A case of endoscopic full-thickness resection for gastric gastrointestinal stromal tumor in the submucosal tunnel

The patient was a 49-year-old female with a submucosal tumor (12×12 mm) located in the lesser curvature side of the stomach. The diagnosis by endoscopic ultrasound fine-needle aspiration was of a gastrointestinal stromal tumor. Computed tomography and endoscopic ultrasound showed gastrointestinal stromal tumor with an intra-luminal growth type. Endoscopic full-thickness resection was then performed. To achieve good counter traction, enough safety margin, and minimal defect of muscle, full-thickness resection via creating a submucosal tunnel was performed as a new technique. The final histological diagnosis was gastrointestinal stromal tumor with R0 resection.

Endoscopic ligation technique for refractory gastrotracheal fistula

Endoscopic therapy has recently undergone remarkable progress, including the use of suturing procedures within the gastrointestinal tract using flexible endoscopes. However, existing suturing techniques primarily involve closure using instruments or continuous sutures using an endoscopic needle holder, leaving a gap in nodal suturing methods with extracorporeal ligation. This paper introduces a novel approach, the endoscopic ligation technique, wherein a flexible endoscope is utilized for nodal suturing through extracorporeal ligation.

Association between Vascular Calcification and Intraplaque Hemorrhage in Coronary Atherosclerosis from Autopsy: The Hisayama Study

AIMS

Vascular calcification is observed in advanced atherosclerotic lesions. Vascular calcification is considered to increase the risk of intraplaque hemorrhage and subsequent plaque destabilization; however, there is limited pathohistoological evidence of the association between vascular calcification and intraplaque hemorrhage. The aim of this study was to investigate the association between vascular calcification and intraplaque hemorrhage in the coronary arteries.

METHODS

We examined 374 coronary arteries obtained from the autopsy samples of 126 deceased individuals. The vascular calcification levels of each artery were categorized into no calcification and quintiles of calcification area size among the arteries with calcification. Macrophage infiltration and neovascularization were also evaluated. The association of the calcification area, macrophage area, or number of vessels with the presence of intraplaque hemorrhage in the coronary arteries was estimated using a logistic regression analysis.

RESULTS

Calcification lesions were observed in 149 coronary arteries. Arteries in the fourth quintile of calcification area size had a significantly greater likelihood of intraplaque hemorrhage than the arteries without calcification, after adjusting for confounders: odds ratio 13.13 (95% confidence interval: 2.97-58.16). After evaluating the influence of macrophage infiltration, the highest odds ratio of intraplaque hemorrhage was associated with the combination of large macrophage area and moderately sized calicification areas. The odds ratio of intraplaque hemorrhage additively increased with the combination of calcification and the number of vessels.

CONCLUSIONS

The present findings suggest that vascular calcification is significantly associated with intraplaque hemorrhage. The association between vascular calcification and intraplaque hemorrhage may decrease above a certain size of the calcification area.

A case of breast milk-acquired cytomegalovirus infection in an extremely low birth weight infant

INTRODUCTION

Although breast milk is considered the optimal nutrition for infants, it is also the primary cause of postnatal cytomegalovirus (CMV) infection. Preterm infants with postnatal CMV infections are susceptible to a variety of life-threatening conditions.

CASE SUMMARY

Twin male infants were delivered via emergency caesarian section at 27 weeks' gestation secondary to maternal complete uterine rupture. The Apgar scores at 1 and 5 min were 1 and 1 for the older twin (Twin A) and 0 and 3 for the younger twin (Twin B). Their birth weights were 1203 g (+ 0.65SD) and 495 g (- 3.79SD) respectively. On day 41, laboratory blood test results for Twin B showed a moderate elevation in C-reactive protein (CRP), thrombocytopenia. CMV quantitative polymerase chain reaction (qPCR) tests in Twin B's urine and blood as well as in the mother's breast milk were positive, but stored, dried umbilical cord CMV qPCR tests were negative. Twin B was diagnosed with a postnatal CMV infection secondary to infected breast milk and ganciclovir was commenced on day 52. Treatment was switched to valganciclovir at 74 days of age, but a negative CMV-DNA level in the blood was not achieved. Postnatal CMV infection in this infant led to an exacerbation of pre-existing bronchopulmonary dysplasia (BPD) and he demised at 182 days of age.

CONCLUSION

Postnatal cytomegalovirus infections may lead to exacerbations of BPD. Early use of raw breast milk in preterm infants should be done with careful consideration of this potential complication.

CKD, Brain Atrophy, and White Matter Lesion Volume: The Japan Prospective Studies Collaboration for Aging and Dementia

Rationale & Objective

Chronic kidney disease, defined by albuminuria and/or reduced estimated glomerular filtration rate (eGFR), has been reported to be associated with brain atrophy and/or higher white matter lesion volume (WMLV), but there are few large-scale population-based studies assessing this issue. This study aimed to examine the associations between the urinary albumin-creatinine ratio (UACR) and eGFR levels and brain atrophy and WMLV in a large-scale community-dwelling older population of Japanese.

Study Design

Population-based cross-sectional study.

Setting & Participants

A total of 8,630 dementia-free community-dwelling Japanese aged greater than or equal to 65 years underwent brain magnetic resonance imaging scanning and screening examination of health status in 2016-2018.

Exposures

UACR and eGFR levels.

Outcomes

The total brain volume (TBV)-to-intracranial volume (ICV) ratio (TBV/ICV), the regional brain volume-to-TBV ratio, and the WMLV-to-ICV ratio (WMLV/ICV).

Analytical Approach

The associations of UACR and eGFR levels with the TBV/ICV, the regional brain volume-to-TBV ratio, and the WMLV/ICV were assessed by using an analysis of covariance.

Results

Higher UACR levels were significantly associated with lower TBV/ICV and higher geometric mean values of the WMLV/ICV (P for trend = 0.009 and <0.001, respectively). Lower eGFR levels were significantly associated with lower TBV/ICV, but not clearly associated with WMLV/ICV. In addition, higher UACR levels, but not lower eGFR, were significantly associated with lower temporal cortex volume-to-TBV ratio and lower hippocampal volume-to-TBV ratio.

Limitations

Cross-sectional study, misclassification of UACR or eGFR levels, generalizability to other ethnicities and younger populations, and residual confounding factors.

Conclusions

The present study demonstrated that higher UACR was associated with brain atrophy, especially in the temporal cortex and hippocampus, and with increased WMLV. These findings suggest that chronic kidney disease is involved in the progression of morphologic brain changes associated with cognitive impairment.

Endoscopic full‐thickness resection of an esophageal leiomyoma located in close proximity to the azygos vein

Third‐space endoscopic techniques, such as peroral endoscopic tumor resection (POET) and submucosal tunneling endoscopic resection (STER), enable access to deep organs and tissues that have been previously inaccessible with an endoscope. We present a 29‐year‐old man with a submucosal tumor (40 × 25 mm) located at 5 o'clock in the upper thoracic esophagus. Histological diagnosis by endoscopic ultrasound–fine needle aspiration was leiomyoma. Computed tomography showed the azygos vein posterior to the tumor. However, because endoscopic ultrasound revealed space between them, POET was performed. Because the tumor originated from the deep layer of the muscularis propria, full‐thickness resection was performed to achieve R0 resection. The azygos vein arch was seen through the mediastinal space after tumor enucleation. The final histopathological diagnosis was leiomyoma. POET is a potentially revolutionary endoscopic technique that enables full‐thickness resection of nonepithelial lesions. Preoperative computed tomography or endoscopic ultrasound to determine peritumoral anatomy is important to ensure safety. During the procedure, it is important to operate under direct vision, accurately identify the tumor boundary, and dissect along the boundary to avoid damaging the tumor and surrounding structures.

Effect of kinematics on the torque/force generation, surface characteristics, and shaping ability of a nickel titanium rotary glide path instrument: an ex-vivo study

AIM

To evaluate the effect of various rotational motions on the torque/force generation, surface wear, and shaping ability of the ProGlider glide path instrument (Dentsply Sirona).

METHODOLOGY

Mesiobuccal and mesiolingual canals of mandibular molars were selected based on the canal volume, length, angle of curvature (25°-40°), and radius of curvature (4-8 mm) after micro-computed tomographic scanning. The samples were randomly assigned to four groups (n = 13, each) according to movement kinematics [continuous rotation (CR; 300 rpm), optimum torque reverse motion (OTR; 180° forward and 90° reverse when torque > 0.4 N·cm), time-dependent reciprocal motion (TmR; 180° forward and 90° reverse), and optimum glide path motion (OGP; a combination of 90° forward, 90° reverse, 90° forward, and 120° reverse)]. Instrumentation was performed with an automated root canal instrument and torque/force analysing device. Maximum torque/force values, canal volume changes, and canal-centring ratios at 1, 3, 5, and 7 mm were evaluated. Surface defects (pits, grooves, microcracks, blunt cutting edges, and disruption of cutting edges) and spiral distortion on the ProGlider instrument were scored at the tip and 5 mm short of the tip before and after five consecutive uses with scanning electron microscopy. The Kruskal-Wallis test followed by Dunn's post-test with Bonferroni correction and Wilcoxon signed-rank test were used to analyse the data (α = 0.05).

RESULTS

OGP generated significantly less clockwise torque and greater upward force than other groups (P < 0.05). OGP resulted in significantly fewer surface defects than CR (P < 0.05). In OGP and CR, the tip exhibited more surface defects than 5 mm short of the tip (P < 0.05). CR resulted in greater volume changes than OGP and TmR (P < 0.05) and greater centring ratios (i.e., more deviation) than OGP at 1 mm and OTR at 3 mm (P < 0.05).

CONCLUSIONS

Under laboratory conditions using the ProGlider instrument, OGP generated significantly less clockwise torque and greater upward force than the other rotatory motions. OGP generated fewer superficial defects than CR, and the three modes of reciprocal rotation better maintained the apical curvature of root canals than CR with the ProGlider instrument.

Verification of the Usefulness of an Assessment and Risk Control Sheet that Promotes Management of Cancer Drug Therapy

Background: Proper management of adverse events is crucial for the safe and effective implementation of anticancer drug treatment. Showa University Hospital uses our interview sheet (assessment and risk control [ARC] sheet) for the accurate evaluation of adverse events. On the day of anticancer drug treatment, a nurse conducts a face-to-face interview. As a feature of the ARC sheet, by separately describing the symptoms the day before treatment and the day of treatment and sharing the information on the medical record, it is possible to clearly determine the status of adverse events. In this study, we hypothesized that the usefulness and points for improvement of the ARC sheet would be clarified by using and evaluating a patient questionnaire.

Methods: This study included 174 patients (144 at Showa University Hospital (Hatanodai Hospital) and 30 at Showa University Koto Toyosu Hospital (Toyosu Hospital) who underwent pre-examination interviews by nurses and received cancer chemotherapy at the outpatient center of Hatanodai and Toyosu Hospital. In the questionnaire survey, the ARC sheet’s content and quality, respondents’ satisfaction, structural strengths, and points for improvement were evaluated on a five-point scale.

Results: The patient questionnaire received responses from 160 participants, including the ARC sheet use group (132 people) and the non-use group (28 people). Unlike the ARC sheet non-use group, the ARC sheet use group recognized that the sheet was useful to understand the adverse events of aphthous ulcers (p = 0.017) and dysgeusia (p = 0.006). In the satisfaction survey questionnaire, there was a high sense of security in the pre-examination interviews by nurses using the ARC sheet.

Conclusions: The ARC sheet is considered an effective tool for comprehensively evaluating adverse events. Pre-examination interviews by nurses using ARC sheets accurately determined the adverse events experienced by patients with anxiety and tension due to confrontation with physicians.

Serum Uric Acid Levels and Nephrosclerosis in a Population-Based Autopsy Study: The Hisayama Study

INTRODUCTION

Information regarding the influence of serum uric acid (SUA) levels on pathological changes in the kidney is limited. In this study, we examined the association between SUA levels and pathological findings of nephrosclerosis in population-based autopsy samples.

METHODS

A total of 923 deceased individuals in a Japanese community underwent autopsy examinations between 1974 and 1994. Of these, 547 individuals with available kidney tissues and health examination data within a median of 3 years before death were eligible for the present study. SUA levels were categorized into quintiles (Q1, 107-237; Q2, 238-279; Q3, 280-326; Q4, 327-380; Q5, 381-755 μmol/L). Advanced degrees of glomerular sclerosis, kidney arteriolar hyalinosis, and kidney arteriosclerosis were defined as the 90th percentile or more of a glomerular sclerosis index and an arteriolar hyalinosis index, and the 10th percentile or less of a wall-lumen ratio, respectively. A logistic regression model was used to evaluate odds ratios (ORs) and their 95% confidence intervals (CIs) of SUA levels on each kidney lesion.

RESULTS

Higher SUA levels were significantly associated with higher values of the age- and sex-adjusted glomerular sclerosis index and lower values of the wall-lumen ratio (both p for trend <0.01). Individuals in the Q5 group had a significantly greater likelihood of advanced glomerular sclerosis (OR 7.19, 95% CI 2.42-21.38) and advanced kidney arteriosclerosis (OR 5.28, 95% CI 1.77-15.80) than individuals in the Q1 group after adjusting for potential covariates. There was no evidence of significant associations of SUA levels with either the arteriolar hyalinosis index or the presence of advanced arteriolar hyalinosis.

CONCLUSIONS

Elevated SUA levels were significantly associated with advanced glomerular sclerosis and advanced kidney arteriosclerosis, but not with advanced arteriolar hyalinosis in community-based autopsy samples of Japanese.

Influence of rotational speed on torque/force generation and shaping ability during root canal instrumentation of extracted teeth with continuous rotation and optimum torque reverse motion

AIM

To evaluate how different rotational speeds affect the torque/force generation and shaping ability of rotary root canal instrumentation using JIZAI (MANI, Utsunomiya, Japan) nickel-titanium instruments in continuous rotation and optimum torque reverse (OTR) motion.

METHODOLOGY

Mesial root canals of extracted mandibular molars were instrumented up to size 25, 0.04 taper using JIZAI instruments, and anatomically matched canals were selected based on geometric features of the canal [canal volume (mm³ ), surface area (mm² ), length, 15°-20° curvature and radius of curvature (4-8 mm)] after micro-computed tomographic scanning. An automated root canal instrumentation and torque/force analysing device was programmed to permit a simulated pecking motion (2 s downward and 1 s upward at 50 mm min^-1 ). The selected canals were prepared with size 25, 0.06 taper JIZAI instruments using continuous rotation or OTR motion and further subdivided according to the rotational speed (300 or 500 rpm, n = 10 each). Real-time clockwise/counterclockwise torque and downward/upward force were recorded using a custom-made torque/force analysing device. Then, the registered pre- and post-operative micro-computed tomographic datasets were examined to evaluate the canal volume changes and centring ratios at 1, 3, 5 and 7 mm from the apical foramen. Data were analysed using two-way analysis of variance or the Kruskal-Wallis test and Mann-Whitney U test with Bonferroni correction (α = 5%).

RESULTS

Maximum upward force and clockwise torque were significantly smaller in 500 rpm groups than in 300 rpm groups (P < .05); however, no significant difference was found between continuous rotation and OTR motion (P > .05). OTR motion developed higher maximum counterclockwise torque than continuous rotation (P < .05). Maximum downward force, canal volume changes and centring ratios were not significantly different among all groups (P > .05). There was no file fracture in any of the groups.

CONCLUSIONS

Under laboratory conditions using JIZAI instruments, a rotational speed of 500 rpm generated significantly lower maximum screw-in forces and torque values than rotational speed of 300 rpm. Continuous rotation and OTR motion performed similarly in shaping the canals.

Two case of bilateral approach in laparoscopic pancreas-sparing distal duodenectomy for duodenal neoplasms arising from the distal duodenum

•

Surgical procedures for duodenal tumors at third and fourth portion of duodenum.

•

The procedures do not require either Kocher’s maneuver and Cattell–Braasch maneuver.

•

Preferable approach for laparoscopic pancreas sparing distal duodenectomy.

•

Pancreas was safely preserved during the procedures.

Introduction

Laparoscopic pancreas-sparing distal duodenectomy is a less invasive surgical therapy; however, the anatomical complexity of the duodenum increases the difficulty of laparoscopic procedures. We introduce our technique for laparoscopic pancreas-sparing distal duodenectomy for distal duodenal tumors.

Presentation of cases

A first patient was 47-year-old woman who had 30 mm of duodenal tumor which located in third portion of duodenum. A second patient was 66-year-old man who had 35 mm of submucosal tumor which located in the third portion of duodenum. Laparoscopic pancreas-sparing duodenectomy was performed using bilateral approach for both cases. We began by dissecting an avascular area on the right side of the transverse mesocolon to mobilize the second and third portions of the duodenum with the uncinate process of the pancreas. Next, from the left side, the jejunum and the fourth portion of the duodenum were fully mobilized orally from the surrounding tissue, connecting the dissection plane with the right-side area. The jejunum and duodenum were cut with a linear stapler. Intracorporeal reconstruction was performed in an overlapped manner. We performed this procedure in two patients. Operative time was 326 and 370 min, respectively. Patients were discharged on postoperative days 9–12 without postoperative complications.

Discussion

Duodenal tumors are found increasingly often because of developments in endoscopic technology and techniques; therefore, establishing safe surgical procedures for duodenal tumor excision is imperative. Our surgical approach was simple and safe procedure.

Conclusion

Laparoscopic pancreas-sparing distal duodenectomy with a bilateral approach is a useful approach without wide mobilization of duodenum.

Impact of the Coronavirus Disease 2019 Outbreak on Activity and Exercise Levels among Older Patients

OBJECTIVES

This study aimed to clarify the impact of the coronavirus disease 2019 outbreak on the levels of activity among older patients with frailty or underlying diseases. A total of 175 patients (79.0±7.0 years) undergoing outpatient or home-based rehabilitation, stratified into groups, based on frailty status. The percentage of patients who went out at least once a week decreased after the outbreak from 91% to 87%, from 65% to 46%, and from 47% to 36% in the non-frail, frail, and nursing care requirement groups, respectively. The proportion of older patients participating in exercise during the outbreak was 75%, 51%, and 41% in the non-frail, frail, and nursing care requirement groups, respectively. The proportion of older patients participating in voluntary exercise after instruction was lowest in the frail group (35%). Older patients with frailty are susceptible to the negative effects of refraining from physical activity and require careful management.

Functional Analysis of PTH1R Variants Found in Primary Failure of Eruption

Although many variants of the parathyroid hormone 1 receptor (PTH1R) gene are known to be associated with primary failure of eruption (PFE), the mechanisms underlying the link remains poorly understood. We here performed functional analyses of PTH1R variants reported in PFE patients-namely, 356C>T (P119L), 395C>T (P132L), 439C>T (R147C), and 1148G>A (R383Q)-using HeLa cells with a lentiviral vector-mediated genetic modification. Two particular variants, P119L and P132L, had severe reduction in a level of N-linked glycosylation when compared with wild-type PTH1R, whereas the other 2 showed modest alteration. PTH1R having P119L or P132L showed marked decrease in the affinity to PTH_1-34, which likely led to severely impaired cAMP accumulation upon stimulation in cells expressing these mutants, highlighting the importance of these 2 amino acid residues for ligand-mediated proper functioning of PTH1R. To further gain insights into PTH1R functions, we established the induced pluripotent stem cell (iPSC) lines from a patient with PFE and the heterozygous P132L mutation. When differentiated into osteoblastic-lineage cells, PFE-iPSCs showed no abnormality in mineralization. The mRNA expression of RUNX2, SP7, and BGLAP, the osteoblastic differentiation-related genes, and that of PTH1R were augmented in both PFE-iPSC-derived cells and control iPSC-derived cells in the presence of bone morphogenetic protein 2. Also, active vitamin D₃ induced the expression of RANKL, a major key factor for osteoclastogenesis, equally in osteoblastic cells derived from control and PFE-iPSCs. In sharp contrast, exposure to PTH_1-34 resulted in no induction of RANKL mRNA expression in the cells expressing P132L variant PTH1R, consistent with the idea that a type of heterozygous PTH1R gene mutation would spoil PTH-dependent response in osteoblasts. Collectively, this study demonstrates a link between PFE-associated genetic alteration and causative functional impairment of PTH1R, as well as a utility of iPSC-based disease modeling for future elucidation of pathogenesis in genetic disorders, including PFE.

8-Nitro-cGMP is a promoter of osteoclast differentiation induced by RANKL

Osteoclasts are multinucleated giant cells differentiated from monocyte-macrophage-lineage cells under stimulation of receptor activator of nuclear factor κ-B (RANK) ligand (RANKL) produced by osteoblasts and osteocytes. Although it has been reported that nitric oxide (NO) and reactive oxygen species (ROS) are involved in this process, the mechanism by which these labile molecules promote osteoclast differentiation are not fully understood. In this study, we investigated the formation and function of 8-nitro-cGMP, a downstream molecule of NO and ROS, in the process of osteoclast differentiation in vitro. 8-Nitro-cGMP was detected in mouse bone marrow macrophages and osteoclasts differentiated from macrophages in the presence of RANKL. Inhibition of NO synthase suppressed the formation of 8-nitro-cGMP as well as RANKL-induced osteoclast differentiation from macrophages. On the other hand, RANKL-induced osteoclast differentiation was promoted by addition of 8-nitro-cGMP to the cultures. In addition, 8-nitro-cGMP enhanced the mRNA expression of RANK, the receptor for RANKL. However, 8-bromo-cGMP, a membrane-permeable derivative of cGMP, did not have an effect on either RANKL-induced osteoclast differentiation or expression of the RANK gene. These results suggest that 8-nitro-cGMP is a novel positive regulator of osteoclast differentiation, which might help to explain the roles of NO and ROS in osteoclast differentiation.

A cytokine signal inhibitor for rheumatoid arthritis enhances cancer metastasis via depletion of NK cells in an experimental lung metastasis mouse model of colon cancer

Current therapy for rheumatoid arthritis (RA) relies on global suppression of the immune response or specific blockade of inflammatory cytokines. However, it is unclear how immunosuppressants affect patients with cancer. Therefore, in the present study, the effect of three biological agents, tofacitinib, anti-mouse IL-6 receptor antibody (MR16-1) and etanercept, which are used for the treatment of RA diseases, on a tumor-bearing mouse model was investigated. The effect of the three agents was examined using a mouse lung-metastasis model with the murine colon 26 cancer cell line. Lymphocyte subsets and natural killer (NK) cells in peripheral blood and spleen were analyzed using fluorescence-activated cell sorting, and the number of lung surface nodules was examined. In the continuous tofacitinib administration (15 mg/kg/day) group, the number of lung surface nodules was significantly increased compared with that of the vehicle-treated group (vehicle, 1.20±0.58; tofacitinib, 35.6±10.81; P<0.01). NK cell number in the blood and spleen of tofacitinib-treated mice was decreased 10-fold, and the percentage of cluster of differentiation (CD)11⁺CD27^- NK cells was significantly reduced. MR16-1 [8 mg/mouse; once a week; intraperitoneal (i.p.)] or etanercept (1 mg/mouse; 3 times a week; i.p.) treatment did not affect the number of NK cells or lung metastasis. In the present study, immunosuppressants that target cytokines, including tofacitinib, were demonstrated to inhibit the proliferation and differentiation of NK cells, and exhibit the potential to promote cancer metastasis using a mouse model of lung metastasis.

Gene Expression Profiling of Mouse Condylar Cartilage during Mastication by Means of Laser Microdissection and cDNA Array

Little is known about the mechanisms of mandibular condylar growth. In this study, gene expression in the mandibular condylar cartilage of young post-natal mice was monitored by means of a cDNA microarray, real-time PCR, and laser microdissection before and after the initiation of mastication (newborn, 7 days, 21 days, initiation of mastication, and 35 days). Insulin-like growth factor-1 (IGF-I), transforming-growth-factor-beta-2 (TGFbeta2), and aggrecan mRNAs were clearly expressed at 21 days, while the expression of osteopontin mRNAs was most clear at 35 days. Parathyroid-hormone-related protein (PTHrP), Indian-hedgehog (Ihh), and insulin-like growth factor-2 (IGF-2) mRNAs were clearly expressed during lactation (newborn and 7 days). Heat-shock-protein 84 (HSP-84) and heat-shock-protein 86 (HSP-86) were clearly expressed at 35 days. These results revealed that gene expression changed during mandibular condylar cartilage growth, and that, interestingly, these changes coincided with the initiation of mastication.

Gastric metastasis from salivary duct carcinoma mimicking primary gastric cancer

INTRODUCTION

We present a very rare case of gastric metastasis mimicking primary gastric cancer in a patient who had undergone surgery for salivary duct carcinoma.

PRESENTATION OF CASE

A 67-year-old man had been diagnosed as having right parotid cancer and had undergone a right parotidectomy and lymph node dissection. The histological diagnosis was salivary duct carcinoma. One year after the surgery, a positron emission tomography-computed tomography scan using fluorodeoxyglucose (FDG) revealed an abnormal uptake of FDG in the left cervical, mediastinal, paraaortic, and cardiac lymph nodes; stomach; and pancreas. On gastroduodenoscopy, there was a huge, easily bleeding ulcer mimicking primary gastric cancer at the upper body of the stomach. Biopsy revealed poorly differentiated adenocarcinoma. Therefore, we were unable to differentiate between the primary gastric cancer and the metastatic tumor using gastroduodenoscopy and biopsy. Because of the uncontrollable bleeding from the gastric cancer, we performed an emergency palliative total gastrectomy. On histological examination, the gastric lesion was found to be metastatic carcinoma originating from the salivary duct carcinoma.

DISCUSSION

In the presented case, we could not diagnose the gastric metastasis originating from the salivary duct carcinoma even by endoscopic biopsy. This is because the histological appearance of salivary duct carcinoma is similar to that of high-grade adenocarcinoma, thus, resembling primary gastric cancer.

CONCLUSION

When we perform endoscopic examination of patients with malignant neoplasias, a possibility of metastatic gastric cancer should be taken into consideration.

Impact of perioperative probiotic treatment for surgical site infections in patients with colorectal cancer

The aim of the present study was to estimate the effect of the perioperative administration of probiotics in patients undergoing colorectal cancer (CRC) surgery. The study focused on a total of 156 consecutive surgeries carried out from among all the elective CRC surgeries performed between April 2009 and March 2013. The patients involved in surgeries undertaken between April 2009 and October 2011 were placed in the non-probiotic group (group A, 81 patients) and those involved in surgeries between November 2011 and March 2013 were placed in the probiotic group (group B, 75 patients). Postoperative infectious complications were recorded, and the immune responses and fecal microbiota were determined. A breakdown of infectious complications showed that 21 (13.5%) patients experienced superficial incisional surgical site infections (SSIs), of which 16 patients were from group A (19.8%), and five patients from group B (6.7%) (P=0.016). The ImmuKnow® adenosine triphosphate values peaked on the first postoperative day (POD) in both groups. In group A, the ImmuKnow value of the first POD was increased significantly compared with the preoperative value (P=0.022). In group B, the value of the first POD did not increase compared with the preoperative value (P=0.28). In conclusion, probiotic treatment can reduce superficial incisional SSIs in patients undergoing CRC surgery. Perioperative probiotic treatment can enhance immune responses and improve the intestinal microbial environment.

Randomized Controlled Study to Evaluate the Efficacy of a Preoperative Respiratory Rehabilitation Program to Prevent Postoperative Pulmonary Complications after Esophagectomy

BACKGROUND/AIMS

Patients with postoperative pulmonary complications after esophagectomy often have increased mortality. The purpose of the study was to examine the efficacy of preventing postoperative pulmonary complications by an intensive preoperative respiratory rehabilitation (PR) program for esophageal cancer patients.

METHODS

This study was a prospective randomized controlled study. Thirty patients in the PR group and 30 patients in the no preoperative respiratory rehabilitation (NPR) group were included. The PR group received preoperative rehabilitation for more than 7 days, while the NPR group did not receive any preoperative rehabilitation. All patients underwent postoperative rehabilitation from the first postoperative day. The postoperative pulmonary complications were evaluated using the Clavien-Dindo classification (CDC) and the Utrecht Pneumonia Scoring System (UPSS).

RESULTS

The CDC grade in the PR group was significantly lower than that in the NPR group (p = 0.014). The UPSS score in the PR group was significantly lower than that in the NPR group at postoperative day 1 (p = 0.031). In the multivariate analysis, NPR was an independent risk factor for postoperative pulmonary complications greater than CDC grade II (OR: 3.99, 95% CI: 1.28-12.4, p = 0.017).

CONCLUSIONS

This study showed that the intensive PR program was capable of reducing the postoperative pulmonary complications in esophageal cancer patients.

Prone Position Is Useful in Thoracoscopic Enucleation of Esophageal Leiomyoma

A 36-year-old man was admitted to our institute due to the diagnosis of esophageal submucosal tumor detected by a periodical upper gastrointestinal endoscopic examination without any complaint. Thoracoscopic enucleation of the lesion with the preoperative clinical diagnosis of esophageal leiomyoma was performed under general anesthesia in the prone position. After immunohistochemical examination, the pathological diagnosis was leiomyoma. There was no remarkable event during the postoperative hospital stay, and the patient was discharged on the 12th day after surgery. This case report suggests that the prone position might be superior to the left lateral decubitus position in thoracoscopic enucleation of esophageal leiomyoma.

Is the Geriatric Nutritional Risk Index a Significant Predictor of Postoperative Complications in Patients with Esophageal Cancer Undergoing Esophagectomy?

Background: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting the risk of nutrition-related complications. The GNRI has mainly been reported as a simple and accurate tool to assess the nutritional status and prognosis of elderly patients. So far, there have been no reports of the GNRI in patients with gastrointestinal cancer. Our objective was to examine the association between the GNRI and short-term outcomes, especially postoperative complications, in patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. Materials and Methods: The present study enrolled 122 consecutive patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin in g/l) + (41.7 × present/ideal body weight). The characteristics and short-term outcomes were compared between two groups: the high (GNRI ≥90) and the low (GNRI <90) GNRI group. The mortality and morbidity rates, especially the rates regarding respiratory complications and anastomotic leakage, were investigated. Results: The mean age of the 122 patients was 63.9 ± 9.1 years (range 43-83). There were no significant differences in either patient or operative characteristics. The low GNRI group had a significantly higher rate of respiratory complications (p = 0.002). A multivariate analysis demonstrated that the GNRI was the only independent significant factor predicting respiratory complications (hazard ratio 3.41, 95% confidence interval 1.19-9.76; p = 0.022). Conclusion: The GNRI is considered to be a clinically useful marker that can be used to assess the nutritional status and predict the development of postoperative respiratory complications in patients with esophageal cancer undergoing esophagectomy and gastric tube reconstruction.

A Patient with a Large Gastric Tumor and Protein-Losing Gastroenteropathy Successfully Treated with Neoadjuvant TS-1 Combined with CDDP Therapy

Gastric cancer with protein-losing gastroenteropathy is relatively rare worldwide. The most important problem for the treatment of these patients is their low nutritional status and protein level, which can cause severe postoperative complications. We report a 49-year-old Japanese female with a large gastric tumor and protein-losing gastroenteropathy successfully treated with neoadjuvant TS-1 combined with CDDP therapy. She had a type 5 tumor with partially cauliflower-like appearance. Her blood chemistry revealed low serum total protein (3.3 g/dl) and low albumin (1.7 g/dl). She was additionally diagnosed with protein-losing gastroenteropathy based on ^99mTc-human serum albumin scintigraphy. Initial neoadjuvant chemotherapy decreased the size of the tumor and led to a marked improvement in her serum protein levels. She then underwent a total gastrectomy and lymph node dissection (D2) with a combined resection of the spleen and gallbladder. Therefore, neoadjuvant chemotherapy may provide a safe treatment before definitive surgery for gastric cancer with protein-losing gastroenteropathy.

Successful Treatment of Septic Shock due to Spontaneous Esophageal Perforation 96 Hours after Onset by Drainage and Enteral Nutrition

Spontaneous esophageal perforation is relatively uncommon, but carries a high mortality rate if diagnosis or treatment is delayed. We report the case of a 68-year-old man with spontaneous esophageal perforation who was successfully treated over 96 h after onset by thoracic drainage and jejunostomy for enteral nutrition. He vomited after drinking alcohol, soon followed by epigastralgia. Heart failure was suspected on admission to another hospital. Spontaneous esophageal perforation was diagnosed 48 h after admission. Chest tube drainage was performed, but his general condition deteriorated and he was transferred to our hospital. Emergent surgery was performed and esophageal perforation combined with pyothorax and mediastinitis was identified on the left side of the lower esophagus. The left thoracic cavity was rinsed and thoracic drainage was performed. Feeding jejunostomy was performed for postoperative enteral nutrition. Effective drainage and sufficient nutrition management appear extremely valuable in treating spontaneous esophageal perforation.

CD4+ T-lymphocytes are activated by surgical stress following colorectal resection in cancer patients

The aim of the present study was to measure adenosine triphosphate (ATP) levels in CD4⁺ T cells as a marker of T-cell activity following surgery for colorectal cancer using the ImmuKnow assay kit. A total of 16 consecutive patients who underwent surgical resection for colorectal cancer between August and December, 2012 were enrolled in this study, of whom 7 underwent laparoscopic resection and 9 underwent open abdominal surgery. The intracellular ATP levels in CD4⁺ T-lymphocytes were measured using the ImmuKnow assay kit preoperatively and on the 1st, 4th and 8th postoperative days, as were the white blood cell (WBC) count, lymphocyte count and C-reactive protein (CRP) levels. The ATP level of the CD4⁺ T-cells was significantly elevated on the 1st day following surgery compared to the preoperative level (P<0.01) and gradually returned to preoperative levels; the lymphocyte count was significantly decreased on the 1st postoperative day (P<0.001). In addition, the ImmuKnow assay demonstrated that only the ATP level, but not the WBC count, lymphocyte count or CRP level, exhibited a significant difference on the 1st (P=0.080) and 8th (P=0.042) postoperative days between the laparoscopic and open abdominal surgery groups. In conclusion, the ATP level of CD4⁺ T-lymphocytes was increased in response to surgical stress, in tandem with a decrease in the lymphocyte count. Therefore, the ImmuKnow assay kit may be clinically applicable for monitoring the immune response following surgery, as it exhibits a higher sensitivity compared to other assays.

The skeletal maturation status estimated by statistical shape analysis: axial images of Japanese cervical vertebra

OBJECTIVES

To evaluate axial cervical vertebral (ACV) shape quantitatively and to build a prediction model for skeletal maturation level using statistical shape analysis for Japanese individuals.

METHODS

The sample included 24 female and 19 male patients with hand-wrist radiographs and CBCT images. Through generalized Procrustes analysis and principal components (PCs) analysis, the meaningful PCs were extracted from each ACV shape and analysed for the estimation regression model.

RESULTS

Each ACV shape had meaningful PCs, except for the second axial cervical vertebra. Based on these models, the smallest prediction intervals (PIs) were from the combination of the shape space PCs, age and gender. Overall, the PIs of the male group were smaller than those of the female group. There was no significant correlation between centroid size as a size factor and skeletal maturation level.

CONCLUSIONS

Our findings suggest that the ACV maturation method, which was applied by statistical shape analysis, could confirm information about skeletal maturation in Japanese individuals as an available quantifier of skeletal maturation and could be as useful a quantitative method as the skeletal maturation index.

Gastric cancer arising from the remnant stomach after distal gastrectomy: A review

Gastric stump carcinoma was initially reported by Balfore in 1922, and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology, carcinogenesis, Helicobacter pylori (H. pylori) infection, Epstein-Barr virus infection, clinicopathologic characteristics and endoscopic treatment. In particular, it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition, endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast, many issues concerning gastric stump carcinoma remain to be clarified, including molecular biological characteristics and the carcinogenesis of H. pylori infection. We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.

Improvement of high-sensitivity inflammation-based Glasgow prognostic score by gastrectomy is a favorable prognostic factor in patients with gastric cancer

AIM

The aim of the present study was to clarify the efficacy of inflammation-based Glasgow prognostic score after surgery in patients with gastric cancer and to determine clinicopathological factors affecting score improvement.

PATIENTS AND METHODS

Participants in this retrospective study were 236 patients with gastric cancer who underwent gastrectomy at the Fukuoka University Hospital. The high-sensitivity inflammation-based Glasgow prognostic score (HS-GPS) (cut-off values: 0.3 mg/dl for C-reactive protein; 3.5 g/dl for albumin) were calculated before and 1 month after surgery, and correlated to clinicopathological parameters and prognosis after surgery.

RESULTS

HS-GPS was classified as normal (score 0) in 162 patients and abnormal (score 1 or 2) in 74 patients. Out of the 162 patients with normal HS-GPS before surgery, 62 showed abnormal HS-GPS after surgery, while 26 of the 74 patients with abnormal HS-GPS before surgery improved to normal HS-GPS postoperatively. Abnormal HS-GPS before (p<0.0001) and after (p=0.0002) surgery were unfavorable prognostic factors in univariate analysis. HS-GPS after surgery was an independent prognostic factor (p=0.0324) in multivariate analysis, but HS-GPS before surgery was not. In the sub-group with abnormal HS-GPS before surgery (but not normal HS-GPS before surgery), improved HS-GPS after surgery had a favorable prognostic impact in both uni- (p=0.0039) and multivariate analyses (p=0.0032).

CONCLUSION

HS-GPS after surgery may be a valuable prognostic factor in patients with gastric cancer. Supplemental therapy represented by adjuvant chemotherapy might be required for gastric cancer patients showing no improvement in HS-GPS after gastrectomy.

Differences in the developmental origins of the periosteum may influence bone healing

BACKGROUND AND OBJECTIVE

The jaw bone, unlike most other bones, is derived from neural crest stem cells, so we hypothesized that it may have different characteristics to bones from other parts of the body, especially in the nature of its periosteum. The periosteum exhibits osteogenic potential and has received considerable attention as a grafting material for the repair of bone and joint defects.

MATERIAL AND METHODS

Gene expression profiles of jaw bone and periosteum were evaluated by DNA microarray and real-time polymerase chain reaction. Furthermore, we perforated an area 2 mm in diameter on mouse frontal and parietal bones. Bone regeneration of these calvarial defects was evaluated using microcomputed tomography and histological analysis.

RESULTS

The DNA microarray data revealed close homology between the gene expression profiles within the ilium and femur. The gene expression of Wnt-1, SOX10, nestin, and musashi-1 were significantly higher in the jaw bone than in other locations. Microcomputed tomography and histological analysis revealed that the jaw bone had superior bone regenerative abilities than other bones.

CONCLUSION

Jaw bone periosteum exhibits a unique gene expression profile that is associated with neural crest cells and has a positive influence on bone regeneration when used as a graft material to repair bone defects. A full investigation of the biological and mechanical properties of jaw bone as an alternative graft material for jaw reconstructive surgery is recommended.

The high-sensitivity modified Glasgow prognostic score is superior to the modified Glasgow prognostic score as a prognostic predictor in patients with resectable gastric cancer

AIM

The aim of the present study was to evaluate the superiority of the high-sensitivity modified Glasgow prognostic score (HS-mGPS) before surgery in patients with gastric cancer.

PATIENTS AND METHODS

The participants of this retrospective study comprised 552 patients with gastric cancer who underwent gastrectomy at the Fukuoka University Hospital. The HS-mGPS was calculated before surgery based on cutoff values of 0.3 mg/dl for C-reactive protein and 3.5 g/dl for albumin, and correlations between the HS-mGPS and the clinicopathological parameters and prognosis were evaluated. In addition, the superiority of the HS-mGPS to the mGPS as a prognostic indicator was examined in detail.

RESULTS

The mGPS was 0 in 494 patients, 1 in 24 patients and 2 in 34 patients. In contrast, the HS-mGPS was 0 in 411 patients, 1 in 75 patients and 2 in 66 patients. Both the mGPS (p < 0.0001) and HS-mGPS (p < 0.0001) were good prognostic predictors in gastric cancer patients who underwent gastrectomy. Of the 494 patients with an mGPS of 0 before surgery, 51 and 32 exhibited an HS-mGPS of 1 and 2, respectively. The patients who exhibited migration in the HS-mGPS demonstrated a significantly more unfavorable prognosis than the patients with an HS-mGPS of 0 (p < 0.0001). The prognostic impact of the HS-mGPS was especially clear in stage I and IV patients (p = 0.0027, p = 0.017). The HS-mGPS was found to be a superior prognostic predictor compared to the mGPS in a multivariate analysis (p = 0.0002).

CONCLUSIONS

The HS-mGPS before surgery is a superior prognostic predictor in patients with gastric cancer.

[A case of unresected gastric cancer that maintained long tumor dormancy by use of paclitaxel+S-1 combination therapy]

Here we report a case of unresected gastric cancer that maintained long tumor dormancy by use of paclitaxel+S-1 combination therapy. A 58-year-old woman was admitted to the hospital for peritoneal dissemination of unresectable gastric cancer. The patient further showed ileus with peritoneal dissemination in computed tomography(CT), and we performed resection of the intestine to release the stenosis. In addition, combination chemotherapy using paclitaxel(60mg/m2, weekly) and S-1(80mg/m2, every 2 weeks)was started after the operation. The patient was discharged from the hospital 7 3 days after the operation, and we continued combination chemotherapy as an outpatient over the following 3 years without serious side effects. Furthermore, tumor makers for gastric cancer were stable, although we could not examine tumor size since the patient rejected examinations such as CT. After 3 years, the patient was admitted to the hospital with cholecystitis, and we were able to evaluate the benefit of the chemotherapy against gastric cancer. The tumor size clearly remained unchanged compared to previous measurements, suggesting that the tumor maintained dormancy in this case.

Surgical resection for cancer located mainly in the lower esophagus

BACKGROUND/AIMS

The aim of the present study was to clarify the results and feasibility of surgical approaches for cancer, which is mainly occupied by squamous cell carcinoma (SCC), of the lower esophagus.

METHODOLOGY

Forty-four patients (34 men, 10 women) with cancer located at the lower esophagus were enrolled in this study. SCC was diagnosed in 36 cases and adenocarcinoma (ADC) in 8 cases. Thirteen patients underwent transhiatal esophagectomy, 18 underwent lower thoracic esophagectomy by left thoracotomy, and 13 underwent esophagectomy with a right thoracic approach by open thoracotomy or thoracoscopy.

RESULTS

Ten cases (ADC, n = 2; SCC, n = 8) showed involvement of mediastinal lymph nodes, although lymph node dissection varied with each surgical approach. Five-year survival rates were 75% for ADC and 31.9% for SCC, and ADC tended to be associated with a more favorable prognosis than SCC (p = 0.058). Transhiatal esophagectomy was performed more often in older patients (p < 0.05), but no other clinicopathological parameters appeared to affect the selection of surgical approach. No significant prognostic differences existed between surgical approaches (p = 0.35), even though the examination was limited to SCC (p = 0.98).

CONCLUSIONS

No significant prognostic differences were identified between transhiatal and left and right transthoracic approaches for lower esophageal cancer.

Is the prognostic impact of tumor location in patients with surgically resected esophageal squamous cell carcinoma affected by surgical approach?

AIM

The aim of the present study was to clarify differences in node metastasis mode and clinical outcomes based on tumor location in patients with esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

Participants comprised 228 patients with ESCC who underwent radical esophagectomy without preoperative supplement therapies. Lymph nodes were harvested from three fields: the neck, thorax, and abdomen. Patients were divided into three groups depending on tumor location [upper esophagus (UE), middle esophagus, or lower esophagus (LE)] and analyzed clinicopathologically.

RESULTS

The LE group showed significantly more progressive ESCC in terms of tumor invasion (p = 0.025), node metastasis (p = 0.0071), and TNM stage (p = 0.0043). The LE group revealed a tendency to metastasize to extrathoracic (especially abdominal) nodes (p = 0.0008). Recurrent laryngeal node metastasis was increased in the UE group (p = 0.016). However, no prognostic differences were detected between groups according to tumor location. Likewise, subgroup analyses by surgical approach (open thoracotomy vs. thoracoscopy) and cancer stage (stage I/II, III, and IV) did not reveal any significant prognostic impact of tumor location.

CONCLUSION

Lymphatic spread varied by tumor location, but no prognostic impact of tumor location could be detected in patients with ESCC in spite of surgical approach or cancer stage.

Three-dimensional evaluation of upper airway in patients with different anteroposterior skeletal patterns

OBJECTIVES

To investigate variability in the upper airway of subjects with different anteroposterior skeletal patterns by evaluating the volume and the most constricted cross-sectional area of the pharyngeal airway and defining correlations between the different variables.

MATERIAL AND METHODS

The study sample consisted of 60 patients (29 boys, 31 girls) divided into three groups: Class I (1 ≤ ANB ≤ 3), Class II (ANB>3), and Class III (ANB<1), to evaluate how the jaw relationship affects the airway volume and the most constricted cross-sectional area (Min-CSA). Differences between groups were determined using the Tukey-Kramer test. Correlations between variables were tested using Pearson's correlation coefficient.

RESULTS

The volume and the Min-CSA of the pharyngeal airway (PA) were significantly related to anteroposterior skeletal patterns (p < 0.05). The nasopharyngeal airway (NA) volume of Class I and Class III subjects was significantly larger than that of Class II subjects (p < 0.05). The Min-CSA and the length of PA were significantly related to the volume of PA (p < 0.05). The site and the size of the Min-CSA varied among the three groups.

CONCLUSIONS

The volume and the most constricted cross-sectional area of the airway varied with different anteroposterior skeletal patterns. The NA volume of Class I and Class III subjects was significantly larger than that of patients with a Class II skeletal pattern.

Switching to an L/N-type calcium channel blocker shows renoprotective effects in patients with chronic kidney disease: the Kyoto Cilnidipine Study

OBJECTIVE

This open-label, randomized controlled trial investigated the effects of cilnidipine, an L/N-type calcium channel blocker (CCB), in patients with chronic kidney disease (CKD).

METHODS

Sixty patients with CKD and well-controlled hypertension being treated with a renin- angiotensin system (RAS) inhibitor and an L-type CCB (L-CCB) were randomly assigned either to switch from the L-CCB to cilnidipine after a 4-week observation period or to continue with L-CCB treatment. Blood pressure, heart rate and renal function were monitored for 12 months. Data were available for analysis from 50 patients: 24 from the cilnidipine group and 26 from the L-CCB group.

RESULTS

Blood pressure was well controlled in both groups. After 12 months, proteinuria and heart rate were significantly decreased in the cilnidipine group, but proteinuria increased and heart rate remained unchanged in the L-CCB group. There was a significant positive correlation between the percentage changes in proteinuria and heart rate.

CONCLUSIONS

Cilnidipine has antihypertensive effects equivalent to those of L-CCBs. In patients with CKD, proteinuria can be decreased by switching from an L-CCB to cilnidipine, thereby improving renal function.

Medical emergency education using a robot patient in a dental setting

INTRODUCTION

In an ageing society, the frequency of medical emergencies in a dental setting appears to be increasing because of a growing number of medically compromised patients. However, we currently have no dental-specific simulation environment with advanced reproducibility for medical emergencies. Therefore, we used the robot patient in objective structured clinical examinations (OSCEs) for testing student competence in emergency management. This study aimed to evaluate student responses to medical emergencies in the dental setting.

MATERIAL AND METHODS

We used 98 fifth-grade dental students at Showa University as subjects and implemented the OSCE task entitled 'Management of medical emergency using a robot patient'. Candidates were asked to manage an emergency situation immediately after local anaesthesia, with one robot patient configured to develop vasovagal syncope and the other to experience adrenaline hypersensitivity. A questionnaire on the educational value of the robot patient was completed after the examination.

RESULTS

Thirty-two per cent of students could not accurately count her pulse because of an inappropriate method. Moreover, 78% could not correctly attach either the tonometer or pulse oximetry to the patient. Accurate diagnoses were given by only 22% of students, with vasovagal syncope diagnosed by 33% and adrenaline hypersensitivity by 8%. From a questionnaire, 78% of students recognised the usefulness of the robot patient in medical emergency training.

CONCLUSION

We found that student responses to the emergency situation were poor. The robot patient is useful in dental education for medical emergency training and assessment not only for situation management but also for differential diagnosis.

Serum leptin levels negatively correlate with trabecular bone mineral density in high-fat diet-induced obesity mice

OBJECTIVES

This study evaluated the influence of diet-induced obesity on bone tissue quantity and quality in the proximal tibiae of growing mice and also examined the relationships between the serum total cholesterol, leptin, and adiponectin levels and trabecular and cortical bone mineral parameters.

METHODS

Six-week-old male C57BL/6J mice were divided into two groups; one received a control diet, and the other received a high-fat-diet. After treatment for 4, 8, or 12 weeks, the bone quantity and quality were analyzed using peripheral quantitative computed tomography (pQCT), micro-computed tomography and histomorphometry.

RESULTS

In the early stages, trabecular bone density decreased with an increase in the number of adipocytes and the deterioration of trabeculae. In contrast, although cortical bone formation was slower in obese mice compared with control mice, bone formation on the periosteal surface increased with age. Serum leptin levels were correlated with trabecular, but not cortical bone density, whereas neither the adiponectin nor total cholesterol level was correlated with bone mass in mice with diet-induced obesity.

CONCLUSIONS

We conclude that bone loss at these two sites is differentially regulated in mice. Furthermore, we demonstrate that serum leptin may be a useful indicator of risk for osteoporosis associated with diet-induced obesity.

Introduction of a robot patient into dental education

In recent years, with the increasing social awareness of safety in medical practice, improving clinical skills has become very important, especially for recently graduated dentists. Traditionally, mannequins have been used for clinical skill training, but a mannequin is quite different from a real patient because they have no autonomous movement or conversational ability. This indicates that pre-clinical simulation education is inadequate. We have, therefore, developed a robot patient that can reproduce an authentic clinical situation for dental clinical training. The robot patient, designed as a full-body model with a height of 157 cm, has eight degrees of freedom in the head and the ability to perform various autonomous movements. Moreover, saliva secretion and conversation with the trainee can be reproduced. We have introduced the robot patient into an objective structured clinical examination targeted at fifth-grade students in our dental school to evaluate their skills in cavity preparation, whilst considering the safety of the treatment. As a result, many of the students were able to deal appropriately with a patient's unexpected movement. Moreover, results of a questionnaire survey showed that almost all the students recognised the educational value of the robot patient especially for 'risk management', and they preferred the robot patient to traditional mannequins. Practical application of the robot patient in dental clinical education was evaluated through the experiences of the fifth-grade students, which showed the effectiveness of the robot patient in the dental field.

Mineral trioxide aggregate inhibits osteoclastic bone resorption

Mineral trioxide aggregate (MTA), a commonly used endodontic repair material, is useful for both basic and clinical research, and the effect of MTA on osteoblast differentiation has been well-defined. However, the effects of MTA on osteoclastic bone resorption are not fully understood. Hence, the aim of this study is to examine the effect of MTA solution in the regulation of osteoclast bone-resorbing activity using osteoclasts formed in co-cultures of primary osteoblasts and bone marrow cells. MTA solution dose-dependently reduced the total area of pits formed by osteoclasts. The reduction of resorption induced by 20% MTA treatment was due to inhibition of osteoclastic bone-resorbing activity and had no effect on osteoclast number. A 20% MTA solution disrupted actin ring formation, a marker of osteoclastic bone resorption, by reducing phosphorylation and kinase activity of c-Src, and mRNA expressions of cathepsin K and mmp-9. A high concentration of MTA solution (50%) induced apoptosis of osteoclasts by increasing the expression of Bim, a member of the BH3-only (Bcl-2 homology) family of pro-apoptotic proteins. Taken together, our results suggest that MTA is a useful retrofilling material for several clinical situations because it both stimulates osteoblast differentiation and inhibits bone resorption.

Orthodontic treatment of a unilateral impacted mandibular canine and first premolar: a case report

BACKGROUND

Few dentists have seen an impacted mandibular canine and first premolar, and there is little information in the literature on the treatment of this rare condition.

CASE REPORT

A 13-year-old Japanese male with an impacted mandibular right canine and first premolar was treated orthodontically. We discuss both the surgical and orthodontic options and present the successful orthodontic correction of a unilaterally impacted mandibular canine and first premolar.

Prospective randomized trial of a closed-suction drain versus a Penrose drain after a colectomy

BACKGROUND/AIMS

Prospective studies in the gastroenterological surgery literature have shown fewer wound related complications with a closed-suction drainage than with an open passive drainage. This study compared the SSI and cost of closed-suction drainage and open passive drainage in a randomized trial.

METHODOLOGY

This study involved 112 patients undergoing colectomy from December, 2003 through April, 2007. A closed-suction or an open (Penrose) drainage was used based on the surgeon's preference. The cost and the incidence of complications including SSI was compared in the two drain types.

RESULTS

The SSI rate was 13/112 cases 11.6%, but there was no significant difference between the drain groups. In addition, 18 laparoscopic surgery cases did not show any wound infection or drain infections. The closed-suction drain was not expensive regarding personnel expenses and the cost of changing the dressings.

CONCLUSIONS

No statistically significant postoperative differences were observed between a closed-suction drain or an open drain after a colectomy. However, a closed-suction drain management is useful for the reduction of a cost, labor saving, and the decrease of medical waste.

Practical human abdominal fat imaging utilizing electrical impedance tomography

The fundamental cause of metabolic syndrome is thought to be abdominal obesity. Accurate diagnosis of abdominal obesity can be done by an x-ray computed tomography (CT) scan. But CT is expensive, bulky and entails the risks involved with radiation. To overcome such disadvantages, we attempted to develop a measuring device that could apply electrical impedance tomography to abdominal fat imaging. The device has 32 electrodes that can be attached to a subject's abdomen by a pneumatic mechanism. That way, electrode position data can be acquired simultaneously. An applied alternating current of 1.0 mArms was used at a frequency of 500 kHz. Sensed voltage data were carefully filtered to remove noise and processed to satisfy the reciprocal theorem. The image reconstruction software was developed concurrently, applying standard finite element methods and the Marquardt method to solve the mathematical inverse problem. The results of preliminary experiments showed that abdominal subcutaneous fat and the muscle surrounding the viscera could be imaged in humans. While our imaging of visceral fat was not of sufficient quality, it was suggested that we will be able to develop a safe and practical abdominal fat scanner through future improvements.

Analysis of bone volume using computer simulation system for secondary bone graft in alveolar cleft

The purpose of this study was to measure the bone volume necessary for secondary bone grafting in the alveolar cleft using surgical simulation software based on three-dimensional computed tomography (CT) scan data, to compare this measurement with the actual volume of the bone graft, and to evaluate consistency. The subjects were 13 patients with cleft lip and palate who underwent CT using a cone-beam CT unit (CB-CT) 1 month before surgery, followed by bone grafting with particulate cancellous bone and marrow (PCBM) to close the cleft. The bone volume necessary for grafting was measured based on the CB-CT scan data. Correlation analysis, a test of the population mean between two samples, and Wilcoxon's signed rank test were conducted between these measurements and the actual bone volume (PCBM volume) used for grafting. SPSS was used for statistical analysis, and the level of significance was set below the 5% level. The results showed a significant correlation, with no significant differences between the two in all tests. These results suggest that measuring and preoperatively calculating the bone volume necessary for bone grafting with surgical simulation software using CB-CT scan data is beneficial.

[A case of gastric cancer with posterior mediastinal lymph node metastasis responding to combination therapy of Paclitaxel and S-1]

The patient was a 73-year-old man who was hospitalized with advanced gastric cancer. Computer tomography showed multiple liver and mediastinum lymph node metastases. Therefore, he was diagnosed as unresectable gastric cancer(Stage IV). We attempted low-dose combination therapy of CDDP and S-1, but it was ineffective against advance gastric cancer. We decided to change the chemotherapy, using combination therapy of paclitaxel and S-1. In the regimen, paclitaxel (60 mg/m/2) was administered on day 1, day 8, and day 15. S-1 (80 mg/m2) was administered 4 weeks with a 2-week rest. After the 2 courses, computer tomography showed reduction of the liver metastasis and disappeared of the lymph node metastases. Therefore, he could undergo total gastrectomy and radiofrequency ablation of liver metastases. He continued this combination therapy one year after the operation. The cancer has not recurred thus far. When combination chemotherapy of paclitaxel and S-1 was effective against Stage IV gastric cancer, we suggested that radical surgery is possible for those cases.