[Prognostic significance of textbook outcome in advanced gastric patients who underwent neoadjuvant chemotherapy followed by surgical resection]

Objective: To investigate the risk factors and prognostic value of the textbook outcome (TO) in patients with advanced gastric cancer (AGC) who underwent neoadjuvant chemotherapy followed by surgical resection. Methods: This is a retrospective cohort study. A total of 253 patients with AGC who underwent neoadjuvant chemotherapy combined with gastrectomy and D2 lymphadenectomy in the Department of Gastric Surgery, Fujian Medical University Union Hospital from January 2010 to December 2019 were retrospectively included. There were 195 males and 58 females, aged (60.3±10.0) years (range: 27 to 75 years). The patients were then divided into the TO group (n=168) and the non-TO group (n=85). Multivariate Logistic regression was used to analyze the independent predictors of TO. Univariate and multivariate Cox analysis were used to analyze independent prognosis factors for overall survival (OS) and disease-free survival (DFS). Propensity score matching was performed to balance the TO and non-TO groups, and the Kaplan-Meier method was used to calculate survival rates and draw survival curves. Results: Among the 253 patients, 168 patients (66.4%) achieved TO. The Eastern Cooperative Oncology Group score (OR=0.488, 95%CI: 0.278 to 0.856, P=0.012) and ypN stage (OR=0.626, 95%CI:0.488 to 0.805, P<0.01) were independently predictive of TO. Multivariate analysis revealed that TO was an independent risk factor for both OS (HR=0.662, 95%CI: 0.457 to 0.959,P=0.029) and DFS (HR=0.687, 95%CI: 0.483 to 0.976, P=0.036). After matching, the 5-year OS rate (42.2% vs. 27.8%) and the 5-year DFS rate (37.5% vs. 27.8%) were significantly higher in the TO group than in the non-TO group (both P<0.05). Furthermore, patients in the non-TO group benefited significantly from postoperative chemotherapy (both P<0.05), but those in the TO group did not (both P>0.05). Conclusion: TO is an independent prognosis factor in patients undergoing neoadjuvant chemotherapy and surgery for AGC and is associated with postoperative chemotherapy benefits.

[Technical specification for orthodontic transmission straight wire technique]

Malocclusion is an oral disease with a high prevalence. The goal of orthodontic treatment is health, aesthetics, function and stability. The transmission straight wire appliance and technique is an innovative orthodontic system with independent intellectual property rights invented by Professor Jiuxiang Lin's team based on decades of clinical experience, which provides a new solution for the non-surgical correction of skeletal malocclusions, especially class Ⅲ malocclusion, and it is also a good carrier for the implementation of the concept of healthy orthodontics. Due to the lack of guidelines, how to implement standardized application of transmission straight wire technique remains a problem to be solved. This technical specification was formed by combining the guidance from Professor Jiuxiang Lin and joint revision by a number of authoritative experts from the Orthodontic Special Committee, Chinese Stomatological Association, with reference to relevant literatures, and combined with abundant clinical experience of many experts. This specification aims to provide reference to standardize the clinical application of transmission straight wire technique, so as to reduce the risk and complications, and finally to improve the clinical application level of this technique.

[Establishment of a nomogram prediction model using common preoperative indicators for early weight loss after laparoscopic sleeve gastrectomy]

Objectives: To construct a nomogram prediction model using common preoperative indicators for early weight loss (EWL) 1 year after laparoscopic sleeve gastrectomy (LSG). Methods: Relevant data of obese patients who had undergone LSG from January 2015 to May 2022 in Fujian Medical University Union Hospital and Quanzhou First Hospital Affiliated Fujian Medical University were analyzed. Patients with a history of major abdominal surgery, severe gastroesophageal reflux disease, pregnancy within 1 year after surgery, or who were lost to follow-up were excluded, resulting in a total of 200 patients in the study (190 from Fujian Medical University Union Hospital and 10 from Quanzhou First Hospital Affiliated Fujian Medical University). The participants were 51 men and 149 women of a mean age 29.9±8.2 years and a body mass index (BMI) 38.7±6.5 kg/m2. All patients in this group underwent standardized LSG procedure. Achieving ideal weight (BMI≤25 kg/m2) 1 year after LSG was defined as goal of EWL. Logistic regression analyses were performed to identify factors that independently influenced EWL. These factors were incorporated into the nomogram model. Receiver operating characteristic (ROC) curves (the larger the area under the curve [AUC], the better the predictive ability and accuracy of the model), likelihood ratio test (higher likelihood ratio indicates greater model homogeneity), decision curve analysis (higher net benefit indicates a better model), Akaike information criterion (AIC; smaller AIC indicates a better model), and Bayesian information criterion (BIC; smaller BIC indicates a better model) were used to validate the predictive ability of the column line diagram model. Results: In this study of 200 obese patients who underwent LSG surgery, 136 achieved EWL goal, whereas the remaining 64 did not. The rate of EWL goal achievement of the entire group was 68.0%. Compared with patients who did not achieve EWL goal, those who did had lower BMI, alanine transaminase, aspartate transaminase, triglycerides, and higher cholesterol. Additionally, the proportion of female was higher and the proportions of patients with fatty liver and hypertension lower in those who achieved EWL goal (all P<0.05). Univariate and multivariate logistic regression analysis revealed that preoperative BMI (OR=0.852, 95%CI: 0.796-0.912, P<0.001), alanine transaminase (OR=0.992, 95%CI: 0.985-0.999, P=0.024), presence of fatty liver (OR=0.185, 95%CI: 0.038-0.887, P=0.035) and hypertension (OR=0.374, 95%CI: 0.144-0.969, P=0.043) were independently associated with failure to achieve EWL goal. Cholesterol (OR=1.428, 95%CI: 1.052-1.939, P=0.022) was independently associated with achieving EWL goal. We used the above variables to establish an EWL nomogram model. ROC analysis, the likelihood ratio test, decision curve analysis, and AIC all revealed that the predictive value of the model was better than that of BMI alone (nomogram model vs. BMI: area under the curve 0.840 vs. 0.798, P=0.047; likelihood ratio: 58.785 vs. 36.565, AIC: 193.066 vs. 207.063, BIC: 212.856 vs. 213.660). Conclusion: Our predictive model is more accurate in predicting EWL after LSG compared with using BMI.

[Feasibility of a three-sided encapsulation procedure based on fascia anatomy in laparoscopic lateral lymph node dissection for middle and low rectal cancer]

Objective: To explore the feasibility and value of performing a three-sided encapsulation procedure based on fascia anatomy in laparoscopic lateral lymph node dissection (LLND) for middle and low rectal cancer. Methods: This was a retrospective review. The study cohort comprised patients who met the diagnostic criteria for rectal cancer according to the Chinese Guidelines for the Diagnosis and Treatment of Colorectal Cancer, had a short lymph node diameter of >5 mm on the lateral side within the 15 days before surgery, were evaluated as feasible candidates for laparoscopic total mesorectal excision+LLND surgery, had been diagnosed with low or intermediate level rectal cancer, and whose tumor was less than 8 cm away from the anal verge according to pathological examination of the operative specimen. Patients with a history of other malignant tumors of the abdomen or with incomplete follow-up data were excluded. Forty-two patients with middle and low rectal cancer who had undergone lateral lymph node dissection in diagnosis and treatment center of Gastrointestinal Cancer of Guangdong Hospital of Chinese Medicine from Jan.2018 to Dec.2022 were enrolled. There were 24 men (57.1%) and 18 women (42.9%) aged 58.4±11.8 years and the median BMI was 22.5 (19.3-24.1) kg/m2. The main point of the three-sided encapsulation procedure is to expand the external side medial to the external iliac artery and vein, narrowing the range of exterior side dissection. The anterior-medial side is designed to expand the vesical fascia to define the range of anterior-medial side extension. The internal side is fully extended to the ureterohypogastric nerve fascia; the distal point of the caudal extension reaches the level of the Alcock canal and the bottom reaches the piriformis, enabling dissection of the obturator nerve and No.283 lymph nodes. No.263D lymph nodes are dissected by exposing the internal iliac artery and its branches, dissecting the group No.263P lymph nodes, and severing the inferior vesical artery. Finally, the lateral lymphatic tissue is completely resected. Relevant variables were recorded, including the number of lateral lymph nodes detected, the rate of lymph node metastasis, operation duration, intraoperative blood loss, postoperative complications, postoperative hospital stay, and 3-year overall survival rate. Results: Laparoscopic surgery was successfully completed in all patients with no conversions to open surgery and no intraoperative complications. Twenty-seven (64.3%) of the study patients underwent left-sided LLND, 10 (23.8%) right-sided LLND, and five (11.9%) bilateral LLND, with lymph nodes cleared on both sides. All patients' lymph nodes were examined pathologically. A median of 17.0 (11.7, 26.0) lymph nodes was detected, the median of lateral lymph nodes being 5.0 (2.0, 10.2). The median operation time was 254.5 (199.0, 325.2) minutes. The median intra-operative blood loss was 50.0 (30.0, 100.0) mL. All patients were diagnosed with adenocarcinoma by pathological examination of the operative specimen. Two patients developed postoperative intestinal obstruction, one lymphatic leakage, and one a perineal incision infection. There were no cases of anastomotic leakage. The median postoperative hospital stay was 6.0 (5.0, 7.0) days and the median follow-up time 23.5 (9.0, 36.7) months. During follow-up, three patients (7.1%) died of tumor recurrence and metastasis. Two (4.8%) experienced mild urinary dysfunction, and one (2.4%) had moderate postoperative erectile dysfunction. One patient (2.4%) was found to have prostate and lung metastases 3 month after surgery. The 3-year overall survival rate was 74.4%. Conclusions: Three sided encapsulation is a safe and feasible procedure for LLND, achieving accurate and complete clearance of lateral lymphatic tissue.

In-plane reorientation induced single laser pulse magnetization reversal

Single Pulse All Optical Switching represents the ability to reverse the magnetization of a nanostructure using a femtosecond single laser pulse without any applied field. Since the first switching experiments carried out on GdFeCo ferrimagnets, this phenomena has been only recently extended to a few other materials, MnRuGa alloys and Tb/Co multilayers with a very specific range of thickness and composition. Here, we demonstrate that single pulse switching can be obtained for a large range of rare earth-transition metal multilayers, making this phenomenon much more general. Surprisingly, the threshold fluence for switching is observed to be independent of the laser pulse duration. Moreover, at high laser intensities, concentric ring domain structures are induced. These striking features contrast to those observed in Gd based materials pointing towards a different reversal mechanism. Concomitant with the demonstration of an in-plane magnetization reorientation, a precessional reversal mechanism explains all the observed features.

[Advances in assessment methods of midpalatal suture and its clinical application]

Rapid palatal expansion is commonly uesd to correct maxillary transverse deficiency. The timing and effects of palatal expansion, and the choice of palatal expansion devices are related to the condition of midpalatal suture. Nowadays, there are several methods to assess the condition of midpalatal suture, including physiological age, skeletal age, occlusal film, CT, ultrasonography and so on. This narrative review seeks to review these methods for assessment of midpalatal suture.

[Effect of splenic hilar lymphadenectomy on locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction with a tumor diameter ≥4 cm: a five-year survival analysis]

Objective: To examine the long term outcome of splenic hilar lymphadenectomy (SHL) for locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG) with a tumor diameter ≥4 cm. Methods: A total of 489 locally advanced Siewert type Ⅱ and Ⅲ AEG patients with a tumor diameter ≥4 cm who underwent radical resection from January 2010 to April 2016 were included. There were 383 males and 106 females. There were 225 patients aged≥65 years and 264 patients aged <65 years. SHL was conducted in 270 patients(SHL group). Wilcoxon rank-sum test or χ² test were conducted for inter-group comparison. Cox proportional hazard regression was used to analyze the long term outcome of SHL and the prognosis factors of overall survival. Kaplan-Meier curve was drawn finally. The results of survival analysis were verified by Log-rank test. Results: Followed-up to April 2021,the median follow-up time was 78.0 months (range: 74.0 to 85.0 months), the follow-up rate was 95.5%(467/489). The splenic hilar lymphnode metastasis rate of the SHL group was 12.6% (34/270). Younger patients (<65 years old), less complications, higher proportion of patients received adjuvant chemotherapy were demonstrated in the SHL group (χ²: 5.644 to 6.744, all P<0.05). Multivariate analysis showed that SHL was the independent prognosis factor of overall survival for patients with Siewert type Ⅱ and Ⅲ AEG and a tumor diameter≥4 cm (HR=0.68, 95%CI: 0.52 to 0.88, P=0.004) along with preoperative CA19-9, pathological T stage, pathological N stage, adjuvant chemotherapy and postoperative complication. Further subgroup analysis demonstrated that the SHL group had better 5-year overall survival than non-SHL group (62.4% vs. 39.2%, χ²=17.983, P=0.006) in Siewert type Ⅲ AEG rather than in Siewert type Ⅱ AEG(57.3% vs. 53.7%, χ²=3.031, P=0.805). Conclusion: In experienced center, splenic hilar lymphadenectomy can improve the prognosis of Siewert type Ⅲ AEG with a tumor diameter ≥4 cm.

[Quality of life after totally laparoscopic versus laparoscopic-assisted total gastrectomy: a retrospective cohort study with propensity score matching]

Objective: To evaluate the postoperative quality of life in patients after totally laparoscopic total gastrectomy (TLTG). Methods: A retrospective cohort study based on propensity score matching was performed. Clinical and follow-up data of patients who underwent laparoscopic radical gastrectomy at Union Hospital of Fujian Medical University from January 2014 to May 2015 were collected. Case indusion criteria: (1) primary gastric cancer confirmed by postoperative pathology; (2) receiving TLTG or laparoscopic-assisted total gastrectomy (LATG);(3) R0 resection; (4) completing follow-up for 12 months and complete follow-up data. Exclusion criteria: (1) gastric stump cancer; (2) concurrent tumor; (3) distal metastasis found during operation; (4) history of upper abdominal operation. According to surgical procedures, patients were divided into the LATG group (1076 cases) and the TLTG group (106 cases). To eliminate potential bias in baseline data between the two groups, the propensity score was calculated using a logistic regression model with the following covariates, including age, sex, body mass index, American Society of Anesthesiologists score, tumor location, tumor size, pathology type, and stage. The two groups were matched using a 1:2 propensity assessment ratio and a caliper width of 0.01 standard deviation was specified. The primary outcomes were the quality of life of the two groups at 3, 6 and 12 months after gastrectomy, including physical symptoms and social function. Higher function score indicated better function, and higher symptom score presented worse symptoms. Quality of life score = (100 - somatic symptom scale score + social function scale score) / 2. The secondary outcomes were postoperative nutritional recovery and food tolerance at 3, 6 and 12 months after gastrectomy. The categorical variables were expressed as n(%), and compared using the χ² test or Fisher exact test. The continuous variables conforming to the normal distribution were represented by Mean ± SD and compared with the paired t-test. Repeated measurement of variance was used to compare nutrition-related indicators within the group among pre-operation, postoperative 1, 3, 6, 12 months. Results: After PSM, there were no significant differences in clinicopathological baseline data between the TLTG group (n=104) and the LATG group (n=208) (all P>0.05). The physical symptoms scores in the TLTG group before operation and 3, 6 and 12 months after operation were 8.6±5.8, 15.5±8.4, 10.1±5.9 and 6.1±2.4 respectively (F=43.493, P<0.001). In the LATG group, the above mentioned scores were 9.7±6.9, 23.7±10.4, 13.3±8.3 and 8.5±4.2 respectively (F=112.588, P<0.001). Compared with the LATG group, the symptom scores in the TLTG group were lower at 3 and 6 months after operation, and the differences were statistically significant (t=-3.653, P<0.001; t=-2.513, P=0.012). At 12 months after operation, although the physical symptom score in the TLTG group was also lower than that in LATG group, the difference was not statistically significant (t=-1.487, P=0.138). The social function scores in the TLTG group before operation and 3, 6 and 12 months after operation were 90.3±8.9, 77.5±14.3, 87.4±10.3 and 91.7±6.7 respectively (F=28.524, P<0.001). In the LATG group, the above mentioned scores were 92.5±6.3, 68.5±16.8, 79.8±14.7 and 84.7±11.1 respectively (F=57.975, P<0.001). Compared with the LATG group, the social function scores of patients in the LATG group were higher at 3, 6 and 12 months after operation (t=3.543, P<0.001; t=3.216, P=0.001; t=2.235, P=0.026). The total scores of quality of life at 3, 6 and 12 months after operation in the TLTG group were 81.0±15.6, 88.3±8.1 and 93.3±9.1 respectively, and the above mentioned scores in the LATG group were 72.4±13.6, 83.3±11.5 and 88.1±7.7 respectively, whose differences at corresponding time point were all significant between the two groups (all P<0.05). The change of total body mass[(-8.4±1.4)% vs. (-13.2±1.6)%, t=2.273, P=0.024], serum albumin[(-5.1±0.7)% vs. (-7.4±0.8)%,t=2.095, P=0.037], meal quantity [(-15.6±4.7)% vs. (-24.1±6.0)%, t=2.885, P=0.004] and meal times [(20.8±7.1)% vs. (30.6±11.5)%, t=3.043, P<0.001] in the TLTG group were significantly lower than those in the LATG group one year after operation (all P<0.05). At 3, 6 and 12 months after operation, the diet proportions of solid and soft food in the TLTG group were higher than those in the LATG group (all P<0.05). Conclusions: Compared with LATG, patients with gastric cancer undergoing TLTG have better health-related quality of life and faster recovery of nutrition.

[Analysis of characteristics and trends of randomized controlled trials of gastric cancer between 2000 and 2019]

Objectives: To analyze the current development status of gastric cancer (GC) randomized controlled trials (RCT) between 2000 and 2019, and to review the basic characteristics of published RCT. Methods: ClinicalTrials.gov was searched for phase 3 or 4 RCT conducted between January 2000 and December 2019 with the keyword "gastric cancer", and the development trend of different types of RCT during different time periods was described. Basic features of registered RCT such as intervention, study area, single-center or multicenter, sample size, and funding were presented. PubMed and Scopus databases were searched to judge the publication status of studies completed until June 2016. The adequacy of the report was estimated by the Consolidated Standards of Reporting Trials (CONSORT) checklist. Design flaws were evaluated by Cochrane tool and/or whether a systematic literature review was cited. The data was analyzed by χ2 test or Fisher exact test. Results: There were 262 RCT including in the present study. The number of GC-RCT registered on ClinicalTrials.gov had been on the rise from 1 case in 2000 to 30 cases in 2015. The proportion of RCT associated with targeted therapy or immunotherapy increased from 0 during 2000-2004 to 37.1% (36/97) during2015-2019. The RCT registered in Asia was 191 cases, while that in non-Asia region was 71 cases. The proportion of multi-center RCT from non-Asia was higher than that from Asia (70.4% (50/71) vs. 50.3% (96/191), χ²=8.527, P=0.003). The proportion of RCT published was 59.1% (81/137). Among the published RCT, 65 (80.2%) studies were reported adequately, but 63 (77.8%) studies had avoidable design limitations. Conclusions: Targeted therapy and immunotherapy have become research hotspots in the treatment of GC. At present, there are inadequate multicenter RCT in Asia, and the publication rate of RCT is low. A considerable number of published RCT are reported inadequately and have avoidable design flaws.

[Analysis of characteristics and trends of randomized controlled trials of gastric cancer between 2000 and 2019]

Objectives: To analyze the current development status of gastric cancer (GC) randomized controlled trials (RCT) between 2000 and 2019, and to review the basic characteristics of published RCT. Methods: ClinicalTrials.gov was searched for phase 3 or 4 RCT conducted between January 2000 and December 2019 with the keyword "gastric cancer", and the development trend of different types of RCT during different time periods was described. Basic features of registered RCT such as intervention, study area, single-center or multicenter, sample size, and funding were presented. PubMed and Scopus databases were searched to judge the publication status of studies completed until June 2016. The adequacy of the report was estimated by the Consolidated Standards of Reporting Trials (CONSORT) checklist. Design flaws were evaluated by Cochrane tool and/or whether a systematic literature review was cited. The data was analyzed by χ² test or Fisher exact test. Results: There were 262 RCT including in the present study. The number of GC-RCT registered on ClinicalTrials.gov had been on the rise from 1 case in 2000 to 30 cases in 2015. The proportion of RCT associated with targeted therapy or immunotherapy increased from 0 during 2000-2004 to 37.1% (36/97) during 2015-2019. The RCT registered in Asia was 191 cases, while that in non-Asia region was 71 cases. The proportion of multi-center RCT from non-Asia was higher than that from Asia (70.4% (50/71) vs. 50.3% (96/191), χ²=8.527, P=0.003). The proportion of RCT published was 59.1% (81/137). Among the published RCT, 65 (80.2%) studies were reported adequately, but 63 (77.8%) studies had avoidable design limitations. Conclusions: Targeted therapy and immunotherapy have become research hotspots in the treatment of GC. At present, there are inadequate multicenter RCT in Asia, and the publication rate of RCT is low. A considerable number of published RCT are reported inadequately and have avoidable design flaws.

[Establishment of artificial neural network model for predicting lymph node metastasis in patients with stage Ⅱ-Ⅲ gastric cancer]

Objective: To establish a neural network model for predicting lymph node metastasis in patients with stage II-III gastric cancer. Methods: Case inclusion criteria: (1) gastric adenocarcinoma diagnosed by pathology as stage II-III (the 8th edition of AJCC staging); (2) no distant metastasis of liver, lung and abdominal cavity in preoperative chest film, abdominal ultrasound and upper abdominal CT; (3) undergoing R0 resection. Case exclusion criteria: (1) receiving preoperative neoadjuvant chemotherapy or radiotherapy; (2) incomplete clinical data; (3) gastric stump cancer.Clinicopathological data of 1231 patients with stage II-III gastric cancer who underwent radical surgery at the Fujian Medical University Union Hospital from January 2010 to August 2014 were retrospectively analyzed. A total of 1035 patients with lymph node metastasis were confirmed after operation, and 196 patients had no lymph node metastasis. According to the postoperative pathologic staging. 416 patients (33.8%) were stage Ⅱ and 815 patients (66.2%) were stage III. Patients were randomly divided into training group (861/1231, 69.9%) and validation group (370/1231, 30.1%) to establish an artificial neural network model (N+-ANN) for the prediction of lymph node metastasis. Firstly, the Logistic univariate analysis method was used to retrospectively analyze the case samples of the training group, screen the variables affecting lymph node metastasis, determine the variable items of the input point of the artificial neural network, and then the multi-layer perceptron (MLP) to train N+-ANN. The input layer of N+-ANN was composed of the variables screened by Logistic univariate analysis. Artificial intelligence analyzed the status of lymph node metastasis according to the input data and compared it with the real value. The accuracy of the model was evaluated by drawing the receiver operating characteristic (ROC) curve and obtaining the area under the curve (AUC). The ability of N+-ANN was evaluated by sensitivity, specificity, positive predictive values, negative predictive values, and AUC values. Results: There were no significant differences in baseline data between the training group and validation group (all P>0.05). Univariate analysis of the training group showed that preoperative platelet to lymphocyte ratio (PLR), preoperative systemic immune inflammation index (SII), tumor size, clinical N (cN) stage were closely related to postoperative lymph node metastasis. The N+-ANN was constructed based on the above variables as the input layer variables. In the training group, the accuracy of N+-ANN for predicting postoperative lymph node metastasis was 88.4% (761/861), the sensitivity was 98.9% (717/725), the specificity was 32.4% (44/136), the positive predictive value was 88.6% (717/809), the negative predictive value was 84.6% (44/52), and the AUC value was 0.748 (95%CI: 0.717-0.776). In the validation group, N+-ANN had a prediction accuracy of 88.4% (327/370) with a sensitivity of 99.7% (309/310), specificity of 30.0% (18/60), positive predictive value of 88.0% (309/351), negative predictive value of 94.7% (18/19), and an AUC of 0.717 (95%CI:0.668-0.763). According to the individualized lymph node metastasis probability output by N+-ANN, the cut-off values of 0-50%, >50%-75%, >75%-90% and >90%-100% were applied and patients were divided into N0 group, N1 group, N2 group and N3 group. The overall prediction accuracy of N+-ANN for pN staging in the training group and the validation group was 53.7% and 54.1% respectively, while the overall prediction accuracy of cN staging for pN staging in the training group and the validation group was 30.1% and 33.2% respectively, indicating that N+-ANN had a better prediction than cN stage. Conclusions: The N+-ANN constructed in this study can accurately predict postoperative lymph node metastasis in patients with stage Ⅱ-Ⅲ gastric cancer. The N+-ANN based on individualized lymph node metastasis probability has better accurate prediction for pN staging as compared to cN staging.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand

BACKGROUND

Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature.

METHODS

A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance.

RESULTS

There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature.

CONCLUSION

Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Analysis of long non-coding RNA expression profiles in disuse osteoporosis using microarray and bioinformatics

Disuse osteoporosis (DOP) is one of the major consequences of long space flights. DOP also occurs in patients with spinal cord injuries and prolonged bedridden states that can have a severe impact on human health. Bone marrow mesenchymal stem cells (BMSCs) are multipotent stromal cells that play an important role in bone homeostasis. Long non-coding RNAs (lncRNAs) are involved in regulating osteogenic differentiation of BMSCs, and their abnormal expression might lead to the formation of orthopedic diseases. However, the specific mechanism of DOP has not yet been elucidated. All sequencing data were obtained from Gene Expression Omnibus (GEO) datasets. The limma package of R was applied to identify DEmRNAs and DElncRNAs. Pearson correlation coefficients (PCC) between DElncRNADEmRNA expression levels were calculated. Functional annotation was performed for DEmRNAs coexpressed with DElncRNAs. In addition, the Cytohubba plug-in in Cytoscape was applied to determine the top 10 hub genes. Finally, connectivity map (CMap) analysis was used to identify potential therapeutic drugs for DOP. The gene expression data, GSE100930 and GSE17696, were retrieved from the GEO database. A total of 2,212 differentially expressed mRNAs (DEmRNAs) and 22 differentially expressed lncRNAs (DElncRNAs) were obtained. Gene ontology (GO) functional terms, Kyoto Encyclopedia of Genes, and Genomes (KEGG) pathway enrichment analysis reveal 30 significant GO terms and 13 significant pathways. A coding-non-coding gene co-expression (CNC) network was constructed to study the potential role of hub-DElncRNAs and their co-expressed DEmRNAs in DOP. The lncRNAs, GSNAS1, SNHG12, and EPB41LA4A-AS1, were significant in the CNC network and potential regulators of DOP development. Three bioactive compounds (scoulerine, kinetin riboside, dexanabinol) with potential therapeutic significance for DOP were obtained through the Connectivity Map (CMAP) analysis. Our study revealed a new mechanism for a lineage shift of bone marrow mesenchymal stem cells under microgravity, and linked the function of protein-coding mRNAs with ncRNAs, which may contribute to the development of new therapies for DOP.

Difficult diagnosis and management of a complicated Nellix graft infection

An 81-year-old man, with a complex vascular surgical history, presents with sepsis from an infected Nellix stent-graft. He required an urgent laparotomy, explantation of the graft, and extra-anatomical repair. Although now widely used for this indication, the preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography was nondiagnostic for his stent-graft infection. We describe our management of a complicated Nellix graft infection and discuss the utility of positron emission tomography/computed tomography for stent-graft infections.

Delayed presentation of an iatrogenic, traumatic brachio-brachial fistula

Iatrogenic arteriovenous fistulae are rare occurrences after venepuncture, line placement or trauma. Presentations and symptoms can vary but they are usually identified soon after the causative injury due to the development of a visible, palpable, and pulsatile lump that can be concerning for patients. We describe the presentation and management of an unusual case of delayed presentation of an iatrogenic, traumatic brachio-brachial fistula.

[Analysis of single-nucleotide polymorphism of Sonic hedgehog signaling pathway in non-syndromic cleft lip and/or palate in the Chinese population]

OBJECTIVE

To study the relationship between Sonic hedgehog (Shh) associated single-nucleotide polymorphism (SNP) and non-syndromic cleft lip and/or palate (NSCL/P), and to explore the risk factors of cleft lip and/or palate. Many studies suggest that the pathogenesis of NSCL/P could be related to genes that control early development, in which the Shh signaling pathway plays an important role.

METHODS

Peripheral blood was collected from 197 individuals (100 patients with NSCL/P and 97 healthy controls). Haploview software was used for haplotype analysis and Tag SNP were selected, based on the population data of Han Chinese in Beijing of the international human genome haplotype mapping project. A total of 27 SNP were selected for the 4 candidate genes of SHH, PTCH1, SMO and GLI2 in the Shh signaling pathway. The genotypes of 27 SNP were detected and analyzed by Sequenom mass spectrometry. The data were analyzed by chi-squared test and an unconditional Logistic regression model.

RESULTS

The selected SNP basically covered the potential functional SNP of the target genes, and its minimum allele frequency (MAF) was >0.05: GLI2 73.5%, PTCH1 91.0%, SMO 100.0%, and SHH 75.0%. It was found that the genotype frequency of SNP (rs12674259) located in SMO gene and SNP (rs2066836) located in PTCH1 gene were significantly different between the NSCL/P group and the control group. Linkage disequilibrium was also found on 3 chromosomes (chromosomes 2, 7 and 9) where the 4 candidate genes were located. However, in the analysis of linkage imbalance haplotype, there was no significant difference between the disease group and the control group.

CONCLUSION

In China, NSCL/P is the most common congenital disease in orofacial region. However, as it is a multigenic disease and could be affected by multiple factors, such as the external environment, the etiology of NSCL/P has not been clearly defined. This study indicates that Shh signaling pathway is involved in the occurrence of NSCL/P, and some special SNP of key genes in this pathway are related to cleft lip and/or palate, which provides a new direction for the etiology research of NSCL/P and may provide help for the early screening and risk prediction of NSCL/P.

Development and validation of a staging system for gastric adenocarcinoma after neoadjuvant chemotherapy and gastrectomy with D2 lymphadenectomy

BACKGROUND

Neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy is commonly used for patients with locally advanced gastric adenocarcinoma. The eighth AJCC ypTNM staging system was validated based on patients undergoing more limited lymphadenectomy (less than D2). The aim of this study was to develop a system for accurate staging of patients with locally advanced gastric adenocarcinoma who receive neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy.

METHODS

A modified system of ypTNM was developed, based on overall survival (OS) of patients receiving neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy at Memorial Sloan Kettering Cancer Center, and validated using data from an international cohort of patients who had similar treatment.

RESULTS

Of 325 patients in the derivation cohort, 33 (10·2 per cent) had ypT0 N0/+ tumours, which are not classifiable under the AJCC system. The 5-year OS rate for modified ypTNM stages I, II, IIIA and IIIB was 89, 71, 42·3 and 10 per cent respectively, compared with 82, 65·2 and 24·1 for AJCC stages I, II and III respectively. The concordance index (0·730 versus 0·709), estimated area under the curve (0·765 versus 0·740) and time-dependent receiver operating characteristic (ROC) curve throughout the observation period were all superior for modified ypTNM staging. For the validation cohort of 186 patients, the modified system was again better at separating patients into prognostic groups for OS.

CONCLUSION

The modified ypTNM staging system improves the accuracy of OS prediction for patients treated with neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy.

[From coding sequence to non-protein coding region: advances in cleft lip and palate genetic mechanism researches]

With the continuous development of bioinformatics technology and precision medicine, genetic mechanism investigations of genetic diseases including cleft lip and palate (CLP) have been getting more and more attention. Researchers have focused on the coding sequence of the genome and successfully found many CLP causative mutations, but there still remain some unsolved questions. In recent years, researchers' vision has gradually shifted to non-protein coding region of the genome. This article reviews several coding sequence mutations, non-protein coding variants and their genetic mechanisms discovered in CLP researches.

[Electrocardiogram characteristics of patients with ventricular arrhythmia originating from the distal great cardiac vein]

Objective: To explore the electrocardiographic characteristics of patients with idiopathic ventricular arrhythmias (VAs) originating from different portions of distal great cardiac veins (DGCV). Methods: The study included 49 patients underwent successful RFCA of premature ventricular complex(PVCs)/ventricular tachycardia(VT) from different portions of the DGCV in our department from July 2009 to March 2016. The surface 12-lead electrocardiogram (ECG) and intraventricular ablation mapping features were analyzed. Patients were divided into four groups according to the mapping and ablation results: DGCV1(10 patients), DGCV2 (13 patients), proximalanterior interventricular vein (PAIV, 17 patients)and extend distal great cardiac vein (EDGCV, 9 patients). We analyzed the similarities and differences between surface 12-lead ECG of patients with PVCs/VT from different portions of DGCV, and compared with random chosen 290 patients with PVCs/VT from ventricular outflow tract and adjacent structure. Results: A positive R wave in inferior leads, a negative QS morphology in lead aVL and aVR were found among all groups. The different characteristics of surface 12-lead ECG of VAs originating from DGCV were as follows: (1)EDGCV patients demonstrated a positive R or r wave on lead Ⅰ(6/9) while a negative rS or qr wave was evidenced in other three groups (39/40). (2)A positive R pattern on lead V(1), V(5)-V(6) (11/13) was presented in patients of DGCV2 group; R (without S or s) wave on V(1) (9/10), RS or Rs wave on V(5)-V(6) were found in DGCV1 group; RS or rS wave was seen on lead V(1), R(without S)wave in lead V(5)-V(6) (25/26) were found in EDGCV and PAIV group and the amplification of R wave in EDGCV was higher than V(1) of PAIV group.(3)Precordial lead transition zone was in front of V(1) for DGCV1 and DGCV2 groups (23/23), within V(1)-V(3) for EDGCV group, but on V(2) or within V(2)-V(3) for PAIV group.(4)Patients of DGCV1 and DGCV2 demonstrated a longer Pseudo delta wave time(PdW), intrinsicoid deflection time (IDT), significantly larger maximum deflection index (MDI) than those in PAIV and EDGCV groups (P<0.001). (5)The different characteristics of surface 12-lead ECG between VAs originating from DGCV and those from ventricular outflow tract and adjacent structure were as follows: ① The ECG features were similar between PVIA and LCC group, both demonstrated a rs wave on the lead Ⅰ, rS wave on V(1)-V(2) and R wave on V(5)-V(6); ②The ECG features were similar betweenEDGCV and RCC group, both presented with R or r wave on the lead Ⅰ, the QRS wave of precordial leads was similar as PAIV and LCC groups; ③A R wave on the lead V(1), V(5)-V(6) was found in group DGCV2, and ILCC; ④Similar to the group Endo-MAA, patients in DGCV1 group also demonstrated a R wave on the lead V(1) and a Rs wave on V(5)-V(6). Conclusion: A positive R wave in inferior leads, a negative QS morphology in lead aVL and aVR are seen in all patients, but different electrocardiographic characteristics of PVC/VT originating from the different portions of the DGCV are presented on lead Ⅰ and V(1)-V(6).

[Surgical outcomes after laparoscopy-assisted distal gastrectomy and open distal gastrectomy for patients with advanced gastric cancer: a case-control study using a propensity score method]

Objective: To investigate the surgical outcomes after the laparoscopy-assisted distal gastrectomy (LADG) for patients with advanced gastric cancer. Methods: The data of 213 patients who underwent LADG and 213 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method from a prospectively constructed database of 641 patients who underwent radical distal gastrectomy between January 2005 and June 2012 in Department of Gastric Surgery, Fujian Medical University Union Hospital. The baseline characteristics and surgical outcomes were compared using a paired t-test or the Wilcoxon signed ranks test for continuous variables. The cumulative survival rates were compared using the Kaplan-Meier method and log-rank test. Results: Among all patients, there were significant differences in tumor location, digestive tract reconstruction, histologic type, pT stage, and pTNM stage between LADG and ODG group (P<0.05). After propensity score matching, patient distributions were closely balanced. There was no significant difference in clinicopathologic characteristics between the two groups (P>0.05). Regarding perioperative characteristics, the time to first flatus, and time to resumption of diet, did not differ between the two groups (P>0.05), while there were significant differences in the operation time (t=-11.28, P=0.000), blood loss (t=-5.674, P=0.000), number of dissected lymph nodes (t=4.727, P=0.000), and post-operative hospital stay (t=-2.193, P=0.038). LADG group has less morbidity than ODG group (χ²=4.777, P=0.029). Multivariate analysis revealed that the laparoscopic surgery (RR=0.392, P=0.009) was the protected factor for determining postoperative complications. There was no significant difference in the cumulative survival rate at total and each UICC stage between the two groups, either (P>0.05). Conclusion: LADG is an oncological safe minimally invasive procedure for advanced gastric cancer yields comparable oncological outcomes with ODG.

Coadministration of VDR and RXR agonists synergistically alleviates atherosclerosis through inhibition of oxidative stress: An in vivo and in vitro study

BACKGROUND AND AIMS

Diabetes contributes to atherosclerosis partially through induction of oxidative stress. Both vitamin D receptor (VDR) and retinoid X receptor (RXR) agonists exhibit anti-atherogenic effects.

METHODS

We explored the effects of combination treatment with VDR and RXR agonists (represented by calcitriol and bexarotene, respectively) on atherosclerosis progression and the mechanisms involved, using a diabetes model of mice. The animals were intragastrically fed calcitriol (200 ng/kg, twice-a-week), bexarotene (10 mg/kg, once-daily) either alone or in combination for 12 weeks.

RESULTS

VDR and RXR agonists delayed atherosclerosis progression independent of serum lipid and glucose levels, and significantly reduced the protein expression of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunit gp91phox and nuclear factor-kappa B (NF-κB) subunit p65, as well as plasma biomarkers of oxidative stress and inflammation. Combination therapy alleviated atherosclerosis and inhibited indexes of oxidative stress and inflammation to a greater extent than either monotherapy. In the in vitro study, naturally occurring VDR ligand 1α,25-dihydroxyvitamin D3 (1,25[OH]2D3) and RXR ligand 9-cis retinoic acid (9-cis-RA), both significantly inhibited high-glucose-induced endothelial cell apoptosis. Co-administration of VDR and RXR ligands produced synergistic protection against endothelial apoptosis by antagonizing the protein kinase C /NADPH oxidase/reactive oxygen species pathway. The inhibitory effects of 9-cis-RA on oxidative stress was attenuated when VDR was downregulated by VDR siRNA; however, downregulation of RXR by RXR siRNA imposed no influence on the effects of 1,25(OH)2D3.

CONCLUSIONS

Combination treatment with VDR and RXR agonists synergistically alleviated diabetic atherosclerosis through inhibition of oxidative stress, and the preventive effects of RXR agonist may partially depend on VDR activation.

Incidence of hospitalization and its associated factors in first-episode psychosis in Hong Kong

AIM

This study examined the incidence of hospitalization and its associated factors in patients with first-episode psychosis in Hong Kong.

METHOD

From 2009 to 2011, 360 patients were recruited consecutively as part of a controlled study of an early psychosis intervention service (the Jockey Club Early Psychosis project) in Hong Kong. Demographic and clinical information were obtained from face-to-face interviews and was reconfirmed using medical records. Factors relating to hospitalization during first episode were explored.

RESULTS

The incidence of hospitalization during first-episode psychosis was 57.2%. Patients who were hospitalized had higher antipsychotics chlorpromazine equivalent dosage, higher positive and negative syndrome scale total score, higher Udvalg for Kliniske Undersøgelser others mean score and were more likely to have an acute mode of onset compared with those who were not hospitalized.

CONCLUSIONS

Hospitalization was common in first-episode psychosis. Future studies are needed to explore possible programmes to prevent hospitalization in patients with first-episode psychosis.

[NELL-1: a novel highly efficient and specific growth factor]

Regeneration of bone tissue, as well as other tissues, requires involvement and interaction of cells, scaffolds and relevant growth factors, among which growth factors play a crucial role in maintaining the stability of microenvironment. Nel-like-type 1 molecule (NELL-1), a novel growth factor in tissue engineering, has been studied intensively in recent years. Researches mainly covered gene and protein structure and their expression profiling, biological function, molecular mechanisms and disease relevance. NELL-1 expressed in embryonic tissue is essential for growth and development of bone tissue. NELL-1 presents excellent abilities of inducing bone and cartilage regeneration,especially with high specificity to chondrocyte lineage. Compared with classic osteogenic growth factor bone morphogenetic protein 2 (BMP-2), the process of osteogenesis interacted with NELL-1 exhibits stronger specificity, higher bone density and fewerside effects. Furthermore, a recent study shows synergistic effects of NELL-1 and BMP-2. NELL-1 enhances the osteogenic reaction induced by BMP-2 of cells and notably declines inflammation response caused by BMP-2. This review evaluates the current research progress of the function and application of NELL-1 by the systematic method of evidence-based medicine.

Effects of lead contamination on the clonal propagative ability of Phragmites australis (common reed) grown in wet and dry environments

Clonal propagation is important for the survival and maintenance of the common reed Phragmites australis. Pot culture experiments were conducted to investigate the effects of lead (Pb) concentration (0, 500, 1500, 3000, 4500 mg·kg(-1) ) and water stress on the clonal reproductive ability of this species. The Pb concentration found in plant organs, in decreasing order, was roots >shoots >rhizomes. There was a negative relationship between the growth of clonal propagative modules (excluding axillary shoot buds) and Pb concentrations, which caused a decrease in biomass, rhizome growth and number of axillary and apical rhizome buds. Daughter axillary shoots exhibited a tolerance strategy, with no significant change in their number; the axillary and apical rhizome buds, daughter apical rhizome shoots and rhizomes exhibited compensatory growth during the late stage of Pb (excluding 4500 mg·kg(-1) ) treatment in a wet environment. Pb applications above 500 mg·kg(-1) reduced these parameters significantly in the drought treatment, except for the number of axillary shoot buds, which did not change. Our results indicate that clonal propagative resistance to Pb contamination can occur via tolerance strategies, compensatory growth and a Pb allocation strategy, enabling these reeds to maintain population stability in wet environments. However, clonal modular growth and reproductive ability were inhibited significantly by the interaction between drought and Pb, which would cause a decline in P. australis populations in a dry environment. Lead concentrations of 4500 and 500 mg·kg(-1) in soils might meet or exceed the Pb tolerance threshold of clonally propagated reeds in wet and dry environments, respectively.

Prodromal psychosis: a case series of ten symptomatic patients

This case series provides an account of 10 patients with prodromal psychosis in Hong Kong over the course of 12 months between 2012 and 2014. Patterns of symptoms and functioning levels were noted each month and overall presentation was classified into 4 categories. Four patients' conditions were classified as fluctuating, 3 patients as improved, 2 patients as no change, and 1 patient as transition into psychosis. The noted observations were compared to the current conceptualisation of prodromal psychosis according to the clinical staging model of McGorry and colleagues. This case series provides insights into the condition in an Asian population and provides background data to inform future clinical research and mental health services.

Protection from vascular endothelial dysfunction in acute glycemic load-induced primary hypertension by vitamin C and E

This study aimed to investigate the influence of acute glycemic load on vascular endothelial function in patients with hypertension and to evaluate the protective effect of vitamins C and E during the acute glycemic phase. We randomly selected 39 hypertensive patients and 21 normal subjects and divided them into 3 groups: 75 g oral glucose (glycemic load group), 75 g glucose+0.9 g vitamin C (VC group), 75 g glucose+2 g vitamin C+0.8 g vitamin E (VC+VE group). Extravascular color Doppler ultrasound was used to detect brachial artery flow-mediated vasodilation at 0, 1, 2, and 3 h, and, at the same time, serum anti-oxidant products were measured. Basic endothelial functions in patients with hypertension were decreased in the glycemic load group (9.48±3.33 versus 13.09±6.78%, P<0.05), and was even more depressed in the hypertensive group (9.48±3.33 versus 14.20±6.48%, P<0.05). Antioxidant vitamins played a dose-dependent protective role on acute damage of endothelial function due to glycemic load. Acute high blood sugar damaged vascular endothelial functions, especially in hypertensive patients, but this effect can be reversed by large doses of vitamin C and E.

A comparison of two rehabilitation protocols after simultaneous bilateral total knee arthroplasty: a controlled, randomized study

Post-operative outcomes after simultaneous bilateral total knee arthroplasty in 115 patients randomly assigned to two rehabilitation protocols were compared. The traditional-protocol group performed a series of exercises on one leg and then repeated the same sequence on the other leg. The alternate-protocol group performed the same exercises, but alternated between legs with each individual repetition. Symptoms and function were assessed pre-operatively and at 1, 3, 6 and 12 months post-operatively. The alternate-protocol group had lower visual analogue pain scale scores in the early post-operative period, as well as higher Knee Society Scores and SF-12 physical and mental health summary scores after 1 and 3 months compared with the traditional-protocol group, but there were no differences between the two groups from 6 months post-operatively. There were no significant differences between the groups in terms of range of knee motion or incidence of deep vein thrombosis. The alternate-protocol for rehabilitation resulted in an early return to function and decreased pain levels following simultaneous bilateral total knee arthroplasty and was associated with the potential to produce more positive emotional states and earlier functional independence.

Adsorption of basic dye from aqueous solution onto fly ash

The fly ash treated by H2SO4 was used as a low-cost adsorbent for the removal of a typical dye, methylene blue, from aqueous solution. An increase in the specific surface area and dye-adsorption capacity was observed after the acid treatment. The adsorption isotherm and kinetics of the treated fly ash were studied. The experimental results were fitted using Langmuir and Freundlich isotherms. It shows that the Freundlich isotherm is better in describing the adsorption process. Two kinetic models, pseudo-first order and pseudo-second order, were employed to analyze the kinetic data. It was found that the pseudo-second-order model is the better choice to describe the adsorption behavior. The thermodynamic study reveals that the enthalpy (delta H0) value is positive (5.63 kJ/mol), suggesting an endothermic nature of the adsorption.

[Occurrence of Pagumogonimus veocularis in Fujian Province]

OBJECTIVE

To prove that Fujian Province is also a natural focus of Pagumogonimus veocularis(Pv).

METHODS

The adult worms were obtained from a cat fed with Pv metacercariae.

RESULTS

Pv were found in Jianou, Fujian Province. All 1,873 Semisulcospira libertina showed negative. The positive rate of Tricula fujianensis and Erhaia jianouenesis were 0.10% (1/695) and 0.25% (5/2,038), respectively. The main crab host was S. fujianensis. Ps alone and mixed infection with Pv were found in the Sinopotamon, the infection rates were 36.8% (43/117) and 20.5% (24/117), respectively. The numbers of the metacercariae were 806 and 40, respectively. A cat was infected with 12 metacercriae of Pv, eggs were found in the stool 56 days after infection, and 6 worms were found in the lungs 68 days after infection.

CONCLUSION

Fujian is one of the natural focus of Pv, cat is the adequate host. The fluke was identified as Pv according to the characteristics of the metacercariae.

White matter lesions and alteration of vascular cell composition in the brain of spontaneously hypertensive rats

There have been few studies on the white matter lesions of spontaneously hypertensive rats (SHR). From the point of view of hypertension and arteriosclerosis, white matter lesions were examined in SHR and stroke-prone SHR (SHRSP), and were then compared with Wistar-Kyoto (WKY) rats. The vasculopathy was analyzed by morphometric immunohistochemistry for collagen and smooth muscle actin. Both SHR and SHRSP had hypertension at > or = 12 weeks of age, and the latter developed severe white matter lesions at 20 weeks. Immuno- histochemistry revealed proliferation of microglia in the white matter and an increase in smooth muscle actin in the vessels of SHRSP compared with the WKY rats and SHR, but there were no changes in the collagen. These results indicate a role of hypertension in the pathogenesis of white matter lesions. However, genetic difference may also be responsible since SHR and SHRSP showed similar hypertension.

Vascular cell components of the medullary arteries in Binswanger's disease brains: a morphometric and immunoelectron microscopic study

BACKGROUND AND PURPOSE

It has been hypothesized that fibrohyalinosis of the medullary arteries may cause white matter lesions in Binswanger's disease (BD). However, previous reports have been inconsistent on the pathological alterations of the cellular components, which may vary in terms of vessel sizes. We therefore quantitatively examined vasculopathy in the medullary arteries of a defined caliber in BD brains with a quantitative technique.

METHODS

A total of 20 brains were examined: 10 from patients with BD and 10 from age-matched nonneurological control patients. The alterations in the vascular cell components were examined with quantitative immunohistochemistry and immunoelectron microscopy for collagen and smooth muscle actin.

RESULTS

The nonneurological control patients showed no white matter lesions. In contrast, the patients with BD invariably had marked white matter lesions, as well as fibrohyalinosis of the medullary arteries. The ratio of the area immunolabeled for collagen type I and type IV to the cross-sectional area was 2-fold higher in the BD patients than in the control patients, regardless of the vessel caliber (P<0.005). Although the ratio for smooth muscle actin in the BD brains was increased in arteries of <100 microm (P<0.0001), there was no corresponding increase in the arteries of >100 microm. However, in the ultrastructure of these vessels, the cell bodies immunolabeled for smooth muscle actin were hypertrophic and segregated from each other by proliferated fibrils. The basal lamina appeared multilayered, and the endothelial cells were swollen. Collagen type I and type IV immunoreactive fibrils also proliferated in the pericapillary space of the BD brains.

CONCLUSIONS

The proliferation of collagen fibrils in the media and adventitia of the blood vessels in BD brains was not specific to small arteries and arterioles but also occurred in the pericapillary spaces. Pericapillary sclerosis, smooth muscle cell proliferation in the terminal arterioles, and their morphological transformation in the proximal arteries may alter the shear rates and thus cause profound microcirculatory disturbances in BD brains.

The role of Stat5a and Stat5b in signaling by IL-2 family cytokines

The activation of Stat5 proteins (Stat5a and Stat5b) is one of the earliest signaling events mediated by IL-2 family cytokines, allowing the rapid delivery of signals from the membrane to the nucleus. Among STAT family proteins, Stat5a and Stat5b are the two most closely related STAT proteins. Together with other transcription factors and co-factors, they regulate the expression of the target genes in a cytokine-specific fashion. In addition to their activation by cytokines, activities of Stat5a and Stat5b, as well as other STAT proteins, are negatively controlled by CIS/SOCS/SSI family proteins. The outcome of Stat5 activation in regulating expression of target genes varies, depending upon the complexity of the promoter region of target genes and the other signaling pathways that are activated by each cytokine as well. Here, we mainly focus on the IL2-/IL-2 receptor system, as it is one of the best-studied systems that depend on Stat5-mediated signals. We will summarize what we have learned about the molecular mechanisms of how Stat5 is activated by IL-2 family cytokines from in vitro biochemical studies as well as the role that is played by Stat5 in each of the cytokine signaling pathways from in vivo gene-targeting analyses. Oncogene (2000).

Cytokine receptor signaling pathways

Cytokines represent a diverse group of molecules that transmit intercellular signals. These signals may either be autocrine (where the same cell both produces the cytokine and responds to it) or paracrine (where the cytokine is made by one cell and acts on another). Both these situations can occur simultaneously. Cytokines use multiple signaling pathways. This review will focus on signaling by type I cytokines and in particular on signaling by the IL-2 family of cytokines, as an illustrative example. The major signaling pathway that will be discussed is the Jak-STAT pathway, although other pathways will also be reviewed. The Jak-STAT pathway is a very rapid cytosol-to-nuclear signaling pathway that underscores how quickly extracellular signals can be transmitted to the nucleus. Aspects related to cytokine redundancy, pleiotropy, and specificity will be discussed.

Cyclooxygenase-2 is induced in microglia during chronic cerebral ischemia in humans

Cyclooxygenase-2 (COX-2) is known to be up-regulated in ischemic rodent brains, but only little information is available for the human brain. Using immunohistochemistry for COX-2, we investigated brains from control subjects and from patients with cerebrovascular diseases. COX-2 was markedly up-regulated in the neurons and endothelial cells in acute cerebral infarction, but was detected sparsely at chronic stages in these cellular compartments. In contrast, COX-2 immunoreactivity in glial cells was localized to the perinuclear region even in control brains. This immunolabeling was more intense and occurred also in the glial cytoplasm in the brains with chronic cerebral ischemia such as Binswanger's disease. Double-labeling immunohistochemistry confirmed that COX-2-immunoreactive glia were mostly microglia. These results indicate that prostanoid synthesis is up-regulated in microglia during chronic cerebral ischemia, and that these cells may be involved in tissue repair or inflammation-mediated cell responses.

A molecular perspective on the genera Paragonimus Braun, Euparagonimus Chen and Pagumogonimus Chen

The status of the genera Euparagonimus Chen, 1963 and Pagumogonimus Chen, 1963 relative to Paragonimus Braun, 1899 was investigated using DNA sequences from the mitochondrial cytochrome c oxidase subunit I (CO1) gene (partial) and the nuclear ribosomal DNA second internal transcribed spacer (ITS2). In the phylogenetic trees constructed, the genus Pagumogonimus is clearly not monophyletic and therefore not a natural taxon. Indeed, the type species of Pagumogonimus, P. skrjabini from China, is very closely related to Paragonimus miyazakii from Japan. The status of Euparagonimus is less obvious. Euparagonimus cenocopiosus lies distant from other lungflukes included in the analysis. It can be placed as sister to Paragonimus in some analyses and falls within the genus in others. A recently published morphological study placed E. cenocopiosus within the genus Paragonimus and probably this is where it should remain.

Vascular changes in white matter lesions of Alzheimer's disease

The pathogenesis of white matter lesions observed in Alzheimer's disease (AD) is not completely clear. We tested the hypothesis that white matter lesions are correlated with medullary artery sclerosis rather than with amyloid angiopathy. A total of 57 brains were examined, including 39 derived from patients with AD and 13 from patients with Binswanger's disease (BD) along with 5 from non-neurological patients. Moderate or severe amyloid deposits in the meningocortical segment were observed in 32 out of 39 AD patients (82.1%), and in 2 out of 13 BD patients (15.4%). These deposits were not observed in the white matter segment, except for 2 patients with AD. The BD patients invariably had marked white matter lesions and fibrohyalinosis in the medullary arteries, with a mean sclerotic ratio of 48.1%. In contrast, the AD patients had mild or moderate white matter lesions and a sclerotic ratio of 37.9%, which was significantly greater than the controls. The scores for white matter lesions were correlated with the sclerotic ratio of the medullary arteries, but not with the ages of onset or the scores for amyloid angiopathy. Although amyloid angiopathy is an independent risk of white matter lesions, its role is limited in the pathogenesis of those associated with AD. Wall thickening of the medullary arteries, likely due to fibrohyalinosis, is closely correlated with the white matter lesions in AD, thus indicating a heterogeneity in its etiology.

A cyclooxygenase-2 inhibitor attenuates white matter damage in chronic cerebral ischemia

The effects of nimesulide, a cyclooxygenase-2 inhibitor, were examined during chronic cerebral hypoperfusion. After bilateral ligation of the common carotid arteries in 30 rats, 21 received dosages of 2 or 5 mg/kg nimesulide daily and nine received vehicle daily for 14 days. The serum was then analyzed biochemically, and pathological changes were estimated in the white matter by the emergence of major histocompatibility complex (MHC) antigen-immunoreactive activated microglia and white matter lesions. In the vehicle-treated animals, activated microglia and white matter lesions were observed. Following treatment with either 2 or 5mg/kg nimesulide, the magnitude of these changes was reduced (p < 0.001) without significant side effects. These results indicate a potential use for cyclooxygenase-2 inhibitors in cerebrovascular disease.

Signaling from the IL-2 receptor to the nucleus

Interleukin-2 has pleiotropic actions on the immune system and plays a vital role in the modulation of immune responses. Our current understanding of IL-2 signaling has resulted from in vitro studies that have identified the signaling pathways activated by IL-2, including the Jak-STAT pathways, and from in vivo studies that have analyzed mice in which IL-2, each chain of the receptor, as well a number of signaling molecules have been individually targeted by homologous recombination. Moreover, mutations in IL-2Ralpha, gamma(c) and Jak3 have been found in patients with severe combined immunodeficiency. In addition, with the discovery that two components of the receptor, IL-2Rbeta and gamma(c), are shared by other cytokine receptors, we have an enhanced appreciation of the contributions of these molecules towards cytokine specificity, pleiotropy and redundancy.

The immediate-early gene product Egr-1 regulates the human interleukin-2 receptor beta-chain promoter through noncanonical Egr and Sp1 binding sites

The interleukin-2 IL-2 receptor beta-chain (IL-2Rbeta) is an essential component of the receptors for IL-2 and IL-15. Although IL-2Rbeta is constitutively expressed by lymphocytes, its expression can be further induced by a number of stimuli, including phorbol 12-myristate 13-acetate (PMA). We have now characterized factors that bind to an enhancer region located between nucleotides -170 and -139 of the human IL-2Rbeta promoter. Both Sp1 and Sp3 bound to the 5' portion of this region, whereas a PMA-inducible factor (PIF) mainly bound to its 3' portion and bound to the Sp binding motifs as well. In Jurkat T cells, induction of PIF DNA binding activity was rapidly induced, required de novo protein synthesis, and was sustained at a high level for at least 23 h. Interestingly, PIF was constitutively activated in human T-cell leukemia virus type 1-transformed MT-2 cells. In this paper, we demonstrate that PIF is Egr-1 based on its recognition by anti-Egr-1 antisera in gel mobility shift assays, even though the IL-2Rbeta DNA binding motif differed substantially from the canonical Egr-1 binding site. In addition, Egr-1 bound to the Sp binding site. In Jurkat cells, both sites were required for maximal IL-2Rbeta promoter activity, and in HeLaS3 cells, transfection of Egr-1 could drive activity of a reporter construct containing both sites. Moreover, Sp1 and Egr-1 could form a complex with kinetics that correlated with the production of Egr-1 in Jurkat cells upon PMA stimulation. Thus, Sp1 and Egr-1 physically and functionally cooperate to mediate maximal IL-2Rbeta promoter activity.

Differential utilization of Janus kinase-signal transducer activator of transcription signaling pathways in the stimulation of human natural killer cells by IL-2, IL-12, and IFN-alpha

IL-2-, IL-12-, and IFN-alpha-mediated signaling pathways were analyzed in primary NK cells and in the NK3.3 cell line. Gel mobility shift and immunoprecipitation analyses revealed that in addition to activating STAT3 (signal transducer and activator of transcription-3) and STAT5, IL-2 induced tyrosine and serine phosphorylation of STAT1 alpha, which formed IFN-gamma-activated sequence-binding complexes by itself and with STAT3. Although IL-2 and IFN-alpha activated STAT1 alpha and STAT5, IL-2 predominantly activated STAT5, while IFN-alpha predominantly activated STAT1 alpha. IL-2 induced less STAT1 alpha activation and IFN-alpha induced greater STAT5 activation in NK3.3 cells compared with preactivated primary NK cells. In NK3.3 cells, IL-2 induced comparable formation of c-fos promoter sis-inducible element IFN-gamma-activated sequence-binding complexes containing STAT3 alone with complexes containing STAT3 and STAT1 alpha, while in preactivated primary NK cells, it preferentially induced complexes containing STAT3 and STAT1 alpha. Thus, signaling in NK3.3 cells is not always identical with that in primary NK cells. In contrast to IL-2 and IFN-alpha, IL-12 induced strong tyrosine phosphorylation of STAT4 and variable weak phosphorylation of STAT3. However, supershift analyses using the c-fos promoter sis-inducible element probe showed that IL-12 activated STAT4, STAT1 alpha, and STAT3, and induced complexes containing STAT4 only, STAT4 with STAT1 alpha, STAT3 with STAT1 alpha, or STAT1 alpha only in preactivated primary NK cells. STAT1 alpha activation by IL-12 correlated with increased phosphorylation of serine, but not tyrosine. Finally, IL-2 induced tyrosine phosphorylation of JAK1 and JAK3, while IL-12 induced phosphorylation of JAK2 and TYK2 in both preactivated primary NK and NK3.3 cells. Differential phosphorylation and consequent differential activation of both separate and overlapping STAT proteins by IL-2, IL-12, and IFN-alpha may provide a molecular basis for the similarities and differences in the actions of these cytokines on NK cells.

Differential utilization of Janus kinase-signal transducer activator of transcription signaling pathways in the stimulation of human natural killer cells by IL-2, IL-12, and IFN-alpha

IL-2-, IL-12-, and IFN-alpha-mediated signaling pathways were analyzed in primary NK cells and in the NK3.3 cell line. Gel mobility shift and immunoprecipitation analyses revealed that in addition to activating STAT3 (signal transducer and activator of transcription-3) and STAT5, IL-2 induced tyrosine and serine phosphorylation of STAT1 alpha, which formed IFN-gamma-activated sequence-binding complexes by itself and with STAT3. Although IL-2 and IFN-alpha activated STAT1 alpha and STAT5, IL-2 predominantly activated STAT5, while IFN-alpha predominantly activated STAT1 alpha. IL-2 induced less STAT1 alpha activation and IFN-alpha induced greater STAT5 activation in NK3.3 cells compared with preactivated primary NK cells. In NK3.3 cells, IL-2 induced comparable formation of c-fos promoter sis-inducible element IFN-gamma-activated sequence-binding complexes containing STAT3 alone with complexes containing STAT3 and STAT1 alpha, while in preactivated primary NK cells, it preferentially induced complexes containing STAT3 and STAT1 alpha. Thus, signaling in NK3.3 cells is not always identical with that in primary NK cells. In contrast to IL-2 and IFN-alpha, IL-12 induced strong tyrosine phosphorylation of STAT4 and variable weak phosphorylation of STAT3. However, supershift analyses using the c-fos promoter sis-inducible element probe showed that IL-12 activated STAT4, STAT1 alpha, and STAT3, and induced complexes containing STAT4 only, STAT4 with STAT1 alpha, STAT3 with STAT1 alpha, or STAT1 alpha only in preactivated primary NK cells. STAT1 alpha activation by IL-12 correlated with increased phosphorylation of serine, but not tyrosine. Finally, IL-2 induced tyrosine phosphorylation of JAK1 and JAK3, while IL-12 induced phosphorylation of JAK2 and TYK2 in both preactivated primary NK and NK3.3 cells. Differential phosphorylation and consequent differential activation of both separate and overlapping STAT proteins by IL-2, IL-12, and IFN-alpha may provide a molecular basis for the similarities and differences in the actions of these cytokines on NK cells.

Cloning of human Stat5B. Reconstitution of interleukin-2-induced Stat5A and Stat5B DNA binding activity in COS-7 cells

We have isolated a second human Stat5 cDNA, Stat5B, and demonstrated that the genes encoding both Stat5A and Stat5B are located at chromosome 17q11.2. Both genes were constitutively transcribed in peripheral blood lymphocytes. By using specific antisera, we demonstrated that both Stat5A and Stat5B are activated by interleukin-2 (IL-2) in peripheral blood lymphocytes, natural killer-like YT leukemia cells, and human T cell lymphotropic virus type I-transformed MT-2 T cells. In COS-7 cells, which constitutively express the Janus family tyrosine kinase Jak1, reconstitution of IL-2-induced Stat5A and Stat5B DNA binding activities was dependent on the coexpression of Jak3 along with the IL-2 receptor beta chain and the common cytokine receptor gamma-chain. This IL-2-induced Stat5 activation was dependent on the presence of either of two tyrosines (Tyr-392 or Tyr-510) in the IL-2 receptor beta chain, indicating that either of these two tyrosines can serve as a docking site. Moreover, we demonstrated that human Stat5 activation is also dependent on Tyr-694 in Stat5A and Tyr-699 in Stat5B, indicating that these tyrosines are required for dimerization. The COS-7 reconstitution system described herein provides a valuable assay for further elucidation of the IL-2-activated JAK-STAT pathway.

Constitutively activated Jak-STAT pathway in T cells transformed with HTLV-I

Human T cell lymphotropic virus I (HTLV-I) is the etiological agent for adult T cell leukemia and tropical spastic paraparesis (also termed HTLV-I-associated myelopathy). HTLV-I-infected peripheral blood T cells exhibit an initial phase of interleukin-2 (IL-2)-dependent growth; over time, by an unknown mechanism, the cells become IL-2-independent. Whereas the Jak kinases Jak1 and Jak3 and the signal transducer and activator of transcription proteins Stat3 and Stat5 are activated in normal T cells in response to IL-2, this signaling pathway was constitutively activated in HTLV-I-transformed cells. In HTLV-I-infected cord blood lymphocytes, the transition from IL-2-dependent to IL-2-independent growth correlated with the acquisition of a constitutively activated Jak-STAT pathway, which suggests that this pathway participates in HTLV-I-mediated T cell transformation.

The role of shared receptor motifs and common Stat proteins in the generation of cytokine pleiotropy and redundancy by IL-2, IL-4, IL-7, IL-13, and IL-15

To understand the molecular bases for cytokine redundancy and pleiotropy, we have compared the Stat proteins activated in peripheral blood lymphocytes (PBLs) by cytokines with shared and distinct actions. Interleukin-2 (IL-2) rapidly activated Stat5 in fresh PBL, and Stat3 and Stat5 in preactivated PBL. IL-7 and IL-15 induced the same complexes as IL-2, a feature explained by the existence of similar tyrosine-phosphorylated motifs in the cytoplasmic domains of IL-2R beta and IL-7R that can serve as docking sites for Stat proteins. IL-13 Induced the same complexes as IL-4, a finding explained by our studies implicating IL-4R as a shared component of the receptors. These studies demonstrate that a single cytokine can activate different combinations of Stat proteins under different physiological conditions, and also indicate two mechanisms by which distinct cytokines can activate the same Stat protein.

Regulation of cell-type-specific interleukin-2 receptor alpha-chain gene expression: potential role of physical interactions between Elf-1, HMG-I(Y), and NF-kappa B family proteins

The interleukin 2 receptor alpha-chain (IL-2R alpha) gene is rapidly and potently induced in T cells in response to mitogenic stimuli. Previously, an inducible enhancer between nucleotides -299 and -228 that contains NF-kappa B and CArG motifs was identified. We now report the characterization of a second essential positive regulatory element located between nucleotides -137 and -64 that binds Elf-1 and HMG-I(Y). This element had maximal activity in lymphoid cells, paralleling the cell type specificity of Elf-1 expression. Transcription from the IL-2R alpha promoter was inhibited when either the Elf-1 or the HMG-I(Y) binding site was mutated. Coexpression of both proteins activated transcription of the -137 to -64 element in COS-7 cells. Elf-1 physically associated with HMG-I and with NF-kappa B p50 and c-Rel in vitro, suggesting that protein-protein interactions might functionally coordinate the actions of the upstream and downstream positive regulatory elements. This is the first report of a physical interaction between an Ets family member and NF-kappa B family proteins. These findings provide significant new insights into the protein-protein and protein-DNA interactions that regulate cell-type-specific and inducible IL-2R alpha gene expression and also have implications for other genes regulated by Elf-1 and NF-kappa B family proteins.

[Electromyography of perioral muscles in the cleft lip and palate patients with crossbite]

In this study, twenty-nine cleft lip and palate patients with anterior crossbite were chosen as study group and twenty-eight normal children, twenty-seven patients with anterior crossbite as the control groups. All subjects were examined with EMG, and found some characters of the perioral muscles activity of the cleft patients. (1) The electromyographic amplitude of the upper lip and chin muscles was higher in cleft patients than that of other two groups during swallowing of saliva (2) Activity of chin muscle in cleft patients and crossbite patients in rest position were higher than that of normal occlusion (3) The Asymmetry index of the activity of upper lip muscle in every functional positions of the cleft patients are higher than ther groups. The abnormal activity of perioral muscles of the cleft patients demonstrate that functional repairment of cleft lip and needed lip bumper are necessary.