The effectiveness of fascial closure with antimicrobial-coated sutures in preventing incisional surgical site infections in gastrointestinal surgery: a systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis of the efficacy of fascial closure using antimicrobial-sutures specifically for the prevention of surgical site infections (SSIs) in gastrointestinal surgery, as part of the revision of the SSI prevention guidelines of the Japanese Society of Surgical Infectious Diseases (JSSI). We searched CENTRAL, PubMed and ICHUSHI-Web in May 2023, and included randomized controlled trials (RCTs) comparing antimicrobial-coated and non-coated sutures for fascial closure in gastrointestinal surgery (PROSPERO No. CRD42023430377). Three authors independently screened the RCTs. We assessed the risk of bias and the GRADE criteria for the extracted data. The primary outcome was incisional SSI and the secondary outcomes were abdominal wall dehiscence and the length of postoperative hospital stay. This study was supported partially by the JSSI. A total of 10 RCTs and 5396 patients were included. The use of antimicrobial-coated sutures significantly lowered the risk of incisional SSIs compared with non-coated suture (risk ratio: 0.79, 95% confidence intervals: 0.64-0.98). In subgroup analyses, antimicrobial-coated sutures reduced the risk of SSIs for open surgeries, and when monofilament sutures were used. Antimicrobial-coated sutures did not reduce the incidence of abdominal wall dehiscence and the length of hospital stay compared with non-coated sutures. The certainty of the evidence was rated as moderate according to the GRADE criteria, because of risk of bias. In conclusion, the use of antimicrobial-coated sutures for fascial closure in gastrointestinal surgery is associated with a significantly lower risk of SSI than non-coated sutures.

Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies

BACKGROUND

The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies.

METHODS

Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months).

RESULTS

Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%).

CONCLUSIONS

The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.

Sympathetic Nerve Activity During Tooth Extraction in Women Is Related to Dental Anxiety Immediately After Surgery

PURPOSE

This study assessed the relationship between changes in autonomic nervous system activity during impacted mandibular third molar extraction and a patient's postoperative psychological status, with the overarching aim of informing the development of interventions to reduce dental phobia and anxiety. We hypothesized that changes in autonomic nervous system activity during tooth extraction are related to postoperative psychology.

METHODS

In our prospective cohort study, heart rate variability, heart rate (HR), and systolic blood pressure (SBP) were recorded during impacted mandibular third molar extraction. Heart rate variability values were dichotomized as either low frequency (LF 0.04-0.15 Hz) or high frequency (HF >0.15 Hz). The relative ratios (intraoperative vs baseline) of LF/HF, HF, HR, and SBP were divided into high and low groups based on their median values; the State Anxiety Inventory (STAI-S) results were compared between the groups with high and low relative ratios.

RESULTS

Data of 34 female patients (age, 28.23 ± 1.05 years) were analyzed. Postoperative STAI-S values were significantly lower than preoperative values. Patients in the high LF/HF group had a significantly lower change in STAI-S values than those in the low LF/HF group (P < .05). There were no significant differences in the change in STAI-S values between the groups with high and low HF, HR, or SBP.

CONCLUSIONS

Patients with low sympathetic nervous system activity had lower anxiety; the LF/HF index was the most sensitive indicator for changes in stress. Additional studies are required to develop optimal interventions for reducing sympathetic nerve activity in patients with dental phobia.

The advanced lung cancer inflammation index predicts outcomes in patients with Crohn's disease after surgical resection

AIM

Precise biomarkers for predicting prognosis could help to identify high-risk Crohn's disease (CD) patients to facilitate better follow-up during the postoperative course. In this study, the primary aim is the identification of the most reliable nutrition marker that predicts surgical relapse in CD patients.

METHOD

We first evaluated the predictive value of various nutrition markers for postoperative surgical relapse in CD patients and identified the advanced lung cancer inflammation index (ALI) as a promising biomarker. Then, we assessed the clinical significance of preoperative ALI in CD patients using two cohorts.

RESULTS

Preoperative ALI showed the highest correlation with reoperation rate compared with other nutritional parameters in CD patients receiving surgical resection (sensitivity 53%, specificity 86%, area under the curve 0.71). Lower levels of preoperative ALI were significantly correlated with the presence of perianal disease. A lower level of preoperative ALI was an independent prognostic factor for reoperation rate after an intestinal resection (hazard ratio 3.37, 95% CI 1.38-10.12, P = 0.006), and the prognostic impact of preoperative ALI was successfully validated in an independent cohort using the same cut-off value.

CONCLUSION

Preoperative ALI might be useful for postoperative management of CD patients.

General Anesthesia During Lip Repair and Palatoplasty After Glenn Surgery

We performed general anesthesia for a lip repair and palatoplasty in a patient with left ventricular hypoplasia following a Glenn procedure. Preoperative examination revealed hemorrhagic diathesis, hypoxemia, and secondary polycythemia. After completion of the palatoplasty, hypoxemia and intraoral bleeding were observed, and reintubation was required. The bleeding risk was likely increased in this patient due to several factors including the surgical procedure and concurrent antithrombotic therapy. In conclusion, the risks associated with hypoxemia and increased bleeding must be considered for the safe provision of general anesthesia during palatoplasty procedures in patients with cyanotic heart disease.

Time to Recovery of Feeding After Alveolar Bone Graft Is Associated With Postoperative Nausea and Vomiting Within 2 Hours in Children

Objective:

To examine the relationship between the method of anesthesia for alveolar bone graft surgery and postoperative nausea and vomiting (PONV) based on the difference in surgical timing and to assess factors related to the postoperative quality of life.

Design:

Retrospective observational study.

Setting:

Hospital.

Participants:

Patients with cleft lip and palate who underwent alveolar bone graft surgery under general anesthesia. The subjects were divided into two groups based on surgical timing: secondary bone graft (SBG) and late secondary bone graft (LSBG) groups.

Main Outcome Measures:

Relationship between time to recovery of feeding and the types of anesthesia, PONV, and postoperative pain period.

Results:

The mean patient age was 9.97 ± 1.33 years in the SBG group and 15.39 ± 0.31 years in the LSBG group. In the SBG group, patients who were administered fentanyl or remifentanil had significantly higher incidence of PONV than those who were not administered these drugs. In the SBG group, the time to recovery of feeding was significantly longer in patients experiencing PONV within 2 hours or that lasted for 24 hours than in those without PONV. In the LSBG group, there was no significant difference regarding any of the above factors.

Conclusions:

Our results suggest that the occurrence of PONV within 2 hours or lasting for 24 hours postoperatively in school-age children prolonged the time to recovery of feeding. This indicates that the time to recovery of feeding can be predicted based on the occurrence of PONV within the first 2 hours.

Ostomy creation with fewer sutures using tissue adhesives (cyanoacrylates) in inflammatory bowel disease: a pilot study

Introduction Fistula formation around the ostomy site is a stoma-related complication often requiring surgical intervention. This complication may be caused by sutures or may develop as a complication of inflammatory bowel disease. Before conducting a clinical trial, we set out to investigate the safety of ostomy creation with fewer sutures using tissue adhesives in this pilot study. Methods Patients with inflammatory bowel disease who required surgery with ostomy creation at the Hyogo College of Medicine between January 2014 and December 2015 were enrolled. Safety was assessed by evaluating the incidence of stoma-related complications. Ostomy was restricted to loop ileostomy and was created with two sutures and tissue adhesives. Results A total of 14 patients were enrolled. Mean body mass index was 18.9 ± 2.0 kg/m². There were no cases of ostomy retraction and no severe adverse events were observed. Conclusions This pilot study demonstrates that ostomy creation using tissue adhesives is safe. Although retraction and adverse events were not observed, even in patients with inflammatory bowel disease who generally exhibit delayed wound healing, the body mass index was extremely low in this series. This study does not strongly recommend ostomy creation with tissue adhesives; further studies are needed to clarify the efficacy and safety of the procedure.

[Additional external radiotherapy to multiple metastases originating from thymic neuroendocrine tumor following peptide receptor radionuclide therapy: a case report]

We describe the case of a 60-year-old man suffering from an advanced thymic neuroendocrine tumor with left supraclavicular lymph node and multiple bone metastases. The patient initially underwent systemic therapy with somatostatin analogues. Thereafter, peptide receptor radionuclide therapy (PRRT) was considered because the lesions had remained stable despite the pharmacological therapy. PRRT was performed 10 months after the initial treatment in a European hospital. Eighteen months after the treatment, cranial nerve palsy arising from skull base metastases and Horner's syndrome induced by left supraclavicular lymph node metastases became exacerbated. Therefore, a course of external radiotherapy was performed with palliative intent in our hospital. During the radiotherapy planning, the biodistribution of 111In-octreotide was examined to determine whether the absorbed dose of the previous PRRT was acceptable. As a result, external radiotherapy was performed, and an acute radiation reaction was observed; the severity of the reaction was typical of reactions to neck radio-therapy. The treatment course of the present case was considered to be instructive because PRRT cannot be performed in Japan at present.

Value of pre- and postoperative meticillin-resistant Staphylococcus aureus screening in patients undergoing gastroenterological surgery

BACKGROUND

Data supporting active surveillance of meticillin-resistant Staphylococcus aureus (MRSA) for the prevention of postoperative infection remain controversial.

AIM

To investigate the efficacy of MRSA screening in patients undergoing gastroenterological surgery.

METHOD

Nasal carriage of MRSA was screened using a polymerase chain reaction (PCR) assay on two gastroenterological surgery wards (A and B). Occurrence of postoperative MRSA infection was analysed according to nasal MRSA carriage status (pre-operative carriage and postoperative acquisition).

FINDINGS

The incidence of pre-operative MRSA carriage was 9.7% on Ward A and 4.3% on Ward B (P = 0.009). Postoperative nasal MRSA acquisition was confirmed in 16.2% and 6.0% of patients, respectively (P < 0.001). There was no significant difference in the incidence of MRSA surgical site infections (SSIs) between patients with and without pre-operative nasal colonization on either ward. On Ward A, where MRSA nasal acquisition was more common, the MRSA infection rate in patients with postoperative nasal acquisition was 26.8%, which was significantly higher than the rates in patients with pre-operative MRSA colonization and patients without colonization during hospitalization. Postoperative nasal MRSA acquisition was an independent factor associated with MRSA infection on both wards [Ward A: odds ratio (OR) 7.192, 95% confidence interval (CI) 2.981-17.352; Ward B: OR 5.761, 95% CI 1.429-23.220].

CONCLUSION

MRSA SSIs were prevented by a screening-based strategy in pre-operative MRSA carriers. Postoperative nasal acquisition was a significant factor affecting MRSA infection, and the effect of screening varied according to the incidence of postoperative MRSA acquisition on the ward.

Improvement of accommodation with anti-oxidant supplementation in visual display terminal users

OBJECTIVE

To determine the antioxidant supplementation effect on accommodation among VDT users.

DESIGN

A double blind randomized placebo controlled study. Registered under ClinicalTrials.gov Identifier No. NCT00877201.

PARTICIPANTS AND CONTROLS

Fourty right eyes of 40 healthy VDT users (30 females, 10 males, mean age: 43.8±2.8 years, range: 40-49 years). 20 subjects (15 females, 5 males; mean age: 44.0±2.7 years, range: 40-49 years).

METHODS

Subjects were required to take an antioxidant supplement, 20 age and sex matched subjects (15 females, 5 males; mean age: 43.6±3.1 years, range: 40-49 years) were required to take placebo medication for 4 weeks.

RESULTS

The mean of the change in accommodation power was significantly higher in the group receiving antioxidant supplements (0.20±0.50 Diopter(D)) compared to the placebo group (-0.12±0.48(D)) (p<0.05).

CONCLUSIONS

Antioxidant supplementation was observed to improve accommodation in Japanese Visual Display Terminal (VDT) Users.

Implementation of a hospital-wide project for appropriate antimicrobial prophylaxis

The aim of this study was to confirm the effect of implementing a hospital-wide project for appropriate use of antimicrobial prophylaxis (AMP) to reduce the rate of antibiotic-resistant organisms. Fifteen different manuals for each surgical department have been simultaneously implemented since February 2007. Compliance rate was compared between pre- and postintervention periods (3 months for each period). As an effect of this intervention, we analyzed changes in the rates of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus among organisms isolated postoperatively. The number of operations was 1,627 in both periods. Among patients whose surgeries were longer than 3 h in duration, 75% received an additional intraoperative antimicrobial dose in the postintervention period and 23% in the preintervention period (P < 0.001). Although most patients received postoperative AMP with an interval of q12 h in the preintervention period, 63% of the patients received AMP with an interval of q8 h in the postintervention period. The duration of AMP use was reduced from 2.4 ± 1.9 to 1.6 ± 1.5 days (P < 0.001). Forty-seven percent of patients discontinued AMP within 24 h and 81% within 48 h. Isolation rates of P. aeruginosa among all gram-negative organisms significantly decreased from 13% (68/538 patients) to 7.3% (37/509 patients) (P = 0.004). Execution of a hospital-wide project to promote the appropriate use of AMP, including shortening the duration of AMP use, was useful to decrease the rate of P. aeruginosa isolated postoperatively.

[Anomalous origin of the right coronary artery from the ascending aorta]

The patient was a 77-year-old man. In June 2008, he underwent off-pump coronary artery bypass (OPCAB) for unstable angina Intraoperative epiaortic echo showed an anomalous origin of theright coronary artery from the ascending aorta 4 cm above the sinotubular junction (STJ). The right coronary artery traveled through the planned proximal anastomotic site of the saphenous vein graft (SVG). If diagnosis of the anomalous origin of the right coronary artery had not been made, there would have been a high likelihood that the right coronary artery could have been injured. Thus, the usefulness of epiaortic echo was reaffirmed. An anomalous origin of the coronary artery is a rare congenital anomaly and its incidence is approximately 1%. An anomalous origin of the right coronary artery is very rare from the ascending aorta 4 cm above the STJ and only a few cases have been reported. An anomalous origin of the coronary artery can cause serious complications affecting the prognosis after open heart surgery. Thus, such an anomalous origin needs to be considered in preoperative evaluation.

I came, I saw, I reflected: a qualitative study into learning outcomes of international electives for Japanese and British medical students

BACKGROUND AND AIM

Although medical students have increasingly more opportunities to participate in international electives, their experiences are usually unstructured and the literature referring to their learning outcomes, educational environment, and assessment is scanty. This study was undertaken to clarify qualitatively what students learn from their international electives.

METHODS

We carried out semi-structured individual interviews with 15 Japanese students studying clinical medicine in British medical schools and six British students studying in Japanese medical schools. The thematic synthesis method was used in analysing the transcribed data and triangulation by multiple researchers was used to achieve higher reliability.

RESULTS

The main learning outcomes identified were skills in history taking and physical examination with clinical reasoning and in management of diseases rarely seen in the students' own countries; awareness of clinical ethics and merits and demerits of different systems of healthcare and medical education; sensitivity to issues in doctor-patient relationships and work ethics; enhancement of cultural competence; and personal development.

CONCLUSIONS

Most learning outcomes of international electives are culture- or system-dependent. Students achieved outcomes related closely to medical professionalism, mainly through reflection. International electives may give students opportunities to learn both professionalism and cultural competence.

Combination treatment of intravenous immunoglobulin and cultivated oral mucosal epithelial transplantation for ocular cicatricial pemphigoid

Ocular cicatricial pemphigoid (OCP) is a progressive cicatrising autoimmune disease affecting the skin and mucous membranes, including ocular surface epithelia. Although systemic immunosuppression is advocated, both progression of ocular surface inflammation and systemic side effects remain a problem. For the treatment of an active OCP, both control of autoimmune reaction and ocular surface reconstruction are necessary. We believe that the combination of intravenous immunoglobulin (IVIg) and cultivated oral mucosal epithelial transplantation (COMET) is a powerful treatment modality while minimising the risk of postoperative consequences inevitably associated with immunosuppression. A patient with OCP successfully treated by a combination of IVIg and COMET is described here.

Effect of liver transplantation on transthyretin Tyr114Cys-related cerebral amyloid angiopathy

OBJECTIVE

Patients with amyloidogenic transthyretin (ATTR) Tyr114Cys develop amyloid deposits in cerebral blood vessels, cerebral hemorrhage, and rapidly progressive dementia that presents with hereditary cerebral amyloid angiopathy (CAA). However, no treatment has been identified for CAA. Although liver transplantation has become an acceptable treatment of TTR-related amyloidosis, liver transplantation may not successfully treat CNS manifestations of the disorder. In this study, we examined the effect of liver transplantation on these manifestations of TTR-related CAA.

METHODS

We compared clinical courses of three patients with CAA associated with ATTR Tyr114Cys who underwent liver transplantation with those of five patients with the disorder who did not undergo liver transplantation.

RESULTS

The mortality and occurrence of cerebral hemorrhage and dementia in patients having transplantations were reduced compared with those in patients not having transplantations. The two groups did not differ with regard to the frequency of episodes of fluctuating consciousness and TIAs. The group undergoing transplantations had significantly smaller volumes of intracranial hemorrhage than did the no-transplantation group.

CONCLUSION

Liver transplantation was effective for CNS manifestations of cerebral amyloid angiopathy associated with amyloidogenic transthyretin Tyr114Cys.

Immediate interlocking nailing versus external fixation followed by delayed interlocking nailing for Gustilo type IIIB open tibial fractures

PURPOSE

To compare immediate interlocking nailing with external fixation followed by delayed interlocking nailing, for Gustilo type IIIB open tibial fractures.

METHODS

23 patients with Gustilo IIIB open tibial fractures were treated with either immediate unreamed interlocking nailing (n=9) or external fixation followed by delayed unreamed interlocking nailing (n=14). Patient age, sex ratio, fracture site, fracture type, and severity were similar in both groups. The time to union, deep infection rate, and nonunion rate in the 2 groups were compared.

RESULTS

In the immediate and delayed nailing groups, respective mean times to union were 21 (standard deviation [SD], 14) months and 14 (SD, 8) months; nonunion rates were 44% (4/9) and 36% (5/14), and deep infection rates were 22% (2/9) and 7% (1/14). All corresponding differences were not statistically significant.

CONCLUSION

Prospective, randomised, multicentre studies are needed to assess whether there are significant differences between the 2 treatment methods.

Iatrogenic amyloid neuropathy in a Japanese patient after sequential liver transplantation

A 57-year-old woman in Japan, the first recipient of part of a liver from a 58-year-old man with familial amyloidotic polyneuropathy (FAP) amyloidogenic transthyretin Val30Met who had had sensorimotor polyneuropathy in the lower limbs for 3 years, started to develop sensory neuropathy 7 years after transplantation. Before the July 1998 sequential transplantation, she had been in a hepatic coma at the terminal stage of primary biliary cirrhosis and waiting for deceased donor liver transplantation. In September 2004, biopsy samples of her duodenum first showed amyloid deposition. Although biopsy materials in 2005 and 2006 showed no changes in amyloid deposition, decreased temperature sensation and pain in fingertips and toes were detected at a neurologic examination in March 2006. Thus, clinical symptoms of FAP appeared about 2 years after amyloid deposition started. Nerve conduction velocity studies revealed mild to moderate axonal sensory polyneuropathy without demyelination. Our findings confirmed iatrogenic sensory neuropathy induced by amyloid deposition 7 years after sequential liver transplantation.

Neuroradiologic and clinicopathologic features of oculoleptomeningeal type amyloidosis

OBJECTIVE

To clarify the pathogenesis of leptomeningeal amyloidosis in familial amyloidotic polyneuropathy amyloidogenic transthyretin Y114C (FAP ATTR Y114C).

METHODS

The authors analyzed eight FAP ATTR Y114C patients. Six patients showed CNS symptoms associated with leptomeningeal amyloidosis. To examine the function of the blood-CSF barrier and blood-brain barrier (BBB), the authors performed CSF and MRI studies. The authors also performed a histopathologic study of autopsy specimens to examine the distribution of amyloid deposition in the CNS.

RESULTS

CSF study showed high total protein concentrations and increased albumin CSF/serum concentration quotients (Qalb; an indication of blood-CSF barrier function). MRI with gadolinium (Gd) revealed enhancement from brainstem to spinal cord. Serial brain MRI studies with FLAIR images after Gd administration showed Gd leakage into the subarachnoid space (two patients). These findings suggested the blood-CSF barrier and BBB dysfunctions. Constructive interference in steady state (CISS) three-dimensional Fourier transformation (CISS-3DFT) sequence analysis demonstrated amyloid-induced funiculus structures joining the spinal cord and dura mater (one patient). Histopathologic study revealed intense amyloid deposition in leptomeninges, vessel walls, and parenchyma in spinal cord and the brain. These distributions of amyloid deposition are unique compared to other TTR related leptomeningeal amyloidosis.

CONCLUSIONS

Patients with familial amyloidotic polyneuropathy amyloidogenic transthyretin Y114C had CNS disorders related to amyloid deposition in leptomeninges, vessel walls, and parenchyma in spinal cord and the brain. The pathogenesis of CNS disorders may reflect disruption of the blood-CSF barrier and blood-brain barrier by amyloid deposition.

Intermittent oro-esophageal tube feeding in acute stroke patients -- a pilot study

OBJECTIVE

Acute stroke patients with dysphagia are usually fed by nasogastric tube. However, this method sometimes causes pneumonia or diarrhea. We investigated the use of a new feeding procedure called intermittent oro-esophageal (IOE) tube feeding in acute stroke patients with severe dysphagia.

MATERIALS AND METHODS

The IOE method was used in 13 acute stroke patients (68 +/- 14 years old; 12 had a brainstem infarction), who were alert, but had severe dysphagia and a weak pharyngeal reflex. IOE tube feeding was carried out as follows. A feeding tube was passed orally into the lower portion of the esophagus, food supplements were administered through the tube at a rate of approximately 50 ml/min, and the tube was removed after finishing the supplement infusion.

RESULTS

We found that the IOE method had the following advantages: (i) IOE feeding took approximately 15 min; (ii) potentially reduced a risk of complications such as pneumonia and diarrhea; and (iii) oral tube insertion stimulated the oral cavity and pharynx, which may improve the swallowing function. However, the IOE feeding method should not be used in patients who: (i) could not understand the IOE procedure; (ii) had an esophageal hiatal hernia or incomplete peristalsis of the esophagus, as such patients are at risk of having the supplement reflux into the oral cavity.

CONCLUSION

The IOE feeding method may be one of the alternatives to continuous nasogastric tube feeding in acute stroke patients with severe dysphagia, who are alert.

Animal model of oculopharyngeal muscular dystrophy

Oculopharyngeal muscular dystrophy (OPMD) is a late-onset polyalanine disorder characterized clinically by progressive ptosis, dysphagia, and limb weakness and pathological hallmarked by unique intranuclear inclusions in the muscles. It is caused by heterozygous expansion of a 10-alanine stretch to 12-17 alanine residues in the N-terminus of the poly(A)-binding protein, nuclear 1 (PABPN1). Although PABPN1 is a major component of the inclusions in OPMD, the associated pathogenic mechanism is undetermined. No animal models of OPMD have been discovered in nature; therefore, we generated transgenic mice expressing human PABPN1 (hPABPN1) using a chicken beta-actin (CAG) promoter. While transgenic mice lines expressing normal hPABPN1 did not show myopathic changes, lines expressing high levels of expanded hPABPN1 with a 13-alanine stretch showed myopathy phenotype with aging. The latter mice disclosed intranuclear inclusions consisting of aggregated mutant hPABPN1 and scattered rimmed vacuoles restricted in the muscles. In particular, the nuclear inclusions closely resembled those of OPMD muscles on electron microscopy, and myopathic changes were more prominent in the eyelid and pharyngeal muscles. The results demonstrated that we had established the first transgenic OPMD model mouse. Recently, two other transgenic mice expressing mutated hPABPN1 with a 17-alanine stretch have been generated; however, the transgenic mouse using its natural promoter did not show myopathy phenotype, and the other using the human skeletal actin (HSA1) promoter disclosed quite different intranuclear inclusions from those of human OPMD muscles. Our transgenic OPMD model mouse appears to have more dramatic alterations in myofiber viability, but is useful for elucidating of molecular mechanisms and establishing therapeutic trials.

Fusiform aneurysm of the vertebral artery presenting with hemifacial spasm treated by microvascular decompression

We report a rare case of symptomatic hemifacial spasm caused by a fusiform vertebral artery aneurysm. A 59-year-old woman presented with left hemifacial spasm of 18 months duration. Magnetic resonance imaging showed an enlarged a fusiform aneurysm of the left vertebral artery which compressed the seventh cranial nerve at its exit from the caudal pons. Microvascular decompression of the facial nerve with moving of the aneurysm resulted in complete relief of the hemifacial spasm. No enlargement of the aneurysm was shown on follow-up for a period of 6 years.

Near-infrared spectrophotoscopy of finger venules in assessment of autonomic dysfunction

The authors evaluated morphologic changes in the venules of the finger using near-infrared spectrophotoscopy in patients with autonomic dysfunction, such as familial amyloidotic polyneuropathy and multiple-system atrophy. Abnormalities of the venules, such as tortuosity, irregular venous caliber, and microaneurysm-like change, and a linear negative correlation between the degree of orthostatic hypotension and the degree of vasoconstriction of the venules were observed.

Ruptured aneurysm at a duplicated middle cerebral artery with accessory middle cerebral artery

Although many cerebral vascular anomalies are widely recognized, others are less well known or unclassified. Accessory middle cerebral artery (MCA) and duplicated MCA are among uncommon anomalies. We present a very rare case of subarachnoid haemorrhage due to rupture of a saccular aneurysm arising from a duplicated middle cerebral artery which was associated with an accessory middle cerebral artery.

Targeted conversion of the transthyretin gene in vitro and in vivo

Familial amyloidotic polyneuropathy (FAP) is the common form of hereditary generalized amyloidosis and is characterized by the accumulation of amyloid fibrils in the peripheral nerves and other organs. Liver transplantation has been utilized as a therapy for FAP, because the variant transthyretin (TTR) is predominantly synthesized by the liver, but this therapy is associated with several problems. Thus, we need to develop a new treatment that prevents the production of the variant TTR in the liver. In this study, we used HepG2 cells to show in vitro conversion of the TTR gene by single-stranded oligonucleotides (SSOs), embedded in atelocollagen, designed to promote endogenous repair of genomic DNA. For the in vivo portion of the study, we used liver from transgenic mice whose intrinsic wild-type TTR gene was replaced by the murine TTR Val30Met gene. The level of gene conversion was determined by real-time RCR combined with mutant-allele-specific amplification. Our results indicated that the level of gene conversion was approximately 11 and 9% of the total TTR gene in HepG2 cells and liver from transgenic mice, respectively. Gene therapy via this method may therefore be a promising alternative to liver transplantation for treatment of FAP.

DWI abnormalities and clinical characteristics in TIA patients

OBJECTIVE

To determine the clinical characteristics of diffusion-weighted images (DWIs) in patients with TIA.

METHODS

The authors performed prospectively MRI including DWI in 129 consecutively studied patients with TIA (mean age, 67 years; 68% men) within 14 days after TIA onset. They examined the frequency of TIA-related DWI abnormalities and compared the clinical background of patients with and without DWI abnormalities. Using multivariate statistical methods, the authors investigated the independent factors associated with detection of DWI abnormalities.

RESULTS

Fifty-seven patients with TIA (44%) had DWI abnormalities (positive group), whereas 72 (56%) had no abnormalities (negative group). Prolonged TIA duration (TIA duration > or = 30 minutes), hemiparesis, monoparesis, disturbance of higher brain function, history of either stroke or TIA, diabetes mellitus, and atrial fibrillation were observed more frequently in the positive group than in the negative group. No difference in other symptoms, vascular risk factors, or emboligenic cardiac and arterial disease was observed between the two groups. A multiple logistic regression model demonstrated that prolonged TIA duration (odds ratio [OR], 3.7; 95% CI, 1.3 to 10.8) and disturbance of higher brain function (OR, 10.2; 95% CI, 2.2 to 46.9) are significant and independent factors in correlating with DWI abnormalities.

CONCLUSIONS

TIA-related DWI abnormalities are associated with prolonged duration of TIA and disturbance of higher brain function. More sustained and extensive ischemia may contribute to DWI abnormalities in patients with TIA.

[Infusion MR arteriography during hepatic arterial infusion chemotherapy: evaluation of clinical usefulness]

PURPOSE

We developed a new method of infusion MR arteriography (IMRA) via an implantable port system using an infusion pump for the evaluation of drug distribution during hepatic arterial infusion chemotherapy. The purposes of this study were to optimize the method and evaluate its clinical usefulness.

MATERIALS AND METHODS

We used 3D-T1 TFE as the most suitable sequence for IMRA according to the results of a phantom model experiment. We examined 33 cases of liver cancer that had been treated by arterial infusion chemotherapy via the port system. The following investigations were performed: degree of tumor enhancement, intra- and extrahepatic perfusion abnormality, and related toxicity. The evaluation of images was performed separately by two radiologists.

RESULTS

IMRA provided good images of contrast enhancement, to reveal the perfusion patterns. The treatment response rate in the tumor group with well enhancement was higher than that of the group with poor enhancement (p < 0.0001). Extrahepatic perfusion was well visualized and was correlated with toxicity (p < 0.0001).

CONCLUSION

IMRA is a useful method to evaluate drug perfusion for the optimization of arterial infusion chemotherapy.

Isolation and characterization of psychrophiles producing cold-active beta-galactosidase

AIMS

The present study was conducted to screen for psychrophilic micro-organisms that are able to hydrolyse lactose at low temperature, and to examine the cold-active beta-galactosidase produced by the isolated psychrophilic micro-organisms.

METHODS AND RESULTS

Psychrophilic bacteria, which grow on lactose as a sole carbon source, were isolated from soil from Hokkaido, Japan. The phenotype and sequence of 16S rDNA of the isolated strains indicated a taxonomic affiliation to Arthrobacter psychrolactophilus. The isolated A. psychrolactophilus strains were able to grow on lactose at below 5 degrees C, and showed cold-active beta-galactosidase activity, which was highly specific at even 0 degrees C.

CONCLUSIONS

Facts in this study may indicate the possibility that the isolated strains produce novel beta-galactosidases that are able to hydrolyse lactose at low temperature, although some strains have isozymes.

SIGNIFICANCE AND IMPACT OF THE STUDY

It may be possible that the cold active beta-galactosidases from the isolated strains can be applied to the food industry, e.g. processing of milk and whey below 5 degrees C.

CSF hypocretin levels in Guillain-Barre syndrome and other inflammatory neuropathies

CSF hypocretin-1 was measured in 28 Guillain-Barré syndrome (GBS), 12 Miller-Fisher syndrome, 12 chronic inflammatory demyelinating polyneuropathy (CIDP), and 48 control subjects. Seven GBS subjects had undetectably low hypocretin-1 levels (<100 pg/mL). Hypocretin-1 levels were moderately reduced in an additional 11 GBS, 5 Miller-Fisher syndrome, and 1 CIDP subject. Low levels in GBS occurred early in the disease and were associated with upper CNS level abnormalities.

A Japanese family with FEOM1-linked congenital fibrosis of the extraocular muscles type 1 associated with spinal canal stenosis and refinement of the FEOM1 critical region

We identified a Japanese family with congenital fibrosis of the extraocular muscles, including 24 affected individuals through five generations. To determine their form of congenital fibrosis of the extraocular muscles, we performed clinical and linkage studies. DNA typing for linkage to the FEOM1 (12p11.2-q12) and FEOM3 (16qter) loci was performed on genomic DNA, using fluorescent microsatellite polymorphic markers. All affected individuals shared the common manifestations of congenital fibrosis of the extraocular muscles type 1 including congenital ptosis, infraducted globe position in primary gaze, and upward gaze palsy in both eyes. Unexpectedly, we found apparent spinal canal stenosis in the cervical spine in all affected family members who were examined. Genetic analysis revealed linkage to the FEOM1 locus with a maximum lod score of 4.42 at theta of zero. One affected family member harbored a recombination event between D12S345 and D12S1692, narrowing the FEOM1 locus from the published 3-cM region flanked by D12S1584 and D12S1668 to a 2.1-cM region flanked by D12S345 and D12S1668. Thus, we have established that this family segregates congenital fibrosis of the extraocular muscles type 1 as an autosomal dominant trait and that their disorder both maps to and refines the FEOM1 locus. This is the first clinical and genetic report of such a family in the Japanese population and the first report of spinal involvement in congenital fibrosis of the extraocular muscles.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and CADASIL-like disorders in Japan

We reviewed 12 patients from 11 Japanese families diagnosed as having CADASIL from 1998 to 2001. The age of onset of focal neurologic deficits ranged from 38 to 71 years (mean: 50.4 +/- 9.8 years). Japanese CADASIL patients rarely had migraine and frequently presented with symptoms of dementia at diagnosis. Notch3 mutations were concentrated in exons 3, 4, and 5. Cysteine was replaced by another amino acid or vice versa in the majority of Japanese CADASIL patients. However, in 2 families, the mutations were not related to cysteine. In the prospective study, 2030 patients with stroke were hospitalized in 6 hospitals with stroke units in the Kumamoto district from 1999 to 2001. Among them, 14 patients fulfilled the criteria of being less than 60 years of age, showing lacunar strokes and/or TIA, presence of a family history, and no risk factors of stroke. One of these 14 patients was diagnosed as having CADASIL by DNA analysis. However, if hyperlipidemia was excluded from the list, 16 patients fulfilled the criteria and 2 patients were diagnosed as having CADASIL by DNA analysis. It was suspected that the incidence of CADASIL is not so rare in Japan. There were some families with CADASIL-like features, but without Notch3 mutations or GOM, suggesting the need for genetic analysis in the future.

CSF hypocretin/orexin levels in narcolepsy and other neurological conditions

OBJECTIVE

To examine the specificity of low CSF hypocretin-1 levels in narcolepsy and explore the potential role of hypocretins in other neurologic disorders.

METHODS

A method to measure hypocretin-1 in 100 microL of crude CSF sample was established and validated. CSF hypocretin-1 was measured in 42 narcolepsy patients (ages 16-70 years), 48 healthy controls (ages 22-77 years,) and 235 patients with various other neurologic conditions (ages 0-85 years).

RESULTS

As previously reported, CSF hypocretin-1 levels were undetectably low (<100 pg/mL) in 37 of 42 narcolepsy subjects. Hypocretin-1 levels were detectable in all controls (224-653 pg/mL) and all neurologic patients (117-720 pg/mL), with the exception of three patients with Guillain-Barré syndrome (GBS). Hypocretin-1 was within the control range in most neurologic patients tested, including patients with AD, PD, and MS. Low but detectable levels (100-194 pg/mL) were found in a subset of patients with acute lymphocytic leukemia, intracranial tumors, craniocerebral trauma, CNS infections, and GBS.

CONCLUSIONS

Undetectable CSF hypocretin-1 levels are highly specific to narcolepsy and rare cases of GBS. Measuring hypocretin-1 levels in the CSF of patients suspected of narcolepsy is a useful diagnostic procedure. Low hypocretin levels are also observed in a large range of neurologic conditions, most strikingly in subjects with head trauma. These alterations may reflect focal lesions in the hypothalamus, destruction of the blood brain barrier, or transient or chronic hypofunction of the hypothalamus. Future research in this area is needed to establish functional significance.