Rikkunshito, a standardized Japanese herbal medicine, is thought to accelerate gastric emptying and relieve dyspepsia, although no large-scale, randomized, placebo-controlled trials of rikkunshito have been conducted. This study aimed to determine the efficacy and safety of rikkunshito for treating functional dyspepsia (FD).

METHODS

FD patients received 2.5 g rikkunshito or placebo three times a day for 8 weeks in this multicenter, randomized, placebo-controlled, parallel-group trial. The primary end point was the proportion of responders at 8 weeks after starting test drug, determined by global patient assessment (GPA). The improvement in four major dyspepsia symptoms severity scale was also evaluated. In addition, plasma ghrelin levels were investigated before and after treatment.

KEY RESULTS

Two hundred forty-seven patients were randomly assigned. In the eighth week, the rikkunshito group had more GPA responders (33.6%) than the placebo (23.8%), although this did not reach statistical significance (p = 0.09). Epigastric pain was significantly improved (p = 0.04) and postprandial fullness tended to improve (p = 0.06) in the rikkunshito group at week 8. Rikkunshito was relatively more effective among Helicobacter pylori-infected participants (rikkunshito: 40.0% vs placebo: 20.5%, p = 0.07), and seemed less effective among H. pylori-uninfected participants (rikkunshito: 29.3% vs placebo: 25.6%, p = 0.72). Among H. pylori-positive individuals, acyl ghrelin levels were improved just in rikkunshito group. There were no severe adverse events in both groups.

CONCLUSIONS & INFERENCES

Administration of rikkunshito for 8 weeks reduced dyspepsia, particularly symptoms of epigastric pain and postprandial fullness. (UMIN Clinical Trials Registry, Number UMIN000003954).

Abstract T P96: Short-term and Mid-term Results of Carotid Artery Revascularization as Carotid Artery Stenting for First-line Treatment: Single Center Experience in Japan

Objective: Penetration ratio of carotid artery stenting (CAS) in carotid revascularization caught up that of carotid endarterectomy (CEA) in 2005, exceeding more than 60% in recent years after CREST in Japan. We choose CAS for first-line treatment, while CEA is applied to CAS high-risk patients dependent on factors including accessibility, plaque diagnosis, and symptom. The aim of this study is to evaluate short-term and mid-term results of single center experience of 266 consecutive cases with CAS / CEA.

Materials / Methods: This is a retrospective analysis of 227 CAS and 39 CEA during January 2009 to March 2013. The primary outcome measures (short-term results) were any periprocedural (within 30 days after procedure) death, stroke, and acute coronary syndrome, and the rate of postoperative positive lesion in diffusion weighted imaging (DWI) on MRI. The mid-term results include death, stroke, and restenosis requiring retreatment during the follow-up periods.

Results: There were no significant differences in age, underlying disease, and the severity of stenosis in both CEA and CAS group. However, the percentage of symptomatic lesion and the MRI T1WI plaque-sternocleidomastoid muscle ratio (index of the vulnerability of plaque) were higher in CEA than CAS group (69% vs. 48%, p=0.015; 1.79±0.46 vs. 1.31±0.37, p<0.0001). Short-term results revealed no mortality in both groups, any stroke 2.6% CEA vs. 4.9% CAS (p=1); major stroke 2.6% CEA vs. 0.9% CAS (p=0.38); acute coronary syndrome 0% CEA vs. 0.9% CAS (p=1); the rate of DWI-positive 24% vs. 39% (p=0.10). Mid-term results during the follow-up periods (CEA 18.3±13.5 month, CAS 20.3±14.1 month): death 5.1% CEA vs. 5.7% CAS (p=1), stroke 7.7% CEA vs. 11.0% CAS (p=0.78), restenosis requiring retreatment 0% vs. 6.6% (p=0.14).

Conclusion: The short-term and the mid-term results were excellent and equivalent in CAS and CEA although we apply CEA to high-risk lesions such as fragile plaque or symptomatic lesion. Our protocol, in which most patients undergo less invasive CAS as the first-line while CEA is selected for CAS high-risk patients, enables to provide high quality treatment for carotid artery revascularization.

Development and fundamental evaluation of flexible viewpoint laparoscope using a oblique viewing laparoscope

We have developed a new type of laparoscope with flexible view point. This system can move the view without moving laparoscope itself. To achieve the wide range of view moving, we used a commercial 30° oblique-viewing laparoscope and special lens. The system control the view by rotating the oblique-viewing laparoscope and a sleeve which is attached to the special lens by motors independently. From the evaluation experiments, we confirmed the laparoscope which has 70° view angle could move the view ±60°. In the image quality evaluation experiment, degradation of the image quality was small. The positioning accuracy was 2.4±1.7 mm repeatability was 0.48 mm which lead to precise view control. The system achieve the safe and smooth manipulation of the laparoscopic view.

p.E66Q mutation in the GLA gene is associated with a high risk of cerebral small-vessel occlusion in elderly Japanese males

BACKGROUND AND PURPOSE

GLA is the causative gene of Fabry disease, an X-linked lysosomal storage disorder resulting from α-galactosidase A (α-GAL) deficiency. Stroke is an important manifestation of Fabry disease, and recent epidemiological studies have indicated that up to 4.9% of young male cryptogenic stroke patients have GLA mutations. To determine the importance of GLA mutations in the general stroke population, the frequency of GLA mutations in Japanese male ischaemic stroke (IS) patients with various risk factors and ages was measured.

METHODS

A total of 475 male IS patients (mean age 69.7 ± 12.5 years), were enrolled in this study. A blood sample was obtained to produce blood spots for measurement of α-GAL activity. Blood samples with decreased enzymatic activity were reassayed and the entire GLA gene was analyzed by direct DNA sequencing if α-Gal A activity was consistently low.

RESULTS

α-Gal A activity was decreased in 10 men, five of whom (1.1%) had the GLA gene mutation, p.E66Q. All IS patients with p.E66Q mutation had substantial residual α-Gal A activity, in contrast to patients with classic-type Fabry disease. Clinically, all patients with p.E66Q mutation were > 50 years old and had multiple small-vessel occlusions (lacunar infarctions). Statistical analysis using Fisher's exact test showed the allele frequency of GLA p.E66Q in patients with small-vessel occlusion to be significantly higher than that in the general Japanese population [odds ratio (OR) = 3.34, P = 0.025).

CONCLUSIONS

GLA p.E66Q mutation is a genetic risk factor for cerebral small-vessel occlusion in elderly Japanese males.

New automatic cell isolation system for flow cytometry: cell isolation unit and staining reagent kit

Flow cytometry is well-known cell analysis method and useful to gain quantitative information from cells in blood, however, it is not widely used for solid tissues in clinical settings. This is partly because it takes a long time to prepare samples and the operation can be complicated. To resolve these problems, we developed a new automatic cell isolation system which consists of cell isolation unit and staining reagent kit specialized for flow cytometry. With this new system, cell isolation can be done more rapidly and easily. By using this method, we could determine optimum condition to disintegrate porcine colon tissue and stain cells stably in 6 minutes. This result indicates that our method can provide analysis data within 10 minutes. We also evaluated our method in colorectal cancer patients, and the result was promising. All the data suggests that this method can support and facilitate rapid diagnosis.

Immunohistochemical detection of CDKN2, retinoblastoma and p53 gene products in primary astrocytic tumors

The expressions of p16(INK4), retinoblastoma (RB) and p53 protein were immunohistochemically examined in 70 primary astrocytic tumors. In 58 patients with high grade astrocytoma (18 anaplastic astrocytomas and 40 glioblastomas), 30 (51.1%) and 15 (25.9%) cases were undetectable for p16(INK4) and pRB, respectively, but their lack occurred infrequently in 12 low grade astrocytomas. The expression of p16(INK4) was inversely correlated with that of PRB, especially in glioblastomas. Accumulation of p53 was detected in 32 (45.7%) of 70 cases without any dependence on the grade. A deregulation of three tumor suppressor gene products most often occurs singly. Only patients with negative staining for pRB were significantly associated with a shorter survival time. Our findings suggest that loss of functional pRB at the G1/S check point may represent an important step in glioblastoma development and have a stronger negative impact on clinical outcome than p16(INK4) or p53 aberrations.

High frequency of overlap between functional dyspepsia and overactive bladder

BACKGROUND

Overactive bladder syndrome (OAB) is defined as a symptom complex comprising urgency, with or without urge incontinence, and usually frequency and nocturia. The association between irritable bowel syndrome (IBS) and bladder symptoms has been reported. This study is designed to investigate whether functional dyspepsia (FD), like IBS, is associated with OAB.

METHODS

A web surveys containing questions about OAB, FD, IBS, and demographics were completed by 5494 public individuals (2302 men and 3192 women) who have no history of severe illness. The prevalence and overlap of OAB, FD, and IBS were examined.

KEY RESULTS

Among participants with FD, 20.5% could also be diagnosed with OAB (odds ratio [OR]: 2.85; 95% confidence interval [CI]: 2.21-3.67). Although concomitant FD and IBS were more strongly associated with OAB (OR: 4.34; 95% CI: 2.81-6.73), OAB was also highly prevalent among participants with FD but without IBS (OR: 3.09; 95% CI: 2.29-4.18). Among participants with FD, an overlapping OAB condition was more prevalent in those with both postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) (OR: 3.75; 95% CI: 2.48-5.67) than in those with PDS or EPS alone. Among participants with OAB, the severity of bladder symptoms was greater in participants with dyspeptic symptoms than without them.

CONCLUSIONS & INFERENCES

Overactive bladder syndrome is common among FD patients, even if they do not have IBS. To improve FD patients' quality of life, it will be important to provide management for OAB.

Enhanced translational diffusion of confined water under electric field

High resolution quasielastic neutron scattering measurements have been used to study the effects of applied electric field on the dynamics of water molecules confined in the pores of folded silica sheet material FSM-12 with an average pore diameter (apd) of 16 Å. In the absence of field, there is a significant slowing down of the water molecule diffusion as the temperature is lowered, in agreement with previous observations. The application of a moderate electric field of 2.5 kV/mm remarkably enhances the translational diffusion of water molecules. We interpret this as being due to a disruption of the hydrogen bonding by the electric field. This new observation suggests that existing theories valid at large electric field strengths may have to be corrected at moderate fields.

Exome sequencing in a family with an X-linked lethal malformation syndrome: clinical consequences of hemizygous truncating OFD1 mutations in male patients

Oral-facial-digital syndrome type 1 (OFD1; OMIM #311200) is an X-linked dominant disorder, caused by heterozygous mutations in the OFD1 gene and characterized by facial anomalies, abnormalities in oral tissues, digits, brain, and kidney; and male lethality in the first or second trimester pregnancy. We encountered a family with three affected male neonates having an 'unclassified' X-linked lethal congenital malformation syndrome. Exome sequencing of entire transcripts of the whole X chromosome has identified a novel splicing mutation (c.2388+1G > C) in intron 17 of OFD1, resulting in a premature stop codon at amino acid position 796. The affected males manifested severe multisystem complications in addition to the cardinal features of OFD1 and the carrier female showed only subtle features of OFD1. The present patients and the previously reported male patients from four families (clinical OFD1; Simpson-Golabi-Behmel syndrome, type 2 with an OFD1 mutation; Joubert syndrome-10 with OFD1 mutations) would belong to a single syndrome spectrum caused by truncating OFD1 mutations, presenting with craniofacial features (macrocephaly, depressed or broad nasal bridge, and lip abnormalities), postaxial polydactyly, respiratory insufficiency with recurrent respiratory tract infections in survivors, severe mental or developmental retardation, and brain malformations (hypoplasia or agenesis of corpus callosum and/or cerebellar vermis and posterior fossa abnormalities).

Classification of functional dyspepsia based on concomitant bowel symptoms

BACKGROUND

  Functional dyspepsia (FD) is a heterogeneous disease, and categorized into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS). However, many FD patients have overlap of both PDS and EPS. The present study was designed to examine whether FD could be categorized based on the presence of concomitant gastrointestinal symptoms.

METHODS

  A web survey comprised of the Gastrointestinal Symptom Rating Scale (GSRS), Rome III criteria of FD, and demographic information was sent to public participants who have no history of severe illness. Factor and cluster analyses were conducted to identify sub-categories of FD based on GSRS.

KEY RESULTS

  A total of 8038 participants completed the survey. A total of 563 participants met the criteria for FD, whereas 6635 participants did not have dyspepsia symptoms. The remainder had either organic disease (377) or uninvestigated dyspepsia (463). The cluster analysis categorized participants as constipation predominant (cluster C), diarrhea predominant (cluster D), or having neither diarrhea nor constipation (cluster nCnD). Cluster C and D were significantly associated with the presence of FD [odds ratio (OR) 2.57, 95% confidence interval (CI) 2.06-3.21; OR 2.80; 95% CI 2.27-3.45, respectively]. In FD, especially in PDS cases, the scores of upper gastrointestinal symptoms were higher in cluster C or D than in cluster nCnD.

CONCLUSIONS & INFERENCES

  The severity of dyspepsia symptoms is associated with the presence of bowel symptoms especially in PDS. This novel categorization of FD based on concomitant constipation or diarrhea may improve classification of patients.

Rapid formation of cerebral microbleeds after carotid artery stenting

Background

Recent studies reported that cerebral microbleeds (CMBs), i.e. small areas of signal loss on T₂*-weighted gradient-echo (GE) imaging, could develop rapidly after acute ischemic stroke. We hypothesized that CMBs rapidly emerge after carotid artery stenting (CAS).

Objective

We investigated the frequency of and predisposing factors for CMBs after CAS.

Methods

We retrospectively examined MRI before and after CAS in 88 consecutive patients (average age: 71.7 ± 7.2 years, average rates of carotid stenosis: 72.6 ± 12.8%) who underwent CAS for carotid artery stenosis between March 1, 2009, and September 30, 2010. We defined new CMBs as signal losses that newly appeared on the follow-up GE. We examined the association of new CMBs with demographics, risk factors, and baseline MBs.

Results

Among 88 patients, 18 (20.5%) had CMBs initially, and 7 (8.0%) developed new CMBs right after CAS. New CMBs appeared on the same side of CAS in all of the 7 patients. New CMBs appeared significantly more frequently in the CMB-positive group than in the CMB-negative one (22% vs. 4%, p = 0.03) on the pre-CAS MRI. Multivariate analysis also revealed that the presence of CMBs before CAS was an independent predictor of new development of CMBs after CAS (odds ratio: 8.09, 95% confidence interval: 1.39–47.1).

Conclusion

CMBs can develop rapidly after CAS, especially in patients with pre-existing CMBs. Since the existence of CMBs prior to CAS suggests a latent vascular damage which is vulnerable to hemodynamic stress following CAS, particular attention should be paid to the prevention of intracerebral hemorrhage due to hyperperfusion after CAS.

Abstract 2383: The Antiplatelet Effect Of Clopidogrel Is Associated With CYP2C19 *2 And *3 Polymorphism But Not With Pon-1 Q192R Polymorphism In Japanese Patients Undergoing neurointervention

Background Patients with cervical carotid or intracranial stenting are routinely premedicated with antithrombotic agents, clopidogrel and aspirin (ASA). A recent study has showed paraoxonase-1 (PON-1) Q192R genotypes impacts on antiplatlet effect of clopidogrel rather than CYP2C19 mutation. We investigate the influence of CYP2C19 *2, *3, and PON-1 Q192R genotypes on antiplatelet effect of clopidogrel in Japanese patients scheduled for neurointervention such as extracranial carotid artery stenting, intracranial artery stenting, or coil embolization of the cerebral aneurysm.

Method A total of 102 consecutive patients scheduled for neurointervention and treated with ASA and clopidogrel were enrolled. Genotyping of three single-nucleotide polymorphisms (SNPs) defining the two major CYP2C19 alleles *2, *3 and PON-1 Q192R was performed with the use of TaqMan® SNP Genotyping Assays (Applied Biosystems, CA) from stored DNA. Antiplatlet effect of clopidogrel was assessed by VerifyNow P2Y12 assay.

Result The frequencies of CYP2C19 *1/*1, *1/*2, *1/*3, *2/*2, *2/*3, and *3/*3 were 28 (27.5%), 39 (38.2%), 13 (12.7%), 9 (8.8%), 11 (10.8%), and 2 (2.0%), respectively. On the basis of CYP2C19 genotype, 28 patients (27.5%) were classified as an extensive metabolizer (EM), 52 (51.0%) as an intermediate metabolizer (IM) and 22 (21.6%) as a poor metabolizer (PM). The proportion of patients harboring CYP2C19 loss of function SNPs is 72.5%. The frequencies of PON-1 QQ192, QR192, and RR192 were 8 (7.8%), 52 (51.0%), and 42 (41.2%), respectively. P2Y12 reaction unit (PRU) in the VerifyNow P2Y12 assay was significantly higher in patients with CYP2C19 loss of function SNPs than those without (253.6±100.2 vs. 161.3±85.5, P<0.001). However, the PRU in patients with QR192 or RR192 were not significantly different from those with QQ192 ( 227.0±128.1 vs. 228.8±103.0, P=0.973).

Conclusion: In Japanese patients undergoing neurointervention, antiplatlet effect of clopidogrel was associated with CYP2C19 genotype *2and *3 but not with PON-1 Q192R genotype.

Over-expression of the LTC4 synthase gene in mice reproduces human aspirin-induced asthma

BACKGROUND

The pathogenesis of aspirin-induced asthma (AIA) is presumed to involve the aspirin/non-steroidal anti-inflammatory drug (NSAID)-induced abnormal metabolism of arachidonic acid, resulting in an increase in 5-lipoxygenase (5-LO) metabolites, particularly leukotriene C(4) (LTC(4) ). However, the role of LTC(4) in the development of AIA has yet to be conclusively demonstrated.

OBJECTIVE

The aim of this study was to evaluate the contribution of the lipid product LTC(4) secreted by the 5-LO pathway to the pathogenesis of AIA.

METHODS

To evaluate antigen-induced airway inflammation, the concentrations of T-helper type 2 cytokine in bronchoalveolar lavage fluid (BALF) obtained from LTC(4) synthase-transgenic (Tg) and wild-type (WT) mice after challenge with ovalbumin were measured. Subsequently, the ex vivo and in vivo effects of the NSAID sulpyrine were investigated in these Tg and WT mice by measuring the secretion of LTC(4) from sulpyrine-treated BAL cells and the levels of LTC(4) in BALF following challenge with sulpyrine. Finally, the sulpyrine-induced airway response by the administration of pranlukast, an antagonist of the cysteinyl (cs)-LT1 receptor, was analysed.

RESULTS

The concentrations of IL-4, -5, and -13 in BALF from Tg mice were significantly higher than those in WT mice. In addition, sulpyrine augmented the secretion of LTC(4) in BALF and by BAL cells in Tg mice, but not in WT mice. Additionally, the increased airway resistance induced by sulpyrine could be reduced by treatment with pranlukast. Furthermore, the secretion of LTC(4) from mast cells, eosinophils, and macrophages was increased in the allergen-stimulated LTC(4) synthase gene Tg mice, even in the absence of sulpyrine, as well as in BAL cells after sulpyrine.

CONCLUSION AND CLINICAL RELEVANCE

The over-expression of the LTC(4) synthase in a mouse asthma model also replicates the key features of AIA. And our study supports that cys-LTs play a major role in the pathogenesis of AIA in patients with chronic asthma.

Preparation of Highly Ordered Mesoporous Thin Film with Alkyltrimethylammonium(CnTMA+)

We synthesized the highly ordered mesoporous thin films with alkyltrimethyl-ammonium (CnTMA+). The arrangement of mesopores was depend on the Si/surfactant ratio. The hexagonal(P6mm) arrangement was observed, when Surfactant/Si ratio was 1/10. Increasing the Surfactant/Si ratio to 1.6/10, the cubic (Pm3n) arrangements were observed. A steel vessel for the measurement of the nitrogen adsorption isotherms of thin film on the substrate was designed. It was found that mesopore arrangements in the film is more regular than that in the powder samples prepared by the same acidic synthesis conditions.

Preliminary results of a study comparing conventional radiography with phase-contrast radiography for assessing root morphology of mandibular third molars

OBJECTIVES

The aim of this study was to evaluate the usefulness of phase-contrast radiography for assessing root morphology of mandibular third molars in comparison with conventional radiography.

METHODS

We studied 37 extracted mandibular third molars. One oral surgeon compared the number of roots and root curvature of the extracted teeth on conventional radiographs with those on phase-contrast images.

RESULTS

The number of roots and root curvature on conventional images differed significantly from those on phase-contrast images.

CONCLUSIONS

Our results suggest the possibility that phase-contrast radiography is more useful than conventional radiography for assessing the root morphology of mandibular third molars.

[A case of herpetic meningoencephalitis associated with massive intracerebral hemorrhage during acyclovir treatment: a rare complication]

We report a case of a 35-year-old female with herpetic meningoencephalitis confirmed by polymerase chain reaction and immunohistochemical study for herpes simplex virus-1 accompanied with a massive intracerebral hematoma as a complication. A hematoma localized at the medial temporal lobe and the medial frontal lobe occurred on the 11th day after initiation of acyclovir treatment. She subsequently required emergency surgery for temporal lobectomy, as well as hematoma and external decompression. Intracerebral hematoma with MR imaging showed gyral pattern along the cortex of the medial temporal lobe and the base of the medial frontal lobe. We speculate that the hemorrhage occurred by rupture of small vessels affected by vasculitis in addition to hypertension caused by increased intracranial pressure. We therefore emphasize the risk of intracerebral hemorrhage at an early stage or during acyclovir treatment, especially during one or two weeks after initiation of the treatment, and the necessity of careful observation during these periods.

Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is feasible as a treatment for early gastric cancer (EGC) when it is performed by an experienced endoscopist. We investigated whether it was feasible for novice endoscopists to perform ESD for EGC, and how difficult it was to learn the procedure.

METHODS

This case series study was performed in a cancer referral center. Three resident endoscopists, who had already learned basic procedures, performed ESD under supervision for 30 consecutive lesions, and their procedures were analyzed. The procedure was divided for assessment into (i) mucosal incision and (ii) submucosal dissection by completion of the circumferential mucosal cut. An insulated-tip knife was used for mucosal incision and submucosal dissection. A total of 90 mucosal EGCs (< or = 2 cm) without ulcers or scars in 87 patients were included. Outcomes were: rates of complete resection, complications, and self-completion; operation time; learning curve; and reasons for change of supervisor as an indicator of difficulty.

RESULTS

Among the 90 procedures, there was a good overall complete resection rate of 93 %, with an acceptable complication rate of 4.4 %; the complications were delayed hemorrhage in two patients, and perforations in another two patients that were repaired successfully by endoscopic clipping. The self-completion rate and operation time were significantly worse for submucosal dissection than for mucosal incision. Two of the three operators showed a flat learning curve for submucosal dissection. Difficulty with the procedure was related mainly to uncontrollable hemorrhage.

CONCLUSIONS

With appropriate supervision, gastric ESD by residents is feasible, with equivalent complete resection rates and acceptable complication rates compared with those of experienced endoscopists, although there was difficulty in achieving sufficient self-completion rates in submucosal dissection. Better control of bleeding during submucosal dissection may be a key to improving the procedure.

Combined surgery, radiation, and chemotherapy for oligodendroglial gliomatosis cerebri

Gliomatosis cerebri (GC), which mainly consists of oligodendroglial tumour cells, is rare and six cases have been documented to date. We present a new case of oligodendroglial gliomatosis cerebri with a favourable response to combination treatment using surgery, radiotherapy and chemotherapy.