Robotic Radical Trachelectomy Using the Double Bipolar Method- Aiming for a Bloodless Operative Field

Study Objective

To report the application of the double bipolar technique in a patient with 1b1 cervical cancer who wished to preserve her fertility potential.

Design

After experiencing 105 cases of laparoscopic and robotic radical trachelectomy with a 5 year survival rate of 98% and the birth of 29 babies from 51 of these patients who attempted pregnancy, we introduced the double bipolar method to overcome technical difficulties of the procedure due to the necessity for precise dissection and reconstruction in the deep pelvis. We will show our operative techniques, such as nerve sparing radical trachelectomy and retroperitoneal lymphadenectomy for early invasive cervical cancer in a bloodless operative field.

Setting

Urban general hospital.

Patients or Participants

Robotic radical trachelectomy using the double bipolar method was performed in three patients with 1b1 cervical cancer.

Interventions

After Robotic radical trachelectomy using monopolar scissors in 30 cases of stage Ib1 cervical cancer, we considered techniques for a more bloodless operative field. The double bipolar method (DBM) was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. Using robotic Maryland forceps as a cutting device allows for pinpoint accuracy that cannot be found in other instruments. It is important for bladder and ureteral dissection and exposure of vessels. Cuts are made at a very limited point by a lightning strike mechanism, meaning there is minimal thermal spread to adjacent organs.

Measurements and Main Results

Blood loss was 250ml in the cases presented. In surgeries not using the DBM(n=34), the blood loss ranged from 350ml(100-1200ml). While there is no supporting data, the dissection of the ureter was very smooth.

Conclusion

A bloodless operative field allows for accurate dissection and can prevent intraoperative injuries. The double bipolar method is able to provide precision cutting and limit thermal spread to adjacent tissue, reducing injury and allowing for a clear operative field.

Role of Neuron-Glial Interaction Mediated by IL-1β in Ectopic Tooth Pain

Although many reports have demonstrated that ectopic pain develops in the orofacial region following tooth pulp inflammation, which often causes misdiagnosis and inappropriate treatment for patients with pulpitis, the precise mechanism remains unknown. In the present study, we hypothesized that the functional interaction between satellite glial cells and neurons mediated by interleukin 1β (IL-1β) in the trigeminal ganglion (TG) is involved in ectopic orofacial pain associated with tooth pulp inflammation. The digastric muscle electromyogram (D-EMG) activity elicited by capsaicin administration into the maxillary second molar tooth pulp was analyzed to evaluate the noxious reflex and was significantly increased in rats with inflammation of the maxillary first molar (M1) versus rats injected with saline. A significant increase in the expression of connexin43 (Cx43), a gap junction containing protein, was observed in activated satellite glial cells surrounding second molar-innervating neurons in the TG after M1 pulpitis. Daily administration of Gap26, a Cx43 mimetic peptide and inhibitor, in the TG significantly suppressed the enhancement of capsaicin-induced D-EMG activity and the percentage of Fluoro-Gold (FG)-labeled cells encircled by glial fibrillary acid protein-immunoreactive (IR) + Cx43-IR cells after M1 pulp inflammation ( P < 0.01). The percentage of FG-labeled cells encircled by glial fibrillary acid protein-IR + IL-1β-IR cells, IL-1 type I receptor-IR cells labeled with FG, and TRPV1-IR cells labeled with FG significantly increased after M1 pulp inflammation ( P < 0.01). Daily administration of IL-1ra, an IL-1 receptor antagonist, into the TG significantly reduced the enhancement of capsaicin-induced D-EMG activity and the percentage of TRPV1-IR neurons labeled with FG after M1 pulp inflammation ( P < 0.01). The present findings suggest that satellite glial cell is activated in the TG via activated gap junctions composed of Cx43 following tooth pulp inflammation, which leads to the hyperactivation of remote neurons via IL-1β mechanisms and results in ectopic tooth pulp pain in the adjacent tooth.

For the day when I can return: the future is one step away

Iitate, a village in Fukushima Prefecture, suffered little damage from the Great East Japan Earthquake that struck on 11 March 2011. However, all village residents were belatedly ordered to evacuate 1 month after the accident at Fukushima Daiichi nuclear power plant. My family and I had to evacuate to the city of Fukushima, located 40 km from our home in Iitate. This came at a time when my husband and I were planning to start research on Natsuhaze (a type of blueberry grown in Japan) after his retirement. There were conflicting reports. On one hand, the media reported that it was not possible to live in Fukushima. The village of Iitate organised a lecture by an expert to assuage the fear of the residents. The evacuation order 1 month after the disaster contradicted what the expert was saying, and appeared to amplify distrust among the residents. I tried to arrive at my own judgement by measuring the ambient radiation dose in and around my house. Participating in the International Commission on Radiological Protection dialogue seminars provided accurate understanding of the situation. Measurement of radiation doses of wild plants that my husband's father had been cultivating for over 30 years has given me many insights, and I had no concerns about returning to Iitate.

One-minute mental status examination for category fluency is more useful than mini-mental state examination to evaluate the reliability of insulin self-injection in elderly diabetic patients

AIMS/INTRODUCTION

We investigated the factors associated with the reliability of insulin self-injection in elderly diabetic patients receiving insulin therapy.

MATERIALS AND METHODS

We enrolled diabetic patients aged ≥65 years and receiving insulin therapy, and assessed their cognitive function by the mini-mental state examination and 1-min mental status examination for category fluency. We also observed their technique of insulin self-injection, and evaluated whether or not patients were able to inject insulin by themselves according to nine defined details in terms of insulin self-injection. The predictive factors for the reliability of insulin self-injection were determined by univariate and multivariate logistic regression analysis. There were 278 participants (135 males, 143 females) enrolled in the present study.

RESULTS

According to multivariate logistic regression analysis, only the 1-min mental status examination score was found to be a significant independent predictor of the reliability of insulin self-injection (odds ratio 0.75; 95% confidence interval 0.62-0.90; P = 0.002).

CONCLUSIONS

The 1-min mental status examination for category fluency can be considered more useful than mini-mental state examination to evaluate the reliability of insulin self-injection in elderly diabetic patients receiving insulin therapy.

[A questionnaire survey on current status of anti-diabetic therapy for diabetic patients with dementia]

AIM

It is important to establish treatment goals and optimal anti-diabetic therapy for diabetic patients with dementia. However, there are currently no established treatment guidelines. Recently, the West Tokyo Diabetes Association has established the Diabetes and Dementia Study Group to investigate the status of anti-diabetic therapy for diabetic patients with dementia. Here, we assessed the current status of such patients by a questionnaire survey.

METHODS

In November 2011, we conducted a mailed survey to the clinics and hospitals affiliated with Kita-Tama, Hachioji and Tachikawa Medical Associations in Tokyo, Japan. The survey evaluated the most suitable anti-diabetic therapy for elderly diabetic patients or diabetic patients with dementia, combined anti-diabetic therapy, insulin therapy for elderly diabetic patients and diabetic patients with dementia, combination therapy of insulin and oral anti-diabetic agents for diabetic patients with dementia, factors that make it difficult for diabetic patients with dementia to continue insulin therapy, and selection of treatment or care for diabetic patients with dementia.

RESULTS

The responses indicated that the anti-diabetic agents appropriate for diabetic patients with dementia are dipeptidyl peptidase-4 inhibitors. Those inappropriate for the same patients are metformin and insulin. Family support was a major factor for insulin therapy continuation for diabetic patients with dementia. Moreover, anti-diabetic agents for these patients are selected according to their ease of use and compatibility with available familial and social resources.

CONCLUSION

Our survey results can be utilized for the creation of new guidelines and educational resources for the anti-diabetic therapy of diabetic patients with dementia.

[Endosaccular embolization of an intrasellar aneurysm with hypopituitarism: case report]

An 81-year-old male presented with weight loss and hyponatremia. A baseline endocrinological examination revealed anterior pituitary dysfunction. A computed tomography and MRI revealed a large, unruptured intrasellar aneurysm protruding from the right internal carotid artery and pushing the pituitary stalk leftward. The patient developed polyuria and polydipsia from 10 days after commencing corticosteroid supplementation and was diagnosed with partial central diabetes insipidus (DI). Balloon assisted endosaccular embolization was performed about one month after the posterior pituitary dysfunction was identified. The unruptured aneurysm was successfully embolized with Guglielmi detachable coils (GDCs) without narrowing of the parent vessel. DI resolved completely and the posterior pituitary dysfunction improved soon after endosaccular embolization. The remission of DI after coil embolization suggested that the DI might have been induced by the progressive mass effect of the aneurysm rather than by the steroid. An endocrinological evaluation and cerebral angiography confirmed partial recovery of anterior pituitary dysfunction and almost complete obliteration of the aneurysm, respectively at 1 year after the operation. We report a case of hypopituitarism secondary to the large intrasellar aneurysm. This aneurysm was embolized with GDCs, resulting in partial recovery of anterior pituitary dysfunction and complete recovery of posterior pituitary dysfunction.

Olfactory neuroblastoma causing ectopic ACTH syndrome

A 39-year-old woman who presented with typical Cushingoid appearance (moon facies, central obesity, purpura) was admitted to our hospital because of pulmonary infection. She was found to have hypertension, severe hypokalemia, and metabolic alkalosis. Endocrine data revealed elevated plasma levels of ACTH and cortisol with lack of circadian rhythm, non-suppressibility to high-dose dexamethasone, and hyperresponsiveness to CRH stimulation. Although no pituitary mass was detected by MRI of the brain, inferior petrosal sinus sampling showed a step-up of central to peripheral ACTH levels; these data are consistent with the diagnosis of Cushing's disease. She was successfully treated with metyrapone to control hypercortisolemia. Ten months later, a mass was detected in the ethmoid sinus, which was surgically removed. After resection of the ethmoid sinus tumor, her Cushingoid features and hypercortisolemia disappeared, but recurred after enlargement of a second mass in the maxillary sinus. After resection of the maxillary sinus tumor, her hypercortisolemia subsided. Histologically, the tumor tissues from both the ethmoid and maxillary sinus were identical and consistent with the diagnosis of olfactory neuroblastoma. Immunohistochemically, the immunoreactivities of ACTH and POMC were positive in the cytoplasm of tumor cells, and immunoreactive ACTH was demonstrated in both tumor tissues. Thus, this is the second rare case with ectopic ACTH syndrome caused by olfactory neuroblastoma thus far reported.

A case with primary aldosteronism due to unilateral multiple adrenocortical micronodules

A 46-year-old male with long-term treatment-resistant hypertension and past history of cerebral hemorrhage was found to have suppressed plasma renin activity (PRA) and normal plasma aldosterone concentration (PAC) with aldosterone/renin ratio of 25.3. Furosemide plus upright test did not stimulate PRA, but computed tomography scan of the abdomen revealed no abnormal lesions in either adrenal gland. Selective adrenal venous sampling (SAVS) showed that PAC in the left and the right adrenal vein were 1000 ng/dl and 230 ng/dl, respectively, which increased to 1500 ng/dl and 620 ng/dl, respectively, after ACTH stimulation. Diagnosis of primary aldosteronism due to hypersecretion of aldosterone from the left adrenal gland was made, and laparoscopic left adrenalectomy was performed. Pathological examination of the 'apparently normal' adrenal tissue resected revealed the presence of poorly encapsulated multiple adrenocortical micronodules which showed positive immunoreactivity for 3beta-hydroxysteroid dehydrogenase by immunohistochemical study, but negative immunoreactivity in the hyperplastic zona glomerulosa consistent with paradoxical hyperplasia associated with primary aldosteronism. Postoperatively, PRA was normalized and his high blood pressure was well controlled with lower doses of antihypertensive drugs than those used before surgery. The clinicopathological features of our case are consistent with the diagnosis of unilateral multiple adrenocortical micronodules (UMN), a new subset of primary aldosteronism, in which SAVS proved to be a useful diagnostic tool for its localization.

Psychosocial predictors of relapse among diabetes patients: a 2-year follow-up after inpatient diabetes education

In a 2-year follow-up study of diabetes patients (N=309) who received 2 weeks of inpatient diabetes education, the authors investigate the relationship of several demographic, clinical, and psychosocial factors with relapse, defined as the worsening of glycemic control. The patients with no improvement in glycemic control after diabetes education were more likely to have higher scores on the depression subscale of the Profile of Mood States, compared to the patients with improvement. Kaplan-Meier survival analyses showed that patients who had no prior diabetes education, whose meals were prepared by their spouses, and who had less social support were more likely to relapse and relapsed within a significantly shorter period of time than those who had prior diabetes education, cooked for themselves, and had more social support.

Technical Note: Vaginal Absorption of 1,25(OH)2D3 in Cattle

Although exogenous 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] administered via intravenous, intramuscular, and oral routes has been tested for efficacy in preventing parturient hypocalcemia in dairy cows, there are few reports concerning intravaginal administration. For this study, 1,25(OH)2D3 was administered via the bovine vaginal lumen, and subsequent changes in blood chemistry, including levels of 1,25(OH)2D3 and several minerals, were measured to confirm vaginal absorption. Each of 5 heifers received a single intravaginal dose of 1 microg of 1,25(OH)2D3/kg body weight; a single control heifer received the ethanol carrier alone. In heifers receiving 1,25(OH)2D3, the plasma 1,25(OH)2D3 levels increased markedly from baseline (88.3 +/- 20.3 pg/mL) within 2 h and reached a peak at 6 h after treatment (1967.4 +/- 1139.6 pg/mL). Plasma Ca levels increased from baseline (10.4 +/- 0.4 mg/dL) to a peak of 11.96 +/- 0.7 mg/dL at 24 h. The levels of inorganic phosphate in plasma increased over time from 7.3 +/- 0.5 to 8.1 +/- 0.8 mg/dL by 6 h and were maintained at a plateau level (9.1 +/- 0.7 to 8.6 +/- 0.6 mg/dL) from 24 to 96 h after treatment. Plasma magnesium decreased from a baseline level of 2.1 +/- 0.1 mg/dL to a plateau level of 1.8 +/- 0.1 mg/dL, which was sustained from 24 to 48 h after treatment. The present study provides evidence of the absorption of exogenous 1,25(OH)2D3 from the bovine vaginal wall, as shown by the marked elevation of plasma 1,25(OH)2D3 levels by 2 h after administration, and indicates the possible utility of intravaginal administration of 1,25(OH)2D3 for prophylaxis of hypocalcemia.

Synthesis and biological properties of DNA-sugar conjugates

In order to improve the pharmacological properties of antisense and antigene oligonucleotides, oligodeoxynucleotides conjugated with amino sugars at the 5'-terminus were synthesized by solid phase fragment condensation (SPFC) method. The obtained DNA-sugar conjugates were evaluated in their chemical and biological activities to show that 5'-end modification of oligonucleotides with sugars enhanced the thermal stability of the hybrid duplex with complementary DNA, the resistance against nuclease digestion and the membrane permeability of the conjugates.

Word-length effect in verbal short-term memory in individuals with Down's syndrome

BACKGROUND

Many studies have indicated that individuals with Down's syndrome (DS) show a specific deficit in short-term memory for verbal information. The aim of the present study was to investigate the influence of the length of words on verbal short-term memory in individuals with DS.

METHODS

Twenty-eight children with DS and 10 control participants matched for memory span were tested on verbal serial recall and speech rate, which are thought to involve rehearsal and output speed.

RESULTS

Although a significant word-length effect was observed in both groups for the recall of a larger number of items with a shorter spoken duration than for those with a longer spoken duration, the number of correct recalls in the group with DS was reduced compared to the control subjects. The results demonstrating poor short-term memory in children with DS were irrelevant to speech rate. In addition, the proportion of repetition-gained errors in serial recall was higher in children with DS than in control subjects.

CONCLUSIONS

The present findings suggest that poor access to long-term lexical knowledge, rather than overt articulation speed, constrains verbal short-term memory functions in individuals with DS.

Chromosomal localization, structure, single-nucleotide polymorphisms, and expression of the human H-protein gene of the glycine cleavage system (GCSH), a candidate gene for nonketotic hyperglycinemia

Nonketotic hyperglycinemia (NKH) is an inborn error of metabolism caused by deficiency in the glycine cleavage system (GCS); this system consists of four individual constituents, P-, T-, H-, and L-proteins. Several mutations have been identified in P- and T-protein genes, but not in the H-protein gene (GCSH), despite the presence of case reports of H-protein deficiency. To facilitate the mutational and functional analyses of GCSH, we isolated and characterized a human p1-derived artificial chromosome (PAC) clone encoding GCSH. GCSH spanned 13.5kb and consisted of five exons. Using the PAC clone as a probe, we mapped GCSH to chromosome 16q24 by fluorescence in situ hybridization. The transcription initiation site was determined by the oligonucleotide-cap method, and potential binding sites for several transcriptional factors were found in the 5' upstream region. Direct sequencing analysis revealed five single-nucleotide polymorphisms. The expression profiles of P-, T-, and H-protein mRNAs were studied by dot-blot analysis, using total RNA from various human tissues. GCSH was expressed in all 29 tissues examined, while T-protein mRNA was detected in 27 of the 29 tissues. In contrast, the P-protein gene was expressed in a limited number of tissues, such as liver, kidney, brain, pituitary gland, and thyroid gland, suggesting distinct transcriptional regulation of each GCS constituent.

Content analysis of group work sessions in the context of an educational program for inpatient diabetes patients

This study investigated the changes in emotions and attitudes of diabetic patients as observed in group work sessions linked to an inpatient diabetic educational program. Using content analysis of transcripts from Sessions 1 and 3 of 8 selected groups (40 patients), in Session 1 negative emotions or attitudes such as anxiety, remorse, or self-blame, a lack of understanding of diabetes, along with a willingness to undertake self-care were frequently expressed. In Session 3, more positive emotions and attitudes towards self-care (willingness, specific plans, and resolutions), satisfaction, and relief or hope were frequently expressed. These results suggest that the patients participating in the group work sessions moved toward adaptation to diabetes, although the effects of the group work were not separated from those of the inpatient educational program.

Morphological differences between glomerular epithelial cells (GEC) excreted during chemotherapy with antineoplastic drugs and GEC excreted in renal diseases

BACKGROUND

To better understand the mechanisms of glomerular epithelial cell (GEC) injuries in various diseases, we compared GEC excreted during chemotherapy (antineoplastic drugs) and GEC excreted in renal diseases.

METHODS

For 19 patients undergoing chemotherapy (85 courses), 69 patients with IgA nephropathy and 16 patients with Henoch-Schölein purpura nephritis, the number of excreted GEC and GEC casts were counted by an immunofluorescent study. The morphological features of GEC were also studied in an immunofluorescent study combined with Hoechst stain.

RESULTS

Glomerular epithelial cells were detected in 78% of the chemotherapy courses and in 94% of the patients with renal diseases. The GEC casts were observed in 2% of chemotherapy courses, while in renal diseases GEC casts were observed in 60% of the patients. Proteinuria (>30 mg/dL) and hematuria were not identified in any of the chemotherapy courses. The morphology and size of GEC were more variable than that in patients with nephropathy. Furthermore, GEC in patients undergoing chemotherapy often showed small nuclei and fragmented nuclei, which were rarely observed in patients with nephropathy.

CONCLUSIONS

These results showed that the detachment of podocytes was not directly associated with proteinuria or hematuria. The findings also suggest that GEC are damaged via an apoptotic process by chemotherapy. On the contrary, GEC may be detached through a non-apoptotic process in renal diseases.

Phospholipid alterations in hepatocyte membranes and transporter protein changes in cholestatic rat model

Biliary components are transported by hepatic adenosine triphosphate-binding cassette (ABC) transporters that are located in canalicular membranes. Physiological transporter function is related to membrane fluidity, which is modulated by the phospholipid composition of the lipid bilayer. We hypothesized that cholestasis may alter transporter function by modifying phospholipid species to protect the cell from cholestatic damage. Therefore, we examined the expression of ABC transport proteins and their mRNA levels in canalicular membrane vesicles isolated from rat liver 6 hr or three days after bile duct ligation. Membrane lipid composition and membrane fluidity of both sinusoidal and canalicular membrane vesicles were also examined. By 6 hr after bile duct ligation, we found a clear increase of mdr2 and bsep mRNA. These changes were associated with an increase of mdr-Pgp and with a clear decrease of mrp2 protein, and small decrease of bsep protein. In addition, mdrlb mRNA showed a strong increase by three days after bile duct ligation. Canalicular membrane fluidity decreased in a marked time-dependent manner, whereas sinusoidal membranes showed biphasic changes: increased fluidity at 6 hr and a decrease at three days. These changes were closely related to the changes of membrane lipid constitution; the saturated/unsaturated fatty acid ratio increased for phosphatidylcholine in canalicular membrane and the reverse occurred in sinusoidal membrane, and those for sphingomyelin showed the opposite pattern. We conclude that cholestasis causes modulation of ABC transporters as well as that of the lipid constitution in lipid bilayer. These may confer cytoprotective resistance to hepatocytes against cholestatic stress.

A patient with Wegener's granulomatosis with initial clinical presentations of Henoch-Schönlein purpura

The initial presentation of a patient with Wegener's granulomatosis was indistinguishable from that of Henoch-Schönlein purpura. The patient presented with skin purpura and pulmonary hemorrhage followed by purpura in the colon. The diagnosis of this patient at that time was Henoch-Schönlein purpura. With time, massive lesions in the sinus and those with cavities in the lung became apparent, and a specimen obtained from the sinus massive lesion was disclosed to be granulomatous inflammation. Retrospectively, the proteinase 3 antineutrophil cytoplasmic antibody turned out to be strongly positive in her stored serum from the time of the initial presentation.

Dose-dependent conjugation of sulfobromophthalein and hepatic transit time in bile fistula rats: role of the microtubule-dependent vesicle pathway

Sulfobromophthalein (BSP) is selectively taken up by the liver and secreted into the bile as unconjugated and conjugated forms. Our previous study demonstrated that unconjugated BSP, but not conjugated BSP, caused the dissociation of biliary lipid secretion from that of bile acids, suggesting that the hepatic BSP conjugation rate partly regulated biliary lipid secretion. To evaluate the mechanisms through which biliary lipid secretion is regulated by exogenous organic anions, we intravenously administered BSP to male Sprague-Dawley rats at various doses either continuously or as a bolus. Then the relationship of the dose of BSP to its conjugation rate, hepatic transit time, and biliary lipid secretion was determined. BSP decreased biliary secretion of cholesterol and phospholipids in a dose-dependent manner without affecting bile acid secretion. In contrast, the proportion of conjugated BSP in bile was associated with the dose. Although the serum clearance of BSP after bolus infusion was constant regardless of the dose administered (50 or 200 nmol/100 g), BSP secretion was delayed with increasing doses: unconjugated BSP was secreted predominantly in the early phase (0-15 min after bolus injection), and conjugated BSP was the predominant form in the late phase (15-30 min). Pretreatment with colchicine reduced the conjugation rate and hepatic transit time of BSP, suggesting that the microtubule-dependent vesicle pathway plays a role in biliary excretion and conjugation of BSP. We conclude that biliary lipid secretion is influenced by organic anions with an affinity for bile acids such as BSP and that this effect is dependent upon the hepatic metabolic rate, i.e., conjugation rate. The hepatic transit time also plays a key role in this process by influencing metabolism.