Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

A vanished gastric gastrointestinal stromal tumor

BACKGROUND

Local resection is the standard treatment for gastrointestinal stromal tumors (GISTs). Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive surgery used to resect GISTs. Herein, we report an extremely rare case of a gastric GIST that grossly vanished during LECS.

CASE PRESENTATION

A 50-year-old Japanese female was referred to our hospital after an abnormality was detected during an esophagogastroduodenoscopy (EGD) at her annual health checkup. Based on EGD, endoscopic ultrasound (EUS), and computer tomography (CT) findings, the patient was diagnosed with a 50-mm submucosal tumor (SMT) with intraluminal growth on the anterior wall of the lesser curvature of the upper body of the stomach. We routinely use LECS to treat the intraluminal growth type of GISTs. During the intraoperative endoscopy, the intraluminal submucosal tumor, which was detected preoperatively, had vanished. A red-white scar was observed in the regressed tumor region. LECS was performed by resecting at a distance away from the scar tissue and closing the gastric wall with intracavitary sutures. In the evaluation from the tumor section view of the original resected specimen, a 22 × 14 × 8 mm lobular neoplasm was observed that was predominantly located in the gastric submucosa to the muscularis propia. Pathological findings confirmed the diagnosis of GIST with intermediate risk indicated by the Fletcher classification. The patient continued postoperative adjuvant chemotherapy with imatinib and no recurrence was detected over 12 months after surgery.

CONCLUSION

LECS was performed on the vanished gastric GIST, providing the best surgical treatment and leading to an accurate diagnosis and optimal postoperative care.

Pathological complete response with nivolumab for recurrence of liver metastasis after gastrectomy of gastric cancer

BACKGROUND

Advanced gastric cancer has an unfavorable prognosis and poor curability. Immune checkpoint inhibitors, such as nivolumab, have recently emerged as a potential solution for this aggressive disease. However, there is a lack of established evidence on the clinical efficacy of these agents, particularly in the perioperative period for advanced gastric cancer patients who are unresectable, recurrent, or preoperative. Despite the limited data available, there have been rare cases of dramatic therapeutic effects. In this study, we present a successful case of nivolumab treatment along with surgery.

CASE PRESENTATION

A 69-year-old female presented with pericardial discomfort and was diagnosed with advanced gastric cancer following upper gastrointestinal endoscopy. Laparoscopic distal gastrectomy with D2 lymph node dissection was performed, resulting in a final pathological diagnosis of Stage IIIA. The patient received postoperative adjuvant chemotherapy with oral S-1 therapy, but was found to have multiple liver metastases at 8 months postsurgery. Weekly paclitaxel and ramucirumab therapy was initiated, but the patient experienced adverse side effects, leading to the discontinuation of treatment. Nivolumab monotherapy was then administered for 18 cycles, resulting in a partial therapeutic response and PET-CT revealed a complete metabolic response. However, the patient developed a Grade 3 pemphigoid as an immune-related adverse event, leading to the cessation of nivolumab. The patient underwent laparoscopic partial hepatectomy. Postoperative pathology showed no residual tumor cells, indicating a complete response. At present, 25 months after surgery, the patient was alive without recurrence.

CONCLUSION

In this report, we present a case of gastric cancer with liver metastatic recurrence, in which a complete pathological response was achieved with nivolumab treatment. Although determining whether surgical intervention is necessary following successful drug treatment can be challenging, PET-CT imaging may be useful in decision-making regarding surgical treatment.

Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial

BACKGROUND

The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance.

METHODS

A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications.

RESULTS

Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8 min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different.

CONCLUSIONS

No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.

Agenesis of the Left Hepatic Lobe Accompanied by Esophagogastric Cancer: A Case Report and Literature Review

Agenesis of the left hepatic lobe is an exceedingly rare morphological anomaly. Moreover, agenesis of the left hepatic lobe accompanied by esophagogastric cancer is even rarer, with no reports to date. Agenesis of the hepatic lobe is commonly related to some anatomical variations of the gastrohepatic system. A 76-year-old man was referred to our hospital for surgery for esophagogastric cancer with short Barrett’s esophagus. Multiple preoperative imaging modalities revealed agenesis of the left hepatic lobe accompanied by esophagogastric cancer. Robotic proximal gastrectomy and transhiatal lower esophagectomy were performed. Intraoperative findings showed agenesis of the left hepatic lobe. The patient’s postoperative course was favorable. Today, 16 months after surgery, the patient is alive without recurrence of esophagogastric cancer. We report a case of agenesis of the left hepatic lobe in a patient undergoing robotic proximal gastrectomy and transhiatal lower esophagectomy for esophagogastric cancer. Preoperative comprehension of various visceral anomalies reduces the risk of surgical complications.

Long-term outcomes of postgastrectomy syndrome after total laparoscopic distal gastrectomy using the augmented rectangle technique

BACKGROUND

For total laparoscopic distal gastrectomies for gastric cancer, the reconstruction method is critical to the clinical outcome of the procedure. However, which reconstruction technique is optimal remains controversial. We originally reported the augmented rectangle technique (ART) as a reconstruction option for total laparoscopic Billroth I reconstructions. Still, little is known about its effect on long-term outcomes, specifically the incidence of postgastrectomy syndrome and its impact on quality of life.

AIM

To analyze postgastrectomy syndrome and quality of life after ART using the Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37) questionnaire.

METHODS

At Juntendo University, a total of 94 patients who underwent ART for Billroth I reconstruction with total laparoscopic distal gastrectomies for gastric cancer between July 2016 and March 2020 completed the PGSAS-37 questionnaire. Multidimensional analysis was performed, comparing those 94 ART cases from our institution (ART group) to 909 distal gastrectomy cases with a Billroth I reconstruction from other Japanese institutions who also completed the PGSAS-37 as part of a larger national database (PGSAS group).

RESULTS

Patients in the ART group had significantly better total symptom scores in all the symptom subscales (i.e., esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation, and dumping). The loss of body weight was marginally greater for those in the ART group than in the PGSAS group (-9.3% vs -7.9%, P = 0.054). The ART group scored significantly lower in their dissatisfaction of ongoing symptoms, during meals, and with daily life.

CONCLUSION

ART for Billroth I reconstruction provided beneficial long-term results for postgastrectomy syndrome and quality of life in patients undergoing total laparoscopic distal gastrectomies for gastric cancer.

Prognosis of hemodialysis patients undergoing surgery for gastric cancer: Results of a multicenter retrospective study

BACKGROUND

Little is known about the survival outcomes of and predictive factors for survival in hemodialysis patients undergoing surgery for gastric cancer.

METHODS

We performed a multicenter retrospective study from 9 institutions to investigate the survival outcomes of 75 hemodialysis patients with gastric cancer. Patient characteristics included demographic data, hemodialysis- and gastric cancer-related variables. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and non-gastric cancer related death.

RESULTS

Stage I disease was predominant (58.7%) in our series. The overall morbidity and the 30-day mortality rates were 25.3% and 1.3%, respectively. The 5-year overall survival rates of patients with pStages I, II, III, and IV disease were 59.2%, 42.9%, 32.3%, and 0%, respectively. Eleven (14.7%) patients died of gastric cancer, whereas many more (40.0%) died owing to causes other than gastric cancer. Non-gastric cancer-related death was especially prevalent in patients with pStages I (95.2%) and II (75.0%) disease. Multivariable analysis revealed advanced age, long duration of hemodialysis (> 5 years), total gastrectomy, and pStage IV disease to be independently associated with poor overall survival. Notably, advanced age, long duration of hemodialysis, and the presence of cardiovascular disease were all independent predictors of non-gastric cancer-related death. Patients with all 3 factors had very poor survival outcomes (3-year overall survival; 14.3%).

CONCLUSION

The survival outcomes of hemodialysis patients with gastric cancer, especially those with early-stage gastric cancer, were clearly poor, largely owing to the increased risk of non-gastric cancer-related death. Preoperative comorbidities and hemodialytic features were useful for predicting long-term outcomes of this vulnerable population.

RNA-seq analysis of diet-driven obesity and anti-obesity effects of quercetin glucoside or epigallocatechin gallate in Drosophila adults

OBJECTIVE

High-fat diet (HFD) feeding stimulates fat accumulation in mammals and Drosophila. In the present study, we examined whether simultaneous feeding of familiar anti-obesity drugs, quercetin glycosides (QG) and epigallocatechin gallate (EGCG), to Drosophila has the same suppressive effect on fat accumulation as previously reported in rats and mice. To understand the underlying molecular mechanisms of HFD diet-induced obesity and the suppression effect of the drugs, we performed transcriptome analyses.

MATERIALS AND METHODS

We induced extra fat accumulation by feeding Drosophila fly food containing 20% coconut oil and quantified the triglyceride accumulated in flies. The effects of anti-obesity drugs were also evaluated. We isolated total RNA from each sample and performed RNA-seq analyses and quantitive Real Time-Polymerase Chain Reaction (qRT-PCR) to investigate altered gene expression.

RESULTS

The mRNA levels of several genes involved in lipid metabolism, glycolysis/gluconeogenesis, and anti-oxidative stress changed in HFD-fed adults. Moreover, the levels altered in those fed an HFD with QG or EGCG. The qRT-PCR further confirmed the RNA-seq data, suggesting that the expression of five essential genes for lipid metabolism changed in HFD-fed flies and altered in the flies treated with anti-obesity drugs. The most remarkable alteration was observed in the dHSL gene encoding a lipase involved in lipid-storage after HFD feeding and HFD with QG or EGCG. These alterations are consistent with HFD-induced fat accumulation as well as the anti-obesity effects of the drugs in mammals, suggesting that the genes play an important role in anti-obesity effects.

CONCLUSIONS

These are the first reports to date of entire profiles of altered gene expression under the conditions of diet-induced obesity and its suppression by anti-obesity drugs in Drosophila.

Lysophosphatidic Acid Synthesis and its Receptors' Expression in the Bovine Oviduct During the Oestrous Cycle

Lysophosphatidic acid (LPA) is a naturally occurring simple phospholipid which in the bovine reproductive system can be produced in the endometrium, corpus luteum, ovarian follicle and embryo. In this study, we examined the possibility that LPA receptors are expressed, and LPA synthesized, in the bovine oviduct. We found that the concentration of LPA was highest in infundibulum in the follicular phase of the oestrous cycle and was relatively high during the early-luteal phase in all examined parts of the oviduct. We also documented that LPA synthesis engages both available pathways for LPA production. The autotaxin (ATX) protein expression was significantly higher in the infundibulum compared to the isthmus during the follicular phase of the oestrous cycle. During the early-luteal phase of the oestrous cycle, ATX and phospholipase A2 (PLA2) protein expression was highest in ampulla, although the expression of LPARs was not as dynamic as LPA concentration in the oviduct tissue, and we presume that in the bovine oviduct, the most abundantly expressed receptor is LPAR2. In conclusion, our results indicate that the bovine oviduct is a site of LPA synthesis and a target for LPA action in the bovine reproductive tract. We documented that LPAR2 is the most abundantly expressed in the bovine oviduct. We hypothesize that in the bovine oviduct, LPA may be involved in the transport of gametes, fertilization and cellular signalling between the oviduct and cumulus-oocyte complex.

104 EXPRESSION OF ACTIVIN A AS A LOCAL REGULATOR IN THE BOVINE OVIDUCT

Activin (ACV) is known as a local regulator of several reproductive functions including follicular development and implantation in mammals. ACVA is a glycopeptide belonging to the transforming growth factor β superfamily, and is a homodimer of inhibin ßA (INHBA) subunits. Follistatin (FST), an ACV-specific binding protein, inhibits ligand-receptor binding. ACV receptor (ACVR) is a hetero-tetramer consisting of 2 kinds of protein, ACVR1 or ACVR1B and ACVR2A or ACVR2B. The oviduct provides an optimal environment for sperm capacitation, fertilization, and early embryonic development. Previous reports have demonstrated that ACVRs were expressed in bovine oocytes and embryos, and that early embryonic development is facilitated by ACVA in vitro. ACVA produced by the bovine oviduct may affect gametes and embryos as well as oviductal cells as a local regulator in cow. Bovine oviductal samples were classified into 6 stages of the oestrous cycle (day of ovulation; Days 2–3 after ovulation; Days 5–6; Days 8–12; Days 15–17; Days 19–21). We examined (1) protein expression of ACVA and FST in oviductal fluid collected from the ampulla and isthmus, (2) mRNA expression of INHBA and FST in the ampullary and isthmic oviductal tissues during the oestrous cycle, (3) the effects of oestradiol-17β (E2: 0.1, 1, 10 nM) and progesterone (P4: 1, 10, 100 nM) on mRNA expressions of INHBA and FST in cultured oviductal epithelial cells isolated from the ampulla and isthmus, and (4) mRNA expression of ACVRs in tissues and in cultured epithelial and stromal cells. The main findings were as follows: (1) Both ACVA and FST were detected throughout the oestrous cycle in the oviductal fluid of the ampulla and isthmus. (2) INHBA expression was higher in the isthmus than in the ampulla. FST expression in the ampulla was lowest at peri-ovulation, INHBA expression in the isthmus was highest on the day of ovulation and FST in the isthmus during Days 2–6 was highest. Because an increase of ACVA production and a decrease of FST production raise ACVA bioactivity, ACVA seems to be most active at peri-ovulation in both the ampulla and isthmus. (3) In the cultured isthmic oviductal epithelial cells, 10 nM E2 significantly stimulated INHBA expression, but tended to suppress FST expression. Therefore, the bioactivity of ACVA seems to be controlled by E2 during the oestrous cycle in the isthmus. (4) The expression of ACVR1B and ACVR2A was clearly detected in the tissues as well as in cultured epithelial and stromal cells. The overall findings suggest that ACVA secreted into oviductal fluid plays an important role in oviductal functions, including fertilization in the ampulla and sperm motility and viability in the isthmus. It is also suggested that ACVA acts on both epithelial and stromal cells as a local regulator of cellular functions, such as cellular proliferation and secretion in the cow.

105 EFFECT OF LYSOPHOSPHATIDIC ACID ON PROSTAGLANDIN PRODUCTION IN THE BOVINE OVIDUCT

The oviduct is an essential organ for successful pregnancy in mammals. The transport of gametes and early embryos is mainly induced by contraction and relaxation of smooth muscle. The contraction and relaxation of bovine oviductal smooth muscle are induced by prostaglandin (PG) F2α and PGE2, respectively. Lysophosphatidic acid (LPA), a type of phospholipid, is involved in various physiological actions such as promoting inflammation and cellular proliferation in various organs. LPA acts through at least 6 G protein-coupled receptors. Both LPA and LPA receptors are expressed in endometrium and, moreover, LPA affects PG production by the endometrium in cow. Based on the above findings, we hypothesised that LPA is locally involved in PG production by oviductal cells to promote motility of oviductal smooth muscle in cow. Oviductal samples ipsilateral to a corpus luteum or a dominant follicle at peri-ovulation (0–6 and 19–21 days after ovulation) were collected in abattoir. Messenger RNA expression of LPA receptors (LPAR1–6) and LPA-producing enzymes (ATX, PLA1α, PLA1β) was examined in ampullary and isthmic tissues. Expression in cultured epithelial and stromal cells isolated from the bovine oviduct were also examined to determine the cells possessing LPA receptors and LPA-producing enzymes. In addition, the effect of LPA (0.1, 1, 10 μM) on the expression of cyclooxygenase (COX)-1 and COX-2 (PG-synthesising enzymes) and on PGE2 and PGF2α production by cultured epithelial and stromal cells was investigated. The significant differences (P < 0.05) were determined by Student's t-test for 2 groups, and by one-way ANOVA followed by Tukey's multiple comparison test for more than 3 groups. LPAR1–6, ATX, PLA1α, and PLA1β were expressed in both ampullary and isthmic tissues as well as in both cultured epithelial and stromal cells. The expression of LPAR1–3 was significantly lower in the isthmic tissues than in the ampullary tissues, whereas the expression of LPAR4–6 was significantly higher in the isthmic tissues than in the ampullary tissues. The expression of COX-2 was significantly stimulated by 10 μM LPA in cultured isthmic stromal cells. In addition, LPA significantly stimulated both PGE2 and PGF2α production by cultured isthmic stromal cells. In the isthmus of the oviduct, LPA produced by epithelial and stromal cells may stimulate the expression of COX-2 in the stromal cells, followed by increased PG production. Because the mRNA expression of LPAR4–6 is higher in the isthmus than in the ampulla, those effects of LPA might be mediated by activation of LPAR4–6. The overall findings suggest that LPA is one of the regulating factors for transport of gametes and early embryos by controlling the motility of smooth muscle in the bovine oviduct.

Diffuse pachymeningeal hyperintensity and subdural effusion/hematoma detected by fluid-attenuated inversion recovery MR imaging in patients with spontaneous intracranial hypotension

BACKGROUND AND PURPOSE

Fluid-attenuated inversion recovery (FLAIR) MR imaging has advantages to detect meningeal lesions. FLAIR MR imaging was used to detect pachymeningeal thickening and thin bilateral subdural effusion/hematomas in patients with spontaneous intracranial hypotension (SIH).

MATERIALS AND METHODS

Eight patients were treated under clinical diagnoses of SIH. Chronologic MR imaging studies, including the FLAIR sequence, were retrospectively reviewed.

RESULTS

Initial MR imaging showed diffuse pachymeningeal thickening as isointense in 6 cases, hypoisointense in 1 case, and isohyperintense in 1 case on the T1-weighted MR images, and hyperintense in all cases on both T2-weighted and FLAIR MR images. Dural (pachymeningeal) hyperintensity on FLAIR MR imaging had the highest contrast to CSF, and was observed as linear in all patients, usually located in the supratentorial convexity and also parallel to the falx, the dura of the posterior fossa convexity, and the tentorium, and improved after treatment. These characteristics of diffuse pachymeningeal hyperintensity on FLAIR MR imaging were similar to diffuse pachymeningeal enhancement (DPME) on T1-weighted imaging with gadolinium. Initial FLAIR imaging clearly showed subdural effusion/hematomas in 6 of 8 patients. The thickness of subdural effusion/hematomas sometimes increased transiently after successful treatment and resolution of clinical symptoms.

CONCLUSION

Diffuse pachymeningeal hyperintensity on FLAIR MR imaging is a similar sign to DPME for the diagnosis of SIH but does not require injection of contrast medium. FLAIR is useful sequence for the detection of subdural effusion/hematomas in patients with SIH.

Assessment of hemorrhage in pituitary macroadenoma by T2*-weighted gradient-echo MR imaging

BACKGROUND AND PURPOSE

Intratumoral hemorrhage occurs frequently in pituitary macroadenoma and manifests as pituitary apoplexy and recent or old silent hemorrhage. T2*-weighted gradient-echo (GE) MR imaging is the most sensitive sequence for the detection of acute and old intracranial hemorrhage. T2*-weighted GE MR imaging was used to investigate intratumoral hemorrhage in pituitary macroadenomas.

MATERIALS AND METHODS

Twenty-five consecutive patients who underwent total or subtotal resection of pituitary macroadenoma with heights from 17 to 53 mm, including 1 patient with classic pituitary apoplexy, underwent MR imaging before surgery, including T2*-weighted GE MR imaging. For histologic assessment of the hemorrhage in whole surgical specimens, we used hematoxylin-eosin staining.

RESULTS

T2*-weighted GE MR imaging detected various types of dark lesions, such as "rim," "mass," "spot," and "diffuse" and combinations, indicating clinical and subclinical intratumoral hemorrhage in 12 of the 25 patients. The presence of intratumoral dark lesions on T2*-weighted GE MR imaging correlated significantly with the hemorrhagic findings on T1- and T2-weighted MR imaging (P < .02 and <.01, respectively), and the surgical and histologic hemorrhagic findings (P < .001 and <.001, respectively).

CONCLUSION

T2*-weighted GE MR imaging could detect intratumoral hemorrhage in pituitary adenomas as various dark appearances. Therefore, this technique might be useful for the assessment of recent and old intratumoral hemorrhagic events in patients with pituitary macroadenomas.

Parent artery occlusion for posterior cerebral artery aneurysms

SUMMARY

We review four cases of posterior cerebral artery (PCA) aneurysm, of which three showed intolerance of parent artery occlusion. In two, balloon test occlusion (BTO) indicated poor opacification of the PCA branches from the anastomoses, and therefore, permanent occlusion was not attempted.

Publication bias in neurosurgery: lessons from series of unruptured aneurysms

BACKGROUND

Bias favouring publication of research with "positive" results over studies with "negative" results is widely suspected. The present investigation addressed this problem in the field of neurosurgery through a review of recent literature concerning outcome of surgery for unruptured intracranial aneurysms.

METHODS AND FINDINGS

A Medline search was performed seeking case series of surgical treatment for unruptured intracranial aneurysms that analyzed 50 or more patients. Ten type I studies (retrospective studies from a single institution; 1457 patients) met these entry criteria. In general, type I studies reported excellent surgical outcome, with mean combined mortality and morbidity of 7.8% (95% confidence interval (CI), 6.4% to 9.2%). We found 4 multicenter or community-based studies (type II studies; 5401 patients). Mean combined mortality and morbidity in the type II studies was 20.3% (95% CI, 19.2% to 21.4%), much higher than in type I studies. Relative risk was 2.6 (95% CI, 2.2 to 3.1) for patients in type II studies compared with those in type I studies. Two meta-analyses (type III studies) described combined mortality and morbidity of 5.0% and 12.7%, essentially corresponding to results of type I studies.

INTERPRETATION

Publication bias is present in the neurosurgical literature. Studies with an excellent surgical outcome are more likely to be published than those with an average outcome. Conclusions of literature reviews or meta-analyses based on published work therefore may be misleading. The solution to the problem would be community-based prospective registration of all patients who underwent surgery, providing a sampling frame free from publication bias.

[Reversible posterior leukoencephalopathy syndrome accompanied by HELLP syndrome and eclampsia: a case report]

We report a case of reversible posterior leukoencephalopathy syndrome accompanied by HELLP syndrome and eclampsia. A 30-year-old woman complained of diminution of visual acuity and eclampsia. Laboratory data revealed hemolysis, elevated liver enzyme and low platelets. CT showed low density areas in the bilateral occipital cortex. T1-weighted images showed a low signal intensity and T2-weighted images showed a high signal intensity in the occipital cortex bilaterally. Magnetic resonance angiography showed stenotic change in the intracranial artery. An operation was performed and significant improvement was seen in her visual function and MRI and MRA returned to normal on a month after operation. The mechanism of a reversible posterior leukoencephalopathy syndrome was discussed.

Two starch-branching-enzyme isoforms occur in different fractions of developing seeds of kidney bean

The nature and enzymic properties of starch-branching enzyme (SBE) are two of the dominant factors influencing the fine structure of starch. To understand the role of this enzyme's activity in the formation of starch in kidney bean (Phaseolus vulgaris L.), a study was undertaken to identify the major SBE sequences expressed during seed development and to characterize the enzymic properties of the coded recombinant enzymes. Two SBE cDNA species (designated pvsbe2 and pvsbe1) that displayed significant similarity (more than 70%) to other family A and B SBEs respectively were isolated. Northern blot analysis revealed that pvsbe1 and pvsbe2 were differentially expressed during seed development. pvsbe2 showed maximum steady-state transcript levels at the mid-stage of seed maturation, whereas pvsbe1 reached peak levels at a later stage. Western blot analysis with antisera raised against both recombinant proteins (rPvSBE1 and rPvSBE2) showed that these two SBEs were located in different amyloplast fractions of developing seeds of kidney bean. PvSBE2 was present in the soluble fraction, whereas PvSBE1 was associated with the starch granule fraction. The differences in location suggest that these two SBE isoenzymes have different roles in amylopectin synthesis in kidney bean seeds. rPvSBE1 and rPvSBE2 were purified from Escherichia coli and their kinetic properties were determined. The affinity of rPvSBE2 for amylose (K(m) 1.27 mg/ml) was lower than that of rPvSBE1 (0.46 mg/ml). The activity of rPvSBE2 was stimulated more than 3-fold in the presence of 0.3 M citrate, whereas rPvSBE1 activity was not affected. The implications of the enzymic properties and the distribution of SBEs and amylopectin structure are discussed.

Acute systemic inflammatory response syndrome in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Systemic inflammatory response syndrome (SIRS) without infection is a well-known phenomenon that accompanies various acute cerebral insults. We sought to determine whether the initial SIRS score was associated with outcome in subarachnoid hemorrhage (SAH).

METHODS

In 103 consecutive patients with SAH, the occurrence of SIRS was assessed according to the presence of >/=2 of the following: temperature of <36 degrees C or >38 degrees C, heart rate of >90 bpm, respiratory rate of >20 breaths/min, and white blood cell count of <4000/mm(3) or >12 000/mm(3). SIRS criteria and other prognostic parameters were evaluated as predictors of dichotomous Glasgow Outcome Scale score.

RESULTS

SIRS was highly related to poor clinical grade (Hunt and Hess clinical grading scale), a large amount of SAH on CT (Fisher CT group), and high plasma glucose concentration on admission. By univariate analysis, the occurrence of SIRS was associated with higher mortality and morbidity rates than was the nonoccurrence (P<0.001). Among individual SIRS criteria, heart rate (P=0.003), respiration rate (P=0.003), and white blood cell count (P=0.03) were significant outcome predictors. By multivariate logistic regression analysis, the presence of SIRS independently predicted outcome. SIRS carried an increased risk of subsequent intracranial complications such as vasospasm and normal pressure hydrocephalus, as well as systemic complications.

CONCLUSIONS

In SAH patients, SIRS on admission reflected the extent of tissue damage at onset and predicted further tissue disruption, producing clinical worsening and, ultimately, a poor outcome.

Hormonal regulation of the human ghrelin receptor gene transcription

The aim of this study is to clarify the hormonal regulation of the human ghrelin receptor gene expression in GH(3) cells transfected with our previously cloned 5'-flanking region inserted into a luciferase reporter vector. Phorbor 12-tetradecanoate 13-acetate (TPA) with simultaneous addition of Bay K8644 mimicking ghrelin action caused a significant inhibition of the luciferase activity through the ghrelin receptor gene upstream proximal to -669 but not to -608 base pairs (bp). Glucocorticoid caused a weak but significant inhibition of the luciferase activity through the ghrelin receptor gene upstream proximal to -531 but not to -475 bp. Electrophoretic mobility shift assay resulted in binding of oligonucleotides between -669 and -640 bp, and between -520 and -491 bp to GH(3) cell nuclear proteins unlike AP(2) or glucocorticoid receptor. These results suggest that both TPA/Bay K8644 and glucocorticoid downregulate human ghrelin receptor gene expression through the transcriptional mechanism involving some nuclear factors.

Injection of a sperm extract triggers egg activation in the newt Cynops pyrrhogaster

Unfertilized eggs of the newt Cynops pyrrhogaster are arrested at the second meiotic metaphase. The primary signal for egg activation is a transient increase in [Ca2+](i), which is triggered by the fertilizing sperm and propagates over the egg cortex as a Ca2+ wave. We injected an extract of Cynops sperm (SE) into unfertilized eggs and induced a wave-like [Ca2+](i) increase which resulted in activation and resumption of meiosis. The SE-injected eggs showed degradation of cyclin B1 and DNA replication. When SE was boiled or treated with proteinase K before injection, it was unable to cause egg activation. Preinjection of Ca2+ -chelator BAPTA before SE injection inhibited egg activation. These results indicate that a heat-labile and proteinaceous factor in the sperm cytoplasm induces a transient increase in [Ca2+](i) which is required for egg activation. Injection of IP3 into unfertilized eggs caused an increase in [Ca2+](i) and egg activation, but injection of cADP-ribose did not. These results support the hypothesis that Ca2+ release at fertilization occurs via IP3 receptors.

Malignant struma ovarii with Graves' disease

BACKGROUND

Malignant struma ovarii is a rare tumor, consisting of a struma ovarii with malignant change. Because of the rarity of the tumor, only a few reports with detailed data of thyroid function of the patient have been published.

CASE

Medical and surgical treatments were performed in a case of malignant struma ovarii with Graves' disease and data from thyroid function tests were analyzed. After removal of the tumor, rapid improvement of thyroid function was observed and thyroglobulin level decreased.

CONCLUSION

This case demonstrates the possible, if not dominant, contribution from the malignant struma ovarii to the hyperthyroidism of the patient.

Migrastatin, a new inhibitor of tumor cell migration from Streptomyces sp. MK929-43F1. Taxonomy, fermentation, isolation and biological activities

A new compound, migrastatin, was isolated from a cultured broth of Streptomyces sp. MK929-43F1, as an inhibitor of tumor cell migration. It was purified by column chromatographies on silica gel and Sephadex LH-20 and HPLC. Migrastatin has the molecular formula of C27H39NO7 consisting of 14-membered macrolide and glutarimide moiety. It inhibited spontaneous migration of human esophageal cancer EC17 cells. Migration inhibitory activity of migrastatin was not dependent on cytotoxicity or inhibition of protein synthesis.

MK800-62F1, a new inhibitor of apoptotic cell death, from Streptomyces diastatochromogenes MK800-62F1. I. Taxonomy, fermentation, isolation, physico-chemical properties and biological activity

A new compound, MK800-62F1, was isolated from a cultured broth of Streptomyces diastatochromogenes MK800-62F1. It inhibited H2O2-induced apoptosis in human small cell lung carcinoma Ms-1 cells as well as in human T-cell leukemia Jurkat cells. In addition, MK800-62F1 also inhibited camptothecin-induced apoptosis in Jurkat cells, which was mediated by intracellular H2O2 generation. MK800-62F1 did not exhibit antioxidative activity in vitro, suggesting that inhibition of apoptosis by MK800-62F1 was not due to the scavenging of H2O2, rather it was due to the modulation of the downstream event of H2O2 generation.

MK800-62F1, a new inhibitor of apoptotic cell death, from Streptomyces diastatochromogenes MK800-62F1. II. Structure elucidation

A new compound, MK800-62F1, was isolated from a cultured broth of Streptomyces diastatochromogenes MK800-62F1. The structure was determined by NMR analysis and degradation experiments.

Lymph node metastases identified with mediastinoscopy in a patient with superficial carcinoma of the esophagus

Superficial esophageal cancers limited to the lamina propria are not associated with lymph node metastases. Mediastinoscopic transhiatal esophagectomy was planned in a patient with widespread superficial cancer of the midthoracic esophagus. Sampling of the upper mediastinal lymph nodes revealed metastases. The operation was converted to a transthoracic esophagectomy with radical lymphadenectomy. Histopathologic examination of the resection specimen showed three metastatic lymph nodes, despite local invasion limited to the lamina propria. This is the first report of a patient with superficial esophageal cancer and lymph node metastases.

8-bromo-cyclicAMP stimulates glucose transporter-1 expression in a human choriocarcinoma cell line

Facilitative glucose transporter-1 (GLUT1) is abundant in trophoblast cells and is responsible for glucose transport in the placenta. However, the change in GLUT expression in human placenta upon trophoblast differentiation remains to be clarified. Therefore, we first examined the localization of GLUT1 and GLUT3 using human first-trimester chorionic villi. We found that GLUT1 and GLUT3 were mainly localized to syncytiotrophoblast and cytotrophoblast cells respectively. We analyzed whether placental GLUT1 and GLUT3 expression changes during differentiation using a human choriocarcinoma (BeWo) cell line which is known to show functional and morphological differentiation in response to cAMP in culture. Treatment of BeWo cells with 8-bromo-cyclicAMP (8-bromo-cAMP) increased the level of hCG secretion and induced cell fusion leading to the formation of large syncytia. Treatment of BeWo cells with 8-bromo-cAMP also resulted in a significant increase in glucose uptake on days 2-3 of culture. The stimulating effect of 8-bromo-cAMP on glucose uptake was concentration dependent. Northern and immunoblot analyses revealed that the levels of mRNA and protein of GLUT1, but not of GLUT3, were significantly increased by 8-bromo-cAMP. These findings suggest that 8-bromo-cAMP stimulates GLUT1 expression with differentiation in BeWo cells.

The expression of three types of CINCs by lipopolysaccharide-stimulated rat macrophages is inhibited similarly by anti-inflammatory steroids

OBJECTIVE

Expression of CINCs was regulated differentially in lipopolysaccharide-stimulated rat macrophages. We examined whether the expression of CINCs in lipopolysaccharide-stimulated rat macrophages is similarly inhibited by anti-inflammatory drugs.

MATERIALS AND METHODS

Rat peritoneal macrophages were stimulated by lipopolysaccharide in the presence of anti-inflammatory steroids (dexamethasone, prednisolone and hydrocortisone) or non-steroidal anti-inflammatory drugs (indomethacin and piroxicam). The production and mRNA expression of three types of CINCs were measured using enzyme-linked immunosorbent assay and northern hybridization.

RESULTS

Anti-inflammatory steroids; dexamethasone, prednisolone and hydrocortisone, dose-dependently inhibited the production of CINC-1, -2 and -3, whose inhibitory patterns were similar to each other. Furthermore mRNA expression of each CINC was inhibited by dexamethasone in a dose-dependent manner. In contrast, non-steroidal anti-inflammatory drugs, indomethacin and piroxicam were without effect. Expression of each CINC was regulated differently; the production of CINC-1 reached a maximum at 12 h and then slightly decreased after lipopolysaccharide stimulation, whereas that of CINC-2 and CINC-3 increased up to 24 h. Dexamethasone inhibited the CINCs production and mRNA expression at 9 h after lipopolysaccharide stimulation.

CONCLUSIONS

These results indicate no difference among CINC-1, -2 and -3 in the inhibition of production and mRNA expression of CINCs by anti-inflammatory steroids, although lipopolysaccharide differentially induces expression of each CINC expression in culture of rat macrophages.

[Acquired pendular nystagmus after pontine hemorrhage]

A 60-year-old hypertensive woman had a pontine hemorrhage that caused slight right hemiplegia, deep sensory disturbance on her right side and dysarthria. Three months after the stroke, she was transferred to our hospital for rehabilitation. Approximately 6 months later, she gradually began to complain of the visual oscillation. Continual, unceasing conjugate vertical/rotatory eye movements were observed. Fixation was momentary at best because of an inability to dampen the spontaneous eye movements. Electrooculography (EOG) showed bilateral vertical/rotatory sinusoidal eye movements of 2.5 Hz frequency and 10- to 35-degree amplitude. Both vertical and horizontal optokinetic nystagmus were absent. Caloric stimulation did not evoke any responses bilaterally. There were no rhythmical movements at similar frequencies in other parts of the body such as palatal myoclonus. MRI revealed not only hematoma mainly at the dorsal pontine tegmentum but also hypertrophy of the inferior olive nucleus, suggesting disruption of the central tegmental tract. Lesions of this tract may be one cause of pendular nystagmus. Several drug therapies were investigated for the nystagmus. There was no response to baclofen 15 mg. Trihexyphenidyl 4 mg was discontinued because of drug-induced hallucinations. Tiapride 600 mg and phenobarbital 90 mg were each slightly effective in reducing both frequency and amplitude of nystagmus. Treatment with clonazepam 1 mg resulted in the striking disappearance of nystagmus. She was aware of this and no longer experienced oscillopsia. Despite the visual benefit, however, the patient did not wish to continue this drug because of drowsiness and muscle relaxation. The potential long-term therapeutic application of clonazepam should be further investigated. To our knowledge, there have been no reports of successful treatment in acquired pendular nystagmus with clonazepam. Therefore, based on this favorable experience, it is suggested that clonazepam should be added to the list of potential therapies for pendular nystagmus.

Cost-effectiveness analysis of screening for asymptomatic, unruptured intracranial aneurysms. A mathematical model

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) due to aneurysmal rupture is a major cause of cerebrovascular disease-related death. This problem could be eliminated by diagnosis and successful treatment of aneurysms before rupture. Recent developments in high-resolution imaging technology have made screening for unruptured aneurysms possible in the general population. Such screening has become widespread in Japan ("No Dokku, " or brain checkup). As a result, unruptured aneurysms are being identified with increasing frequency. However, the economic implications of treatment decisions for unruptured aneurysms have not been analyzed. Therefore, we performed such an analysis.

METHODS

We used a Markov model to evaluate the cost-effectiveness of screening for asymptomatic, unruptured intracranial aneurysms. The model involved a set of variables describing discrete health states. Each state was assigned a quality of life score and an associated medical cost. A comparison of the expected outcomes was then made between 2 hypothetical cohorts, one receiving screening and the other no screening. A sensitivity analysis was performed by altering the input values within clinically reasonable ranges to reflect uncertainty in the baseline analysis and then assessing the effects on outcomes.

RESULTS

Combining the incremental cost and effectiveness data revealed a cost per quality-adjusted life-year of $7760 for an annual rate of subarachnoid hemorrhage due to unruptured aneurysms (rupture rate) of 0.02; this cost was $39 450 for a rupture rate of 0.01. There was no benefit (negative quality-adjusted life-year benefit) for a rupture rate of 0.005, the rupture rate found in a recently published international cooperative study. The risks of surgery for unruptured aneurysms and the discounting ratio used to assess the impact of timing of costs and benefits on future outcomes also had significant effects on the results. Other variables had little impact on cost-effectiveness.

CONCLUSIONS

The cost-effectiveness of screening for an unruptured aneurysm is highly sensitive to the annual rate of subarachnoid hemorrhage due to unruptured aneurysms. The low annual rupture rate seen in the recent large international cooperative study implies that screening asymptomatic populations to identify and treat unruptured aneurysms would not be cost cost-effective.

Increased sarcolemmal permeability in the cerebral artery during chronic spasm: an assessment using DNA-binding dyes and detection of apoptosis

Alteration of sarcolemmal permeability was evaluated in the cerebral artery after subarachnoid hemorrhage. Significance of membrane dysfunction in the pathogenesis of chronic spasm and contribution of apoptosis were investigated in a canine model. Permeability of the smooth muscle cell (SMC) membrane was assessed by double staining with a hydrophilic (ethidium bromide [EB]) and a lipophilic (Hoechst 33342) DNA-binding dye. Quantitative observations were made with a ultraviolet-fluorescence microscope and a ultraviolet-laser confocal microscope. Occurrence of apoptosis was studied using electrophoresis and TUNEL method. In the normal arteries, nuclei of SMC were stained with Hoechst 33342 but not with EB. In the spastic arteries, SMC in the inner layer of the tunica media were stained with EB. The incidence of EB-positive cells reached maximum on day 7 (45 +/- 19%) and decreased in 2 to 4 weeks (13 +/- 5.2% and 5.0 +/- 2.1%, respectively), in parallel with amelioration of spasm. Electron and light microscopic observations revealed increased density of SMC cytoplasm with widening of the extracellular space. Necrosis was not evident. Apoptosis was not detected by the two methods. These results demonstrate that an augmentation in sarcolemmal permeability takes place during the course of chronic vasospasm and suggest its close correlation to pathogenesis.