Macular pucker formation after inverted internal limiting membrane flap technique: Two case reports

Purpose

The inverted internal limiting membrane (ILM) flap technique is generally used to treat refractory macular holes (MHs). Recently, a case of macular pucker formation outside the ILM flap after using silicone oil was reported. Although the pucker formation was attributed to the silicone oil use in that case, here we report two cases of macular pucker that occurred after the inverted ILM flap technique was performed without silicone oil. In one case, the ILM flap and proliferated tissue was removed, followed by their histopathological examination.

Observations

Two patients with MH underwent vitrectomies using the inverted ILM flap technique. In both patients, the visual acuity worsened postoperatively, and macular pucker formation, associated with the ILM flap, was observed. In one patient, visual acuity improved after ILM flap removal, and histopathological examination of the specimen indicated strong cellular proliferation between the ILMs.

Conclusions and Importance

Following the inverted ILM flap technique, macular pucker may occur even without the use of silicone oil. Removal of the flap and associated proliferative tissue was effective and resulted in no recurrence of MH or pucker. Ophthalmologists should consider the possibility that tissues on the ILM may lead to macular pucker formation especially inside the flap, in the area between the ILMs.

Safety and Efficacy of Cold Snare Polypectomy Without Submucosal Injection for Large Sessile Serrated Lesions: A Prospective Study

BACKGROUND & AIMS

Cold snare polypectomy (CSP) has become the standard resection method for small colorectal polyps (<10 mm). Sessile serrated lesions (SSL) have low prevalence of advanced histology irrespective of size, and thus could be amenable to CSP. In this study, we evaluated the safety and efficacy of CSP for SSLs ≥10 mm.

METHODS

Between November 2018 and January 2020, we prospectively enrolled 300 consecutive patients who underwent CSP for 474 SSLs ≥10 mm. To delineate SSL borders, indigo carmine chromoendoscopy and/or image-enhanced endoscopy was conducted. Piecemeal CSP (pCSP) was performed in cases where en-bloc resection was difficult. Biopsy specimens were obtained from the margins of the post-polypectomy defect to confirm complete resection. Surveillance colonoscopy was performed to screen for local recurrence.

RESULTS

All lesions were successfully resected using CSP without submucosal injection. The median diameter of the resected lesions was 14 mm, and pCSP was used to resect 106 (22%) lesions. Post-polypectomy biopsies revealed residual serrated tissue in only one case (0.2%). Adverse events included immediate bleeding in 8 (3%) patients; no delayed bleeding events occurred, irrespective of the use of antithrombotic drugs. During a 7-month median follow-up period, surveillance colonoscopies were performed for 384 lesions (81%), and no local recurrences were detected.

CONCLUSIONS

CSP without submucosal injection is a safe and effective treatment for SSLs ≥10 mm. UMIN Clinical Trials, Number: UMIN000034763.

New hemostatic technique with combined use of Hydrofit® and Surgicel®: an in vitro and in vivo study

We developed an effective hemostatic technique using Hydrofit^® and Surgicel^® simultaneously. The aim of this study was to demonstrate the hemostatic efficacy of the Hydrofit^® and Surgicel^® combination technique through an in vitro experiment and to elucidate mid-term consequences of the combined components through an in vivo experiment. For the in vitro experiment, a closed circuit using a heparin-coated cardiopulmonary bypass circuit and a prosthetic graft was created. The amount of bleeding from the prosthetic graft was measured, and the following three hemostatic methods were applied: only gauze compression in control group, Hydrofit^® application in Hydrofit group, Surgicel^® spread Hydrofit^® application in Hydrofit and Surgicel (HS) group, respectively. In the in vivo experiment, Hydrofit^® and/or Surgicel^® were implanted under skin on the back of rats (n = 10) at 4 points. In the control group, only an incision was made; in the Hydrofit, Surgicel, and HS groups, Hydrofit^® and/or Surgicel^® was implanted. One and three months later, each of the five rats were killed and in each section histopathologic examination was carried out. In the in vitro experiment, the amount of bleeding was 7.84 ± 1.08, 2.26 ± 1.02, and 0.87 ± 0.38 ml in the control, Hydrofit, and HS groups, respectively. The amount of bleeding in the HS group was more suppressed than in the Hydrofit group (p = 0.012). In the in vivo experiment, the maximal depth diameter of each remaining hemostatic sealant was measured. After 3 months, the diameter was 0, 2289.0 ± 768.2, 3850.3 ± 935.8 μm in Surgicel, Hydrofit and HS groups, respectively. The diameter was significantly increased in the HS group compared with the Surgicel and Hydrofit groups (p < 0.001, respectively,). In conclusion, the combination of Hydrofit^® and Surgicel^® was effective in achieving hemostasis. The remnants of Hydrofit^® and Surgicel^® were present for a long time in the tissues which could compress the surrounding tissue.

Risk factors of delayed bleeding after endoscopic resection of superficial non-ampullary duodenal epithelial tumors and prevention by over-the-scope and conventional clipping

OBJECTIVES

This study was aimed to reveal risk factors for delayed bleeding after endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) and at exploring measures to prevent this complication.

METHODS

A total of 235 consecutive patients with 249 SNADETs who had undergone ER were enrolled in this study. They were divided into two groups: OTSC group, consisting of the initial 114 cases in which the defects were closed only using OTSCs; and OTSC-c group, consisting of the later 135 cases in which conventional clips were additionally used to cover the inverted submucosa after post-procedure defect closure using OTSCs. The therapeutic outcomes were then compared between the OTSC and OTSC-c groups.

RESULTS

All lesions were successfully resected en-bloc, and the R0 resection rate was 92.4%. The complete defect closure rate was 90.0% and no delayed perforation occurred when successful defect closure was achieved. The rate of delayed bleeding was significantly higher in the OTSC group than in OTSC-c group (11.4% vs. 1.5%, P = 0.001). Multivariate logistic regression analyses revealed that tumor location distal to the ampulla (OR 10.0; 95% CI 1.24-81.0, P = 0.03) and use of a DOAC (OR 8.83; 95% CI 1.13-68.7, P = 0.04) were significant independent predictors of delayed bleeding. Propensity score-matching analysis revealed that additional use of conventional clips was associated with a significantly reduced risk of delayed bleeding (P = 0.003).

CONCLUSIONS

Additional use of conventional clips after prophylactic defect closure using OTSCs appears to be useful to reduce the risk of delayed bleeding after ER of SNADETs. UMIN Clinical Trials (No. 000035478).

Nanobubble technology to treat spinal cord ischemic injury

Background

Spinal cord ischemic injury is a severe complication of aortic surgery. We hypothesized that cerebrospinal fluid (CSF) oxygenation with nanobubbles after reperfusion could ameliorate spinal cord ischemic injury.

Methods

Twenty white Japanese rabbits were categorized into 4 groups of 5 rabbits each: sham group, with balloon catheter insertion into the aorta; ischemia group, with spinal cord ischemic injury by abdominal aortic occlusion; nonoxygenated group, with nonoxygenated artificial CSF irrigation after spinal cord ischemic injury; and oxygenated group, with oxygenated artificial CSF irrigation after spinal cord ischemic injury. At 48 hours after spinal cord ischemic injury, the modified Tarlov score to reflect hind limb movement was evaluated. The spinal cord was histopathologically examined by counting anterior horn cells, and microarray and quantitative reverse-transcription polymerase chain reaction (qRT-PCR) analyses were performed.

Results

The oxygenated group showed improved neurologic function compared with the ischemia and nonoxygenated groups (P < .01 and P = .019, respectively). Anterior horn neuron prevention in the sham, nonoxygenated, and oxygenated groups was confirmed (mean modified Tarlov score: sham, 9.2 ± 1.9; nonoxygenated, 10.2 ± 2.2; oxygenated, 10.4 ± 2.2; ischemia, 2.7 ± 2.7). Microarray analysis identified 644 genes with twofold or greater increased signals between the ischemia and sham groups. Thirty-three genes related to inflammatory response were enriched among genes differentially expressed between the oxygenated and ischemia groups. Interleukin (IL)-6 and tumor necrosis factor (TNF) expression levels were significantly lower in the oxygenated group compared with the ischemia group, while qRT-PCR showed lower IL-6 and TNF expression levels in the oxygenated group compared with the ischemia group (P < .05).

Conclusions

CSF oxygenation with nanobubbles after reperfusion can ameliorate spinal cord ischemic injury and suppress inflammatory responses in the spinal cord.

Skill-up study of systemic endoscopic examination technique using narrow band imaging of the head and neck region of patients with esophageal squamous cell carcinoma: Prospective multicenter study

OBJECTIVE

To evaluate the usefulness of a training program on endoscopic head and neck surveillance for beginner endoscopists.

METHODS

This prospective multicenter study included 13 beginner endoscopists from 10 institutions who received training in systematic observation techniques and diagnostic criteria, and the training involved hands-on learning. Between May 2016 and February 2017, enrolled patients with current or previously diagnosed esophageal squamous cell carcinomas underwent head and neck surveillance using narrow band imaging (NBI) endoscopy, and histologically confirmed head and neck squamous cell carcinoma (HNSCC) detection rates, endoscopic image quality, and examination times were compared before (group A) and after (group B) the training program. Maximum possible score for the endoscopic images was 30 points.

RESULTS

A total of 330 patients, comprising 181 in group A and 149 in group B, were enrolled. Three patients with HNSCC were detected in group A (1.7%) and in group B (2.0%; P = 1.000). Mean ± standard deviation (SD) examination times were 157 ± 71 s and 174 ± 109 s in groups A and B, respectively, (P = 0.073). Mean ± SD scores of the endoscopic images were 25.04 ± 5.47 points and 27.01 ± 4.35 points in groups A and B, respectively, (P < 0.001).

CONCLUSION

The HNSCC detection rate based on the use of NBI on patients with ESCC did not improve after the training program for beginner endoscopists; however, endoscopic image quality improved significantly after the training program.

P1826Computational fluid dynamic analysis of acute aortic dissection

Background

Mechanism of acute aortic dissection still is not well understood. It is very difficult to predict where, when, and how acute aortic dissection occurs. This time we focused on blood flow velocity (FV), wall shear stress (WSS), and oscillatory shear index (OSI) which is three dimensional fluctuations of WSS inside ascending aorta. It is well recognized that a higher or lower WSS may cause intimal dysfunction, which could result in the progression of atherosclerosis. Furthermore, because of the non-slip boundary mechanical equilibrium of forces, WSS will separate the inner and outer layers of the aorta. This sheer force could stress the medial tissue and result in degeneration. OSI has been reported as important hemodynamic parameter that is highly associated with the progression of atherosclerosis by inducing radical oxygen production of the endothelial cells. Therefore, OSI may be more closely associated with the degeneration of the media in comparison with WSS. This time FV, WSS, and OSI was evaluated using computational fluid dynamics to identify the location of acute aortic dissection entry.

Method

Using computed tomography data of three patients (Case A, B, C) who had acute aortic dissection, each three pre-dissection aorta model was made. Computer simulation images of four dimensional pulsatile blood flow was made and pulsatile cardiac flow from one cardiac cycle was simulated. A three-dimensional movie was made to evaluate FV, WSS, and OSI. One normal size aorta was evaluated as a control.

Results

In control, blood flow inside ascending aorta was laminar, on the contrary, spiral flow was observed in three dissection cases. FV was slightly higher in dissection case (control: 0.56m/s, A: 0.77m/s, B: 1.05m/s, C: 0.35m/s). Maximum WSS in ascending aorta was 3.24Pa in control. In dissection cases, there was patchy high (A: 18.6Pa, B: 25.6Pa, C: 4.0Pa,) WSS lesion in ascending aorta. In case A and B, these patchy high lesions are close to the entry site. In all three dissection case, OSI was high around entry site.

Figure 1

Conclusion

According to our computer simulation, patchy high WSS and high OSI lesion is related with acute dissection entry site at the ascending aorta.

Acknowledgement/Funding

None

Development and validation of the comprehensive assessment scale for chemotherapy-induced peripheral neuropathy in survivors of cancer

Background

Appropriate assessment is essential for the management of chemotherapy-induced peripheral neuropathy (CIPN), an intractable symptom that cannot yet be palliated, which is high on the list of causes of distress for cancer patients. However, objective assessment by medical staff makes it easy to underestimate the symptoms and effects of CIPN in cancer survivors. As a result, divergence from subjective evaluation of cancer survivors is a significant problem. Therefore, there is an urgent need to develop a subjective scale with high accuracy and applicability that reflects the experiences of cancer patients. We developed a comprehensive assessment scale for CIPN in cancer survivors, named the Comprehensive Assessment Scale for Chemotherapy-Induced Peripheral Neuropathy in Survivors of Cancer (CAS-CIPN), and demonstrated its reliability and validity.

Methods

We developed a questionnaire based on qualitative studies of peripheral neuropathy in Japanese cancer patients and literature review. Twelve cancer experts confirmed the content validity of the questionnaire. A draft version comprising 40 items was finalized by a pilot test on 100 subjects. The participants in the present study were 327 Japanese cancer survivors. Construct validity was determined by factor analysis, and internal validity by confirmation factor analysis and Cronbach’s α.

Results

Factor analysis showed that the structure consisted of 15 items in four dimensions: “Threatened interference in daily life by negative feelings”, “Impaired hand fine motor skills”, “Confidence in choice of treatment/management,” and “Dysesthesia of the palms and soles.” The CAS-CIPN internal consistency reliability was 0.826, and the reliability coefficient calculated using the Spearman-Brown formula [q = 2r/(1 + r)] was 0.713, confirming high internal consistency and stability. Scores on this scale were strongly correlated with Gynecologic Oncology Group-Neurotoxicity scores (r = 0.714, p < 0.01), confirming its criterion-related validity.

Conclusions

The CAS-CIPN is an assessment tool with high reliability and validity for the comprehensive evaluation of CIPN in cancer survivors. The CAS-CIPN is simple to use, and can be used by medical professionals for appropriate situational assessment and intervention.

Clinical Outcomes of Patients with Small Rectal Neuroendocrine Tumors Treated Using Endoscopic Submucosal Resection with a Ligation Device

BACKGROUND/AIMS

The therapeutic strategies for small rectal neuroendocrine tumors (NETs) have not been standardized. We examined the efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) and the long-term outcomes after endoscopic treatment.

METHODS

A total of 181 patients with rectal NETs <10 mm who were treated between May 2002 and May 2017 were retrospectively enrolled. All the lesions had been resected using ESMR-L, and the follow-up strategies were determined according to the pathological examinations. The long-term outcomes after a 53-month follow-up period were also evaluated.

RESULTS

R0 resection was achieved in 180 cases (99.4%). Lymphovascular invasion was confirmed in 67 cases (37.0%), while a curative resection was achieved in 114 cases (63.0%). One perforation (0.6%) and 11 cases with delayed bleeding (6.1%) were observed. A multivariate logistic regression analysis revealed that a tumor size > 5 mm (OR 2.06; 95% CI 1.04-4.08, p = 0.04) was a significant independent predictor of the presence of lymphovascular invasion. Of the 67 patients with non-curative resections, 11 patients underwent additional surgery; lymph node metastasis was confirmed in 2 cases (18.2%). No local or distant metastases were observed during the follow-up period in 77 patients with a curative resection, 9 patients who received additional surgery, and 50 patients with non-curative resections.

CONCLUSION

ESMR-L is an easy, safe and effective treatment for rectal NETs <10 mm in diameter, and the prognosis of patients seems to be good, despite a relatively high rate of lymphovascular invasion.

Differential selective hypothermic intercostal artery perfusion: a new method to probe spinal cord perfusion during thoracoabdominal aortic aneurysm repair

OBJECTIVE

To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP).

METHODS

After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area.

RESULTS

Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries.

CONCLUSIONS

The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.

Hemodialysis is a strong risk factor for post-endoscopic sphincterotomy bleeding in patients with choledocholithiasis

BACKGROUND AND STUDY AIMS

 Hemodialysis (HD) is considered one of the risk factors for post-endoscopic sphincterotomy (ES) bleeding. Therefore, we conducted a retrospective study to evaluate HD as a risk factor for post-ES bleeding in patients with choledocholithiasis.

PATIENTS AND METHODS

 We used the post-ES bleeding rate as the main outcome measure. To evaluate the influence of HD on the risk of post-ES bleeding, logistic regression and propensity score analyses were conducted. In addition, univariate analysis-based comparisons of various clinical parameters (as secondary outcome measures) were performed between the patients in the HD and non-HD groups that experienced post-ES bleeding.

RESULTS

 A total of 1518 patients were enrolled. In the multivariate analysis, a platelet count of < 50,000, anticoagulant therapy, bleeding during ES, and HD were found to be significantly associated with post-ES bleeding (odds ratio [OR]: 35.30, 95 % confidence interval [CI]: 3.81 - 328.00; OR: 4.39, 95 % CI: 1.53 - 12.60; OR: 4.28, 95 % CI: 2.30 - 7.97; and OR: 13.30, 95 % CI: 5.78 - 30.80, respectively). Propensity score matching created 28 matched pairs. Propensity score analysis showed that the risk difference between the groups was 0.214 (95 % CI: 0.022 - 0.407). In a comparison between the patients in the HD and non-HD groups that suffered post-ES bleeding, it was found that the post-ES bleeding was significantly more severe in the HD group (p = 0.033), and massive blood transfusions and long periods of hospitalization were more frequently required in the HD group (p = 0.008 and p < 0.001, respectively).

CONCLUSION

 HD is an independent risk factor for post-ES bleeding and makes post-ES bleeding more serious.

Phenotypic Reversion of Smooth Muscle Cells in Hybrid Vascular Prostheses

Our purpose was to evaluate whether or not and when phenotypic modulation of smooth muscle cells (SMCs) in hybrid vascular prostheses preincorporated with SMCs occurs upon implantation. Two types of hybrid vascular grafts incorporated with vascular cells derived from canine jugular veins were prepared: grafts containing a collagen gel layer covered with an endothelial monolayer at the luminal surface (Model I graft) and those containing an endothelial monolayer and SMC multilayer (Model II graft). They were bilaterally implanted into carotid arteries of the same dogs from which the cells had been harvested for 2 wk (n = 3) and 12 wk (n = 3). The time-dependent changes in populations of three SMC phenotypes (synthetic, intermediate, and contractile) in the neoarterial layers were quantified by morphometric evaluation using a transmission electron microscope in hybrid vascular grafts. Before implantation, all the SMCs were of the synthetic phenotype. In Model II grafts at 2 wk, synthetic and intermediate SMCs were dominant especially in the luminal layer. On the other hand, neoarterial layers at 12 wk were dominated by contractile SMCs, which were evenly distributed throughout the entire neoarterial tissues. A markedly delayed phenotypic reversion was noted for the Model I grafts at 12 wk. In the hybrid grafts, during about 3 mo of implantation, neoarterial SMCs transformed from the synthetic to the contractile phenotypes, which was promoted by SMC incorporation.

Modification of a Standard Thoracoabdominal Incision to Preserve Collaterals to Adamkiewicz Artery

We report a case of a 35-year-old male who underwent thoracoabdominal aortic repair of a chronic dissecting aortic aneurysm, Crawford extent II. Preoperative computed tomography showed thrombosis of almost all intercostal arteries. Precise diagnostic assessment demonstrated the Adamkiewicz artery originating from the left lateral thoracic artery and subscapular artery, which would have been at risk after using a standard Stoney's incision, thus potentially causing paraplegia or paraparesis due to spinal cord ischemia. We modified the lateral thoracic incision anteriorly and successfully preserved the collateral arteries without impairing the spinal cord function.

[Issues in Coronary Artery Bypass Grafting for Kawasaki Disease]

Progressive narrowing at the entrance and exit of coronary artery aneurysm can develop at late phase of Kawasaki disease (KD). Evaluation and prediction of progressive coronary lesions remain a challenge in the treatment of post-KD coronary artery disease. We aimed to elucidate long-standing issues imposed on the patients who underwent coronary artry bypass grafting (CABG) for coronary artery lesions associated with KD. Between January, 2000 and December, 2013, CABG for coronary artery lesions associated with KD were performed in 6 patients (male/female: 5/1, mean age 14.5±10.0). There was no operative mortality. Follow-up for the 6 patients has been performed with the average period of 5 years (1~9 years). Cardiac events occurred in 2 patients during follow-up. In 1 patient, left internal thoracic artery (LITA) occluded due to flow competition between the native artery and LITA graft after LITA to LAD bypass grafting. The other patient required a re-do CABG using the free right internal thoracic artery to the circumflex branch because of occlusion at the coronary artery aneurysms after 4 years postoperatively. Meticulous preoperative diagnostic evaluations of coronary artery aneurysm may further improve the long-term outcome after surgical intervention for coronary lesions in conjunction with an aneurysm.

[Preoperative Use of Tolvaptan in a Patient with Constrictive Pericarditis]

Tolvaptan is a new selective vasopression V2-receptor antagonist. We report our experience with a use of tolvaptan for preoperative fluid management in a patient with severe constrictive pericarditis. A 66-year-old man presented with heart failure symptoms derived from constrictive pericarditis. Chest X-ray showed right pleural effusion and chest computed tomography demonstrated severe pericardial calcification. Despite that he received optimal conventional medical treatments, his hemodynamic condition further exacerbated during hospitalization. We administered tolvaptan in an attempt to optimize preoperative fluid management. Tolvaptan was found to be remarkably effective in that regard. The body weight decreased and the heart failure symptoms improved. Pericardiectomy was performed successfully, and he recovered uneventfully.

[Early Postoperative Outcomes and Evaluation of Hemodynamics after Mitral Valve Replacement with Epic Mitral Bioprosthesis]

BACKGROUND

In Guideline for Surgical and Interventional Treatment of Valvular Heart Disease, revised by Japanese Circulation Society in 2012, mitral valve replacement (MVR) with bioprosthesis is class II b recommendation for patients aged 70 years or older who have no risk factors for thromboembolism. The aim of this study was to evaluate the early postoperative surgical outcomes and the hemodynamic performance with the Epic mitral bioprosthesis.

METHODS

Twenty-six consecutive patients underwent MVR with Epic mitral bioprostesis at Tohoku University Hospital between April 2011 and July 2014. Twenty-five cases of 26 were evaluated their hemodynamics at discharge, and of which 19 cases of 26 were evaluated at the outpatient clinic during follow-up period.

RESULTS

There was 1 hospital death. Long-term mortality or reoperation for any valve abnormality was not observed in the median follow-up of 23.9 ± 11.3 months. Hemodynamic date at discharge obtained by transthoracic echocardiography included mean hemodynamics of mitral valve bioprosthesis as below. Effective orifice area (EOA):2.44 ± 0.62 cm², peak mitral pressure gradient (pMPG):15.8 ± 5.3 mmHg, mean mitral pressure gradient(mMPG):7.2 ± 2.4 mmHg. Hemodynamic parameters at follow-up were found to be stable as EOA:2.25 ± 0.64 cm², pMPG:17.3 ± 5.7 mmHg, mMPG:6.2 ± 2.3 mmHg, respectively.

CONCLUSION

We have attempted to elucidate our preliminary postoperative outcomes and hemodynamics after MVR with Epic mitral bioprosthesis. These in vivo hemodynamic data can serves a clinical reference.

[Leg amputation for severe lower limb ischemia caused by type A acute aortic dissection; report of a case]

A 41-year-old man underwent total arch replacement and aorto-bifemoral bypass owing to type A acute aortic dissection complicated by ischemia of both lower extremities. Just after the operation, he developed myonephropathic metabolic syndrome due to severe ischemia of the right leg, and hemodiafiltration was performed. However, the serum potassium was elevated to an uncontrollable level. Ligation of the right femoral artery and the right branch of the bypass graft was performed one hour after the transfer to intensive care unit (ICU), and the serum potassium dropped to a normal level. He underwent amputation of the right lower limb above the knee on the 13th postoperative day, and was discharged after long-term rehabilitation.

Application of a phosphite dehydrogenase gene as a novel dominant selection marker for yeasts

The use of antibiotic resistance markers in the commercial application of genetically modified microorganisms is limited due to restrictions on the release of antibiotics and their resistance genes to the environment. To avoid contamination by other microorganisms, the development of a dominant selection marker with low environmental risks is still needed. Here we demonstrated a new selection system for Schizosaccharomyces pombe and Saccharomyces cerevisiae using a bacterial phosphite dehydrogenase gene (ptxD). A Sz. pombe transformant carrying ptxD under a strong promoter or on a multicopy plasmid grew on a minimal medium containing phosphite (Pt) as a sole source of phosphorus. To adapt this system to S. cerevisiae strains, codon optimization of ptxD was necessary. The codon-optimized ptxD system appeared effective in not only laboratorial but also industrial S. cerevisiae strains that are diploid or polyploid. Since Pt is a safe and inexpensive chemical, ptxD could be used as a novel dominant selection marker applicable on an industrial scale.

Regulation of L-alanine-initiated germination ofBacillus subtilis spores by alanine racemase

Germination ofBacillus subtilis spores was initiated by L-Ala and competitively inhibited by D-Ala, suggesting the presence of an alanine receptor. The spores showed alanine racemase activity in the spore coat. To investigate the role of alanine racemase (L → D) on germination, net racemase activity was determined using diphenylamine as a germination inhibitor and germination was measured using D-penicillamine as a racemase inhibitor. Apparent affinity of L-Ala to the germinant receptor was more than 1000 times higher than that to the racemase. Germination increased in the presence of D-penicillamine, when the concentration of L-Ala was low and that of spores was high. Racemase activity was optimal at 65°C at pH 9.0 and germination at 43°C at pH 7.2. Under unfavorable growth conditions such as high population of spores in limited nutrients, high temperature and high pH, spore alanine racemase converted the germinant actively to the inhibitor and this conversion may regulate germination for survival of the population.

Surgical treatment for an asymptomatic and unruptured sinus of Valsalva aneurysm: report of a case

A 70-year-old male underwent a transthoracic echocardiography as a screening test for hypertension and an unruptured aneurysm was detected in the right sinus of Valsalva. The right sinus of Valsalva aneurysm obstructed the right ventricle outflow tract but he did not have any symptoms. The sinus of Valsalva aneurysm was treated successfully by a patch closure with a bovine pericardial patch.

Chitinase 3-like 1 promotes macrophage recruitment and angiogenesis in colorectal cancer

Chitinase 3-like 1 (CHI3L1), one of mammalian members of the chitinase family, is expressed in several types of human cancer, and elevated serum level of CHI3L1 is suggested to be a biomarker of poor prognosis in advanced cancer patients. However, the overall biological function of CHI3L1 in human cancers still remains unknown. Studies were performed to characterize the role of CHI3L1 in cancer pathophysiology utilizing human colorectal cancer samples and human cell lines. Plasma protein and tissue mRNA expression levels of CHI3L1 in colorectal cancer were strongly upregulated. Immunohistochemical analysis showed that CHI3L1 was expressed in cancer cells and CHI3L1 expression had a significant association with the number of infiltrated macrophages and microvessel density. By utilizing trans-well migration and tube formation assays, overexpression of CHI3L1 in SW480 cells (human colon cancer cells) enhanced the migration of THP-1 cells (human macrophage cells) and HUVECs (human endothelial cells), and the tube formation of HUVECs. The knockdown of CHI3L1 by RNA interference or the neutralization of CHI3L1 by anti-CHI3L1 antibody displayed strong suppression of CHI3L1-induced migration and tube formation. Cell proliferation assay showed that CHI3L1 overexpression significantly enhanced the proliferation of SW480 cells. ELISA analysis showed that CHI3L1 increased the secretion of inflammatory chemokines, IL-8 and MCP-1, from SW480 cells through mitogen-activated protein kinase (MAPK) signaling pathway. Both neutralization of IL-8 or MCP-1 and inhibition or knockdown of MAPK in SW480 cells significantly inhibited CHI3L1-induced migration and tube formation. In a xenograft mouse model, overexpression of CHI3L1 in HCT116 cells (human colon cancer cells) enhanced the tumor growth as well as macrophage infiltration and microvessel density. In conclusion, CHI3L1 expressed in colon cancer cells promotes cancer cell proliferation, macrophage recruitment and angiogenesis. Thus, the inhibition of CHI3L1 activity may be a novel therapeutic strategy for human colorectal cancer.

Involvement of interleukin-1 in lipopolysaccaride-induced microglial activation and learning and memory deficits

We have developed an animal model of learning and memory impairment associated with activation of microglia in the mouse brain. Injection of lipopolysaccharide into the CA1 region of the mouse hippocampus resulted in an increased production of inflammatory cytokines, such as interleukin-1β. Immunostaining for interleukin-1β revealed an increase in the signal at 6 hr after lipopolysaccharide injection. Immunopositive cells for interleukin-1β were colocalized with those immunopositive for CD11b. When subacute lipopolysaccharide treatment (20 μg/2 μl/injection, bilaterally for 5 consecutive days) was performed, long-term activation of microglia and learning and memory deficits as evaluated using a step-through passive avoidance test were observed in the wild-type mice. Gene expression of the N-methyl-D-aspartate receptor NR1 and NR2A subunits was also decreased by the lipopolysaccharide treatment. In contrast, activation of microglia and the associated behavioral deficits were not observed in mice lacking interleukin-1α and -1β following the subacute lipopolysaccharide treatment, together with little change in the gene expression of NR1 and NR2A subunits. However, the subacute lipopolysaccharide treatment produced almost similar changes in those parameters in the tumor necrosis factor-α knockout mice as in the wild-type animals. The injection of interleukin-1β neutralizing antibody with lipopolysaccharide for 5 consecutive days resulted in the improvement of lipopolysaccharide-induced learning and memory deficits. These findings suggest that the expression of interleukin-1 plays an important role in lipopolysaccharide-induced activation of microglia and the associated functional deficits in learning and memory.

Molecular analysis of digenic inheritance in Bartter syndrome with sensorineural deafness

BACKGROUND

Bartter syndrome (BS) is a genetic disorder accompanied by hypokalaemic metabolic alkalosis. BS with sensorineural deafness (SND, OMIM602522) is a newly identified phenotype caused by mutations in the BSND gene that encodes barttin, a beta-subunit for chloride channel ClC-Ka and ClC-Kb and classified as type IV BS. Type IV BS features the most severe phenotype entailing life-threatening neonatal volume depletion and chronic renal failure developing during infancy. A recent report described a case of BS with SND from a consanguineous family who showed homozygous mutations in the CLCNKA and CLCNKB genes. This case indicated the possibility of the occurrence of digenic inheritance in BS with SND resulting from double mutations in the CLCNKA and CLCNKB genes.

SUBJECT AND RESULTS

The current report concerns a 2-year-old girl from a non-consanguineous family with BS accompanied by SND. In our case, four loss-of-function mutations, consisting of mutations in both parental alleles in both CLCNKA and CLCNKB, were identified. The paternal allele had a nonsense mutation (Q260X) in CLCNKA and a splicing site mutation (IVS17+1 g>a) in CLCNKB. The maternal allele had a large deletion mutation (about 12 kbp) extending from CLCNKA to CLCNKB. Our case provides clear evidence that loss-of-function alleles in both alleles of both CLCNKA and CLCNKB results in a phenotype indistinguishable from that of mutations in BSND (type IV BS).

CONCLUSIONS

Recent advances in genetics have resulted in a better understanding of many human inherited diseases, but most of them are monogenic disorders and more complex inheritance patterns remain unresolved. Our case provides clear evidence of digenic inheritance outside the scope of Mendelian inheritance disorders.

Transcriptional expression of survivin and its splice variants in cervical carcinomas

The objective of this study was to evaluate transcriptional expression of survivin and the two splice variants (survivin-2B and survivin-ΔEx3) in cervical carcinomas. The gene expression levels of survivin and its splice variants in 11 human cervical carcinoma cell lines and 20 malignant and 12 normal cervical tissue samples were analyzed using quantitative reverse transcription–polymerase chain reaction analysis. Gene expression levels of survivin and survivin-ΔEx3 in cell lines were higher than those in normal cervical tissues (P= 0.0193 and 0.0489). Transcript levels of survivin and survivin-ΔEx3 in carcinoma tissues were also higher than those in normal controls (P= 0.0016 and 0.0011). Gene expression levels of survivin and survivin-ΔEx3 in adenocarcinomas were statistically higher than those in squamous cell carcinomas (P= 0.0260 and 0.0487). There was no significant difference in survivin-2B gene expression between malignant and normal cervical samples or different histologic types. The ratios of survivin-2B/survivin and survivin-ΔEx3/survivin in carcinoma tissues were higher than those in normal controls (P= 0.0288 and 0.0081). Interestingly, the ratio of survivin-2B/survivin was increased in the patients with higher stages and with pelvic lymph node metastasis (P= 0.0205 and 0.0437), respectively. We conclude that survivin and its splice variants might be involved in the pathogenesis and development of cervical carcinomas.

Activation of the c-myc p1 promoter in Burkitt's lymphoma by the hs3 immunoglobulin heavy-chain gene enhancer

The expression of c-myc is deregulated in Burkitt's lymphoma by the translocation t(8;14). Most of the increased c-myc expression is from the P1 promoter, which is normally a minor promoter. How the P1 promoter is activated by the immunoglobulin heavy chain gene enhancers is not understood. We identified a YY1 site in the immunoglobulin heavy-chain gene HS3 enhancer, which increased c-myc P1 promoter activity, and a MARE site, which decreased c-myc P1 activity. Small Maf proteins bound to the MARE site both in vitro and in vivo, recruited histone deacetylase 2, and resulted in deacetylation of histones H3 and H4 at the c-myc promoter region. In contrast, YY1 recruited CBP and increased histone acetylation at the c-myc promoter. Rb interacts with YY1 to prevent DNA binding in normal B cells, but no significant interaction with YY1 was detected in Burkitt's cells, and binding of YY1 to the HS3 enhancer was observed by chromatin immunoprecipitaton. Increased expression of MafK and/or decreased expression of YY1 by silencing RNA downregulated endogenous c-myc mRNA levels and increased the sensitivity of the cells to doxorubicin. Mutation of the major active sites (nuclear factor-kappa B and YY1) in the enhancers prevented c-myc activation.

Clinical significance of heterozygous carriers associated with compensated hypothyroidism in R450H, a common inactivating mutation of the thyrotropin receptor gene in Japanese

Loss-of-function mutations in the thyrotropin receptor (TSHR) gene were described as a syndrome characterized by thyroid hyposensivity to biologically active TSH, ranging from euthyroid to severe hypothyroidism. In Japanese, a common mutation in the TSHR gene is R450H, which demonstrated moderately impaired receptor function. We studied six subjects of Japanese origin whose major abnormality was persistent hyperthyrotropinemia by genetic sequence analysis of the TSHR gene. Three subjects were homozygous for the R450H mutation, whereas the three remaining subjects were single heterozygous. Homozygous subjects displayed mild hypothyroidism confirmed by moderately elevated basal TSH levels and excessive TSH response to TRH administration. Heterozygous subjects also demonstrated fully or partially compensated hypothyroidism, but less severe than that of homozygous subjects. More frequent involvement of the R450H mutation in the TSHR gene in Japanese was identified. In addition, a good correlation between phenotype and genotype was demonstrated in respect to biochemical analysis and drug dosage. Our observations showed clinical significance of heterozygosity associated with compensated hypothyroidism in spite of only mildly impaired receptor function.

Embolisation of proximal anastomotic pseudoaneurysm developing after surgical repair of abdominal aortic aneurysm with a bifurcated graft with n-butyl cyanoacrylate

We report a 60-year-old man who after undergoing surgical repair of an abdominal aortic aneurysm with a bifurcated graft subsequently developed a proximal anastomotic pseudoaneurysm, which was successfully treated by embolisation with n-butyl cyanoacrylate.

A case of spinal cord injury that occurred in utero

Spinal cord injury is a rare occurrence that is often difficult to diagnose. This report describes a 2-year-old male with cervicothoracic spinal cord injury. The injury is thought to have occurred in the fetal period because the patient's thorax was markedly hypoplastic at birth and his mother had noticed a decrease in fetal movements for several weeks before the birth. The deep tendon reflex of the upper and lower extremities was absent at birth, as observed in other cases of spinal cord injury. It was noteworthy that deep tendon reflex of the upper and lower extremities remained decreased at 2 years of age despite the injury being located at C(7)-T(1). Based on this case, we propose that spinal cord injuries occurring in utero display different reflex responses from those occurring at birth.

Fas gene promoter -670 polymorphism in gynecological cancer

Single-nucleotide polymorphism at -670 of Fas gene promoter (A/G) was examined in a total of 354 blood samples from normal healthy women and gynecological cancer patients. They consisted of 95 normal, 83 cervical, 108 endometrial, and 68 ovarian cancer cases. Eighty-three patients with cervical cancer had statistically higher frequency of GG genotype and G allele than 95 controls (P= 0.0353 and 0.0278, respectively). There was no significant difference in the genotype or allele prevalence between control subjects and endometrial or ovarian cancer patients. The Fas -670 GG genotype was associated with an increased risk for the development of cervical cancer (OR = 2.56, 95% CI = 1.08-6.10) compared with the AA genotype. The G allele also increased the risk of cervical cancer (OR = 1.60, 95% CI = 1.05-2.43) compared with the A allele. Germ-line polymorphism of Fas gene promoter -670 may be associated with the risk of cervical cancer in a Japanese population.

Fas gene promoter –670 polymorphism in gynecological cancer

Single-nucleotide polymorphism at −670 of Fas gene promoter (A/G) was examined in a total of 354 blood samples from normal healthy women and gynecological cancer patients. They consisted of 95 normal, 83 cervical, 108 endometrial, and 68 ovarian cancer cases. Eighty-three patients with cervical cancer had statistically higher frequency of GG genotype and G allele than 95 controls (P= 0.0353 and 0.0278, respectively). There was no significant difference in the genotype or allele prevalence between control subjects and endometrial or ovarian cancer patients. The Fas −670 GG genotype was associated with an increased risk for the development of cervical cancer (OR = 2.56, 95% CI = 1.08–6.10) compared with the AA genotype. The G allele also increased the risk of cervical cancer (OR = 1.60, 95% CI = 1.05–2.43) compared with the A allele. Germ-line polymorphism of Fas gene promoter −670 may be associated with the risk of cervical cancer in a Japanese population.

Stimulation of the nucleus basalis of Meynert increases diameter of the parenchymal blood vessels in the rat cerebral cortex

To verify the hypothesis that stimulation of the nucleus basalis of Meynert (NBM) induces vasodilation in the cerebral cortical parenchyma, we investigated whether the diameter of parenchymal blood vessels of rat parietal cortex is increased during stimulation of NBM using histological techniques. The parietal cortex was fixed by immersion fixation in situ during focal electrical stimulation of the NBM, which increased cortical blood flow. Cortical tissues were sectioned horizontally to the cortical surface, and the parenchymal blood vessels were morphometrically analyzed using electron microscopy. Mean inner diameter of the parenchymal blood vessels in NBM stimulated rats (5.51+/-0.33 microm) was significantly larger than that in non-stimulated control rats (4.93+/-0.23 microm). The result suggests that functional vasodilation in the cortical parenchyma during NBM stimulation correlates with histologically observed vasodilation in the cortical parenchyma.

Changes in serum 1,25-dihydroxyvitamin D3 and mRNAs for osteocalcin and alkaline phosphatase in femur unloaded by tail suspension in rats

To elucidate the mechanism involved in the development of disuse atrophy of bone by skeletal unloading, changes in osteocalcin and alkaline phosphatase mRNAs, markers for bone formation, were studied in the hind limb bones of tail-suspended rats. Tail suspension for 8 and 14 days resulted in a significant decrease in osteocalcin mRNA in the femur when compared with age-matched non-suspended controls. Serum 1,25-dihydroxyvitamin D3 decreased to 60% of the control level after 8 days of skeletal unloading but regained almost normal levels over the next 7 days. Since it is known that vitamin D3 up regulates and glucocorticoid down regulates transcription of the osteocalcin gene, the endocrine response evoked by tail suspension may have aggravated the disuse atrophy caused by skeletal unloading in this study.