Prognostic impact of concomitant pH-regulating drugs in patients with non-small cell lung cancer receiving epidermal growth factor receptor tyrosine kinase inhibitors: the Tokushukai REAl-world Data project 01-S1

PURPOSE

This study aimed to examine the prognostic impact of concomitant pH-regulating drug use in patients with epidermal growth factor receptor (EGFR)-mutation-positive non-small-cell lung cancer (NSCLC) receiving EGFR-tyrosine kinase inhibitors (TKIs).

METHODS

We conducted a nationwide retrospective cohort study and reviewed clinical data of consecutive patients with NSCLC treated with the first-line EGFR-TKIs in 46 hospitals between April 2010 and March 2020. Cox regression analyses were conducted to examine the differences in overall survival (OS) between patients treated with and without concomitant pH-regulating drugs, including potassium-competitive acid blockers (P-CABs), proton pump inhibitors (PPIs), and H2-receptor antagonists (H2RAs).

RESULTS

A total of 758 patients were included in the final dataset, of which 307 (40%) were administered concomitant pH-regulating drugs while receiving frontline EGFR-TKIs. After adjusting for basic patient characteristics, patients administered gefitinib, erlotinib, afatinib, and osimertinib with concomitant pH-regulating drugs had lower OS than those without concomitant pH-regulating drugs, with hazard ratios of 1.74 (with a 95% confidence interval of 1.34-2.27), 1.33 (0.80-2.22), 1.73 (0.89-3.36), and 5.04 (1.38-18.44), respectively. The 2-year OS rates of patients receiving gefitinib with or without concomitant pH-regulating drugs were 65.4 and 77.5%, those for erlotinib were 55.8 and 66.6%, and those for afatinib were 63.2 and 76.9%, respectively. The 1-year OS rates of patients receiving osimertinib with or without concomitant pH-regulating drugs were 88.1% and 96.9%, respectively.

CONCLUSION

In addition to the first-generation EGFR-TKIs, the second- and third-generation EGFR-TKIs also resulted in OS deterioration in patients with EGFR mutation-positive NSCLC when used concurrently with pH-regulating drugs.

Stepwise prolongation of overall survival from first to third generation EGFR-TKIs for EGFR mutation-positive non-small-cell lung cancer: the Tokushukai REAl-world Data project (TREAD 01)

OBJECTIVE

The introduction of new-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) has afforded promising overall survival outcomes in clinical trials for non-small-cell lung cancer. We aim to investigate the current adoption rate of these agents and the real-world impact on overall survival among institutions.

METHODS

In a nationwide retrospective cohort study of 46 Tokushukai Medical Group hospitals in Japan, we analyzed clinical data of consecutive patients with non-small-cell lung cancer receiving EGFR-TKIs between April 2010 and March 2020. Univariate and multivariate Cox regression analyses examined the associations between overall survival and patient/tumor-related factors and first-line EGFR-TKIs.

RESULTS

A total of 758 patients (58.5% females; median age, 73 years) were included. Of 40 patients diagnosed in 2010, 72.5% received gefitinib, whereas 81.3% of 107 patients diagnosed in 2019 received osimertinib as the first-line EGFR-TKI. With a median follow-up of 15.8 months, the median overall survival was 28.4 months (95% confidence interval, 15.3-31.0). In a multivariate Cox regression analysis, age, body mass index, disease status, EGFR mutational status and first-line epidermal growth factor receptor tyrosine kinase inhibitor were identified as significant prognostic factors after adjusting for background factors including study period, hospital volume and hospital type. The estimated 2-year overall survival rates for gefitinib, erlotinib, afatinib and osimertinib were 70.1% (95% confidence interval 59.7-82.4), 67.8% (95% confidence interval 55.3-83.2), 75.5% (95% confidence interval 64.7-88.0) and 90.8% (95% confidence interval 84.8-97.3), respectively. The median time to treatment failure of gefitinib, erlotinib, afatinib and osimertinib were 12.8, 8.8, 12.0 and 16.9 months or more, respectively.

CONCLUSIONS

Our real-world data revealed that the swift and widespread utilization of newer-generation EGFR-TKIs in patients with EGFR mutation-positive non-small-cell lung cancer, and that these newer-generation EGFR-TKIs can prolong overall survival regardless of hospital volume or type. Therefore, osimertinib could be a reasonable first choice treatment for these patients across various clinical practice settings.

Inflammation‑based prognostic markers of metastatic pancreatic cancer using real‑world data in Japan: The Tokushukai REAl‑world Data (TREAD) project

Inflammation-based prognostic markers based on a combination of blood-based parameters, including the modified Glasgow prognostic score (mGPS), have been associated with clinical outcomes in patients with various types of cancer. The present study aimed to evaluate and compare the accuracy of these previously reported markers in patients with metastatic pancreatic cancer receiving first-line chemotherapy. A total of 846 patients were identified between April 2010 and March 2020 as part of a nationwide real-world study from 46 Tokushukai medical group hospitals in Japan. Blood laboratory data collected within 14 days of starting first-line chemotherapy assessed 17 inflammation-based prognostic markers. Information from patients with no missing data was used to compare the accuracy and performance of the inflammation-based prognostic markers. A total of 487 patients were eligible for this supplemental analysis. The 17 inflammation-based markers demonstrated significant prognostic value. Among them, the concordance rate with overall survival (OS) was highest for mGPS. The median OS time of patients with mGPS 0, 1 and 2 was 8.2, 6.0 and 2.9 months, respectively. Compared with mGPS 0, mGPS 1 and 2 showed hazard ratios of 1.39 (95% confidence interval, 1.07-1.81) and 2.63 (2.00-3.45), respectively. The present real-world data analysis showed that various previously reported inflammation-based markers had significant prognostic value in patients with metastatic pancreatic cancer. Among these markers, the mGPS demonstrated the highest level of accuracy. This trial has been registered in the University Hospital Medical Information Network Clinical Trials Registry as UMIN000050590 on April 1, 2023.

Real‑world treatment outcomes among patients with metastatic pancreatic cancer in Japan: The Tokushukai real‑world data project

The present study aimed to investigate temporal trends in treatment patterns and prognostic factors for overall survival (OS) among patients with metastatic pancreatic cancer. From the Tokushukai REAl-world Data project, 1,093 patients with metastatic pancreatic cancer treated with gemcitabine, tegafur/gimeracil/oteracil (S-1), gemcitabine plus S-1, gemcitabine plus nab-paclitaxel, or fluorouracil, folic acid, oxaliplatin and irinotecan (FOLFIRINOX) between April 2010 and March 2020 were identified. Stratified/conventional Cox regression analyses were conducted to examine associations between patient- and tumor-related factors, study period, hospital volume, hospital type and first-line chemotherapy regimens. Overall, 846 patients were selected (503 male patients; median age, 70 years) after excluding ineligible patients. Over a median follow-up of 5.4 months, the median OS was 6.8 months (95% confidence interval, 6.3-7.4). The median OS for gemcitabine, S-1, gemcitabine plus S-1, gemcitabine plus nab-paclitaxel and FOLFIRINOX regimens was 5.9, 5.3, 7.7, 9.0 and 9.5 months, respectively. The median OS for 2010-2013, 2014-2017 and 2017-2020 was 6.2, 7.1 and 7.8 months, respectively. Performance status, body mass index and first-line chemotherapy regimens were identified to be significant prognostic factors. In summary, the real-world data indicated that standard care, including chemotherapy, for metastatic pancreatic cancer was widely used in hospitals throughout Japan and verified the survival benefits of gemcitabine plus nab-paclitaxel and FOLFIRINOX observed in prior clinical trials. This trial has been registered in the University Hospital Medical Information Network Clinical Trials Registry as UMIN000050590 on April 1, 2023.

Real-World Outcomes of Systemic Therapy in Japanese Patients with Cancer (Tokushukai REAl-World Data Project: TREAD): Study Protocol for a Nationwide Cohort Study

Cohort studies using large-scale databases have become increasingly important in recent years. The Tokushukai Medical Group is a leading medical group in Japan that includes 71 general hospitals nationwide from Hokkaido to Okinawa, with a total of 18,000 beds, and a unified electronic medical record system. This retrospective cohort study aims to evaluate the real-world outcomes of systemic therapy for Japanese patients with cancer using this merit of scale. All adult patients with cancer who received systemic therapy using a centrally registered chemotherapy protocol system at 46 hospitals from April 2010 to March 2020 will be identified (~48,850 patients). Key exclusion criteria include active double cancer and inadequate data extraction. Data will be obtained through electronic medical records, diagnosis procedure combination data, medical prescription data, and the national cancer registration system that includes sociodemographic variables, diagnostic and laboratory tests, concomitant drug prescriptions, cost, and overall survival. Kaplan–Meier estimates will be calculated for time-to-event analyses. Stratified/conventional Cox proportional hazards regression analyses will be conducted to examine the relationships between overall survival and related factors. Our findings provide important insights for future research directions, policy initiatives, medical guidelines, and clinical decision-making.

Monitoring the Sequential Organ Failure Assessment score in nonocclusive mesenteric ischemia increases the survival rate: A single-center observational study

Several large-scale studies have assessed the endovascular and surgical treatments for nonocclusive mesenteric ischemia (NOMI); nonetheless, the prognostic factors for NOMI remain unclear.In this single-center study, we retrospectively reviewed the electronic medical records of 197, 149 patients were retrieved from the inpatient database of our hospital from January 2011 to January 2020; 79 patients with NOMI were observed. A total of 44 patients who underwent laparotomy were statistically analyzed and divided into the survivor and non-survivor groups. Prognostic factors were compared between the 2 groups. Exploratory laparotomy based on a second-look surgery was the first treatment choice.The overall mortality rate was 61.3%, with a male-to-female ratio of 1.6:1. The median Sequential Organ Failure Assessment (SOFA) score was 11.06 [5.75-17.25]. The median SOFA score was 5 [interquartile range: 3-8] in the survivor group and 14.8 [interquartile range: 10.5-19] in the non-survivor group. The log-rank test showed a significant difference in the presence of diabetes mellitus (P = .025), hypoglycemia (P = .001), SOFA score ≥10 (P < .001), hemoglobin levels ≥11 g/dL (P = .003), platelet count ≥12.9 × 104/μL (P = .01), lactate levels ≥2.6 mmol/L (P = .005), and base excess <-3.0 (P < .023). Multivariate analysis using the factors with significant differences revealed that SOFA score ≥10 (hazard ratio for death, 1.199; 95% confidence interval, 1.101-1.305; P < .001) was an independent prognostic factor.The SOFA score can be used to assess disease severity. A SOFA score of ≥10 may be associated with increased mortality.

A cross-population atlas of genetic associations for 220 human phenotypes

Current genome-wide association studies do not yet capture sufficient diversity in populations and scope of phenotypes. To expand an atlas of genetic associations in non-European populations, we conducted 220 deep-phenotype genome-wide association studies (diseases, biomarkers and medication usage) in BioBank Japan (n = 179,000), by incorporating past medical history and text-mining of electronic medical records. Meta-analyses with the UK Biobank and FinnGen (n_total = 628,000) identified ~5,000 new loci, which improved the resolution of the genomic map of human traits. This atlas elucidated the landscape of pleiotropy as represented by the major histocompatibility complex locus, where we conducted HLA fine-mapping. Finally, we performed statistical decomposition of matrices of phenome-wide summary statistics, and identified latent genetic components, which pinpointed responsible variants and biological mechanisms underlying current disease classifications across populations. The decomposed components enabled genetically informed subtyping of similar diseases (for example, allergic diseases). Our study suggests a potential avenue for hypothesis-free re-investigation of human diseases through genetics.

[A Successful Case of Locally Advanced Pancreatic Cancer Undergoing Curative Total Pancreatectomy after Chemotherapy]

A 68-year-old man with jaundice was diagnosed with pancreatic cancer. The tumor seemed to invade the portal vein, the common hepatic artery, and the splenic artery plexus. The initial diagnosis was unresectable pancreatic cancer. The patient was treated with gemcitabine plus nab-paclitaxel therapy. The tumor reduced in size, and invasion of the main vessels was alleviated after 3 courses. Therefore, we performed total pancreatectomywith total gastrectomy. Histopathological findings showed pancreatic adenocarcinoma, T4(PV)N2M0, fStage Ⅳb, R0. There are reports of curative resection for unresectable pancreatic cancer after chemotherapy. However, the majorityof these reports were about pancreatoduodenectomyor distal pancreatectomy. We present a rare case of curative total pancreatectomy after chemotherapy.

Successful treatment of hepatic gas gangrene by open drainage: A case report and review of the Japanese literature

INTRODUCTION

Liver gas gangrene is rare and has a low prognosis. This case, reports a successful treatment of hepatic gas gangrene using an open drainage technique, followed by antibiotics and hyperbaric oxygen therapy (HBO).

PRESENTATION OF THE CASE

An 82-year-old male with a history of left hepatectomy and bile duct resection for hilar cholangiocarcinoma presented with chilling, lethargy and dyspnea. He had a history of diabetes mellitus, hypertension, atrial fibrillation, and angina pectoris. Physical examination revealed scleric icterus, right hypochondrium tenderness and percussion tenderness of the liver, with warm extremities. Laboratory findings revealed leukocytosis and increased levels of hepatobiliary enzymes. A computed tomography (CT) scan showed gas accumulation in an S8 lesion with portal vein gas. Percutaneous drainage was performed immediately, and broad-spectrum antibiotics were started, but the drainage was insufficient. Consequently, laparotomy drainage was carried out, followed by HBO. No abscess was detected at one-year of follow-up.

DISCUSSION

Hepatic gas gangrene progresses rapidly and has a high mortality rate. Malignant disease and diabetes mellitus may be predisposing factors. While half of non-clostridial cases survive, most cases of hepatic gas gangrene are associated with clostridial infection and have a fatal outcome.

CONCLUSION

All survival cases of hepatic gas gangrene were treated by laparotomy drainage, thus immediate laparotomy seems essential to prevent a fatal outcome.

Small intestinal metastases from esophageal carcinoma presenting as a perforation: A case report and review of the literature

INTRODUCTION

Small intestinal metastasis from oesophageal carcinoma is rare. We report a case of small intestinal metastases from oesophageal carcinoma presenting as a perforation and discuss the aetiology with other cases of small intestinal metastasis from oesophageal carcinoma reported in previous literature.

PRESENTATION

An 86-year-old man presented with fever and coughing. He had choked while eating and had history of weight loss. He was diagnosed with aspiration pneumonia. Two days after the admission, he complained of abdominal pain. Physical examination revealed guarding and rebound tenderness in the upper abdomen. A contrast computed tomography of the abdomen showed ascites, free air, and irregular thickness of the small intestinal walls. Small intestinal perforation was noted, and surgical resection of the small intestine was performed. The pathological findings of the resected small intestine revealed ulcers with squamous cell carcinoma, and upper gastrointestinal endoscopy demonstrated oesophageal tumour, whose biopsy revealed squamous cell carcinoma. A diagnosis of small intestinal metastases from oesophageal carcinoma was made, but the patient died one month after the diagnosis.

DISCUSSION

Most cases found in the literature of oesophageal tumour involve squamous cell carcinoma with male patients, and specific symptoms are divided into obstruction and perforation. All patients with small intestinal metastasis from oesophageal carcinoma who survived were treated by a combination of resection and radiation and/or chemotherapy; thus, immediate treatments seem essential to improve the prognosis.

CONCLUSION

Physicians should keep in mind the possibility of small intestinal metastasis when patients with a history of oesophageal cancer have abdominal symptoms.

Successful surgical resection of ruptured cholangiolocellular carcinoma: A rare case of a primary hepatic tumor

Spontaneous rupture is one of the most fatal complications of hepatic tumors such as hepatocellular carcinoma. In fact, many studies have shown that the in-hospital and 30-d mortality rates are as high as 25%-100%. Cholangiolocellular carcinoma (CoCC) is a rare primary hepatic tumor, usually small in size, that is thought to originate from the ductules and/or canals of Hering. Here, we present a case of spontaneous rupture of a CoCC that was successfully resected by radical surgery. Although CoCC is a rare primary hepatic tumor, it demonstrates certain specific clinical features, including a better prognosis than for other primary liver cancers, and thus should be distinguished from those other cancers. Moreover, CoCC can appear as a ruptured huge tumor, and when it does, radical hepatectomy can be an effective measure to achieve both absolute hemostasis and curability of tumor.

Characterization of mesenchymal progenitor cell populations from non-epithelial oral mucosa

OBJECTIVES

The characteristics of cell populations extracted from oral mucosal non-epithelial tissues and their ability to differentiate were evaluated in vitro as a potential source of cells for mandibular and corneal regeneration.

MATERIALS AND METHODS

Oral mucosal non-epithelial cells (OMNECs) were extracted from tissue samples and were studied by flow cytometry and RT-PCR. Cells differentiating into osteoblasts, adipocytes, chondrocytes, neurocytes, or keratocytes were characterized by RT-PCR and cell staining.

RESULTS

OMNECs expressed CD44, CD90, CD105, CD166, and STRO-1 antigens, which are markers for mesenchymal stem cells. In addition, Oct3/4, c-Myc, Nanog, KLF4, and Rex, which are expressed by embryonic or pluripotent stem cells, were detected by RT-PCR. Expression of CD49d, CD56, and PDGFRα, proteins closely associated with the neural crest, was observed in OMNECs, as was expression of Twist1, Sox9, Snail1 and Snail2, which are early neural crest and neural markers. Specific differentiation markers were expressed in OMNECs after differentiation into osteoblasts, adipocytes, chondrocytes, or keratocytes.

CONCLUSIONS

Populations of OMNECs may contain both mesenchymal stem cells and neural crest origin cells and are a potential cell source for autologous regeneration of mandibular or corneal stroma.

Web-based standard-regimen selection (SRS) and cancer-care registry (CCR) systems of a nationwide network in Japan: An attempt to improve breast cancer treatment

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Background: Tokushukai group has a nation-wide network of 67 affiliated hospitals, and has started an “oncology project” to improve the quality of cancer care using web-based SRS and CCR systems. Methods: Every institution has been introduced the same electric-medical-record (EMR) to share the unified code to order chemotherapy regimens, and patient data could be collected on a database in the central office. 141 recommended regimens for 15 types of solid tumor have been approved in the cancer committee consisting of working-group and program-evaluation members. In breast cancer, 31 recommended regimens (7 for adjuvant and 24 for metastatic settings) were selected from the NCCN guidelines and approved by the committee. Not only recommended but also non-recommended regimens have their own specific codes in EMR, and the patterns of care in the selection of chemotherapy regimen were examined. Results: In 2011, 21 of 67 hospitals utilized these systems. 71.8% of 2,676 patients with cancer including 753 with colorectal, 317 with breast, 273 with gastric, 144 with non-small cell lung, 123 with pancreatic, and 73 patients with esophageal cancer had received 97 types of recommended therapies (11,022 cycles). In terms of breast cancer, 86% of 388 patients had been treated with recommended regimens (1,994 cycles). Among 71 patients received non-recommend therapies, only 6 patients (1.5%) had been treated with three regimens which were not regarded as standard regimens. Conclusions: The introduction of web-based SRS and CCR systems in a large medical group could facilitate standard chemotherapy regimen by an accurate examination of current treatment patterns.

Transplantation of corneal endothelium with Descemet's membrane using a hyroxyethyl methacrylate polymer as a carrier

AIMS

To evaluate the histology and function of Descemet's membrane transplanted with intact endothelium.

METHODS

Japanese white rabbits and human eyebank eyes were used as donors and recipients of Descemet's membrane transplantation. Donor endothelium was hydrodissected by injecting indocyanine green from a limbal incision, and then processed as a corneal scleral button. A 6 mm diameter donor sheet was trephined, and folded in half using a 6 mm diameter polymer as a carrier. Recipient endothelium was also hydrodissected from the limbus using trypan blue to stain the Descemet's membrane. Continuous curvilinear descemetorhexis (CCD) was performed to remove a circular section of the Descemet's membrane using a 27 gauge cystotome. Donor tissue was inserted into the anterior chamber through a 5 mm limbal incision and apposed to the host stroma. Polymers were removed following transplantation. Similar surgical procedures were performed in both rabbits and eyebank eyes. Haematoxylin eosin stains were performed after 28 days in rabbits, and eyebank eyes were fixed immediately following surgery for endothelial cell counts.

RESULTS

Rabbit control eyes demonstrated stromal oedema caused by loss of Descemet's membrane, whereas transplanted eyes had clear corneas. The mean (standard deviation) pachymetry of operated eyes was 376.6 (SD 32.5) mum compared with 389.6 (SD 25.1) mum in the unoperated eye. Mean endothelial density immediately following surgery in eyebank eyes was 2749 (SD 288) cells/mm(2).

CONCLUSIONS

Transplantation of Descemet's membrane by CCD produces a functional graft with an optically clear interface similar to control cornea.

Construction of a chimeric shuttle plasmid via a heterodimer system: secretion of an scFv protein from Bacillus brevis cells capable of inhibiting hemagglutination

Passive immunization is an attractive therapy for preventing oral diseases including dental caries and periodontal disease. For this purpose, we attempted to produce a single chain variable fragment, scFv, which inhibited hemagglutination using the Bacillus brevis protein-producing system. To accomplish this, a novel strategy, a heterodimer system, was used for the construction of a chimeric shuttle plasmid. Initially, a set of new plasmids, kanamycin-resistant donor and erythromycin-resistant general cloning plasmids, were constructed. p15A ori was a common replication origin in these plasmids, while the pUB110 rep and minus origin (MO) were cloned into the donor plasmid. Next, the secretion domain of the B. subtilis alpha-amylase gene and the G2-4 gene, coding for the scFv protein, were cloned into the general cloning plasmid and fused by PCR. Both the donor plasmid and the general cloning plasmid containing the fused gene were digested with NotI and them ligated, a dimeric plasmid being constructed. The key restriction sites, AscI, are arranged such that the pUB110 rep-MO moiety was switched from the donor to the general cloning plasmid following AscI digestion. The chimeric shuttle plasmid was readily constructed by simple re-circularization and a B. brevis transformant producing the scFv protein in the culture fluid was isolated.

The effect of deviant stimulus probability on the human mismatch process

The present study addresses the separate activities of frontal and temporal MMN generators which might be differentially affected by a change in the probability of standard stimuli. As the probability of standard stimuli was increased, the frontal MMN component significantly increased in amplitude, while the temporal one was not affected. Correspondingly, the scalp current density (SCD) maps showed that the temporal MMN generator was activated even at low probability of standard stimuli, suggesting that even the weak memory trace could start the automatic mismatch process, whereas the frontal MMN generator was activated only with increased probabilities of standard stimuli, suggesting that the stronger the memory trace is, the easier it might trigger the involuntary switching of attention to stimulus change.

[The day surgery system]

The day surgery system was established in order to satisfy the demand of healthy patients, and we have performed more than 40 types of operation under this system so far. The critical path is an indispensable tool for ensuring safety and efficiency, and the care coordinator is the key person to manage the system for that purpose. In addition, the cost management technique focusing on DRG/PPS and risk management to increase patient satisfaction are particularly important because we must manage numerous surgical cases. The day surgery system is evaluated in relation to the primary education program for surgeons. Such education not only impacts medical and surgical skills, but also is a good opportunity for training in the basic bedside manner to offer the best service to patients.

Automatic auditory information processing in sleep

STUDY OBJECTIVES

The mismatch negativity (MMN) component of the event-related potentials reflects the automatic detection of sound change. Only a few researchers have investigated the MMN elicitation during sleep in adult human and some of them reported that MMN amplitude was decreased in sleep compared to in waking. However, it is not clear that the decrease of MMN amplitude was due to increased drowsiness or long-term response decrement. Two experiments were conducted to clarify whether or not the MMN was elicited in each sleep stage. We presented auditory stimuli to subjects continuously from waking until sleep state (Experiment 1). Using the same experimental condition, we examined whether or not MMN amplitude was influenced by long-term stimulus presentation (80min.) and by vigilance level (Experiment 2).

DESIGN

N/A SETTING: N/A PARTICIPANTS: N/A INTERVENTIONS: N/A MEASUREMENTS & RESULTS: Experiment 1: MMN was obtained in both drowsiness and REM sleep. MMN was significantly smaller in amplitude and shorter in latency in the both stages than in the waking state. However, MMN was not found in another sleep stage. Experiment 2: Amplitudes were no different among 0-20 min., 20-40 min., 60-80 min. But it was decreased in 40-60 min. and power value of alpha-wave was decreased in 40-60 min.

CONCLUSIONS

To obtain the reliable data, by using the automatic spectral analysis, we confirmed that MMN was elicited in REM sleep. MMN was not influenced by long-term stimulation. The result suggested that auditory stimuli could be processed in the pre-attentive sensory memory even in REM sleep.

Mismatch negativity (MMN) reveals sound grouping in the human brain

To investigate a part of the structure of the memory trace, auditory event-related potentials (ERPs) were recorded from reading subjects while they were presented with two different stimulus-series simultaneously. A clear mismatch negativity (MMN) was obtained from each series, when the stimulus sequence consisted of a high-frequency series and a low-frequency series. Moreover, the MMN showed independent elicitation within each series. However, if the frequency range of one series overlapped with that of the other series, the amplitude of the MMN was prominently reduced, suggesting that the two processing functions indexed by MMN coexisted simultaneously in the preattentive acoustic system and were produced by the respective grouping of high-frequency tones and low-frequency tones.

Prevalence of migraine and Raynaud's phenomenon in Japanese patients with vasospastic angina

The prevalence of migraine and Raynaud's phenomenon in Japanese patients with vasospastic angina (group I) were compared with those in 2 control groups: one with effort angina (group II) and the other group without known ischemic heart disease (group III). There were no significant differences among the 3 groups with respect to age and sex. The prevalence of migraine in group I was 23 of 100, as compared with 4 of 100 in group II (p<0.01) and 11 of 100 in group III (p<0.05). The prevalence of Raynaud's phenomenon in group I was 9 of 100, as compared with 3 of 100 in group II and 4 of 100 in group III. Thus, in Japan, the prevalence of migraine in patients with vasospastic angina was higher than those in the 2 control groups, whereas the prevalence of Raynaud's phenomenon did not differ significantly among the 3 groups. The prevalence of Raynaud's phenomenon in Japanese patients with vasospastic angina was different from that reported from North America, although the prevalence of migraine was the same. This may be partially explained by racial differences.

Production, characterization, and application of monoclonal antibodies which distinguish four glucosyltransferases from Streptococcus sobrinus

A 1,3-alpha-glucan synthase (GTF-I), a highly branched 1, 6-alpha-glucan synthase (GTF-U) and a 1,6-alpha-glucan synthase (GTF-T) were purified to near homogeneity from the culture fluid of Streptococcus sobrinus strain B13N (serotype d) and characterized. In addition, a crude preparation of a recombinant oligo-isomaltosaccharide synthase (rGTF-S) was prepared from a cell-free extract of Escherichia coli MD124 transformant. Using four homogeneous GTF preparations including previously purified rGTF-S as antigens for immunization, 11 murine hybridomas producing a monoclonal antibody (MAb) were established through the fusion of myeloma cells (P3X63-Ag8-U1) and spleen cells of immunized BALB/c mice. When the immunoreactivities of the resultant MAbs were tested, all five MAbs raised against GTF-I, all three MAbs raised against GTF-T, and two of three MAbs raised against GTF-U reacted specifically with the homologous enzyme alone, while one MAb (B86) raised against GTF-U cross-reacted strongly with all GTFs. Although no MAb monospecific for rGTF-S was obtained, precise recognition of GTF-S was possible using the nonspecific B86 antibody together with the MAbs monospecific for the three glucan synthases. Thus, a set of four typical MAbs (B17, B76, B19 and B86) were successfully used for the identification of gene products expressed in 24 previously constructed E. coli phage clones, and the findings suggested that six phage clones might express a gtfU gene encoding GTF-U which has not been hitherto isolated.

Evidence of long-term survival of donor-derived cells after limbal allograft transplantation

PURPOSE

Severe destruction of the corneal limbus causes conjunctival invasion and subsequent visual loss. Limbal allograft transplantation (LAT) was recently proposed for the treatment of these disorders. However, whether the method functions as a stem cell transplantation of the corneal epithelium remains unclear. This study provided evidence that donor-derived corneal epithelial cells survive long after LAT.

METHODS

Epithelial cells on the paracentral cornea in patients who have undergone LAT were subjected to fluorescence in situ hybridization (FISH) and polymerase chain reaction restriction fragment length polymorphism (RFLP) analysis. X and Y chromosomes were detected using sex chromosome-specific probes in the FISH analysis, and HLA-DPBI antigens were examined in the RFLP analysis. Eyes receiving conventional penetrating keratoplasty (PKP) served as controls.

RESULTS

Donor-derived epithelial cells were detected in three of five eyes (60.0%) in the FISH analysis and in seven of nine eyes (77.8%) in the RFLP analysis. Among these eyes, one and three eyes in the FISH and RFLP analysis, respectively, had both donor- and recipient-derived cells. In control PKP eyes, none of the eyes in the FISH analysis and one of eight eyes (12.5%) in the RFLP analysis had donor-derived cells.

CONCLUSIONS

These results suggest that donor-derived cells survive much longer after LAT than those after PKP, and that LAT may function as stem cell transplantation of the corneal epithelium.

Treatment of severe ocular-surface disorders with corneal epithelial stem-cell transplantation

BACKGROUND

Conditions that destroy the limbal area of the peripheral cornea, such as the Stevens-Johnson syndrome, ocular pemphigoid, and chemical and thermal injuries, can deplete stem cells of the corneal epithelium. The result is scarring and opacification of the normally clear cornea. Standard corneal transplantation cannot treat this form of functional blindness.

METHODS

We performed and evaluated 70 transplantations of corneal epithelial stem cells from cadaveric eyes into 43 eyes of 39 patients with severe ocular-surface disorders and limbal dysfunction. Medical treatment had failed in all patients. The patients had a mean preoperative visual acuity of 0.004 (only being able to count the number of fingers presented by the examiner) in the affected eyes, which satisfies the criteria for legal blindness in most countries. In 28 eyes, we also performed standard corneal transplantation. Stem-cell transplantations were performed as many as four times on 1 eye if the initial results were not satisfactory; 19 eyes had multiple transplantations. Patients were followed for at least one year after transplantation.

RESULTS

A mean of 1163 days after stem-cell transplantation, 22 of the 43 eyes (51 percent) had corneal epithelialization; of the 22 eyes, 7 eyes had corneal stromal edema and 15 eyes had clear corneas. Mean visual acuity improved from 0.004 to 0.02 (vision sufficient to distinguish the largest symbol on the visual-acuity chart from a distance of 1 m) (P<0.001). The 15 eyes in which the cornea remained clear had a final mean visual acuity of 0.11 (the ability to distinguish the largest symbol from a distance of 5 m). Complications of the first transplantation included persistent defects in the corneal epithelium in 26 eyes, ocular hypertension in 16 eyes, and rejection of the corneal graft in 13 of 28 eyes. The epithelial defects eventually healed in all but two of the eyes.

CONCLUSIONS

Transplantation of corneal epithelial stem cells can restore useful vision in some patients with severe ocular-surface disorders.

Somatosensory automatic responses to deviant stimuli

We studied event-related potentials (ERPs) produced in response to deviant stimuli in a sequence of somatosensory stimuli which were measured under stimulus-ignoring conditions. A change in the repetitive somatosensory input elicited not only a frontal negativity which was similar to the somatosensory mismatch negativity very recently reported by Kekoni et al. [J. Kekoni, H. Hämäläinen, M. Saarinen, J. Gröhn, K. Reinikainen, A. Lehtokoski, R. Näätänen, Rate effect and mismatch responses in the somatosensory system: ERP-recordings in humans, Biol. Psychol. 46 (1997) 125-142] but also a positive deflection ranging in latency from 100 to 200 ms. This somatosensory change-related positivity was reduced with prolongation of the interstimulus interval (ISI) and was different from the responses to the deviant stimuli when they were presented alone. These findings suggest that the somatosensory change-related positivity is probably generated not by activation of new afferent elements but by a detection of change in a process of comparison with sensory memory.

Effects of surfactants on glucosyltransferase production and in vitro sucrose-dependent colonization by Streptococcus mutans

The presence of Tween 80 in media was associated with a significant increase in three glucosyltransferases(GTFs)(I, SI and S), especially GTF-I, produced by Streptococcus mutans strain PS14, indicating that the surfactant is a major cause of the enhanced GTF production observed in cultures in M4 medium. Lecithin and Tween 20 also enhanced GTF-I production, while Triton X-100 depressed it. At a lot concentration of 0.00125%, Tween 80 enhanced markedly only GTF-I production and its effect reached maximum at a concentration of 0.0025%. Water-insoluble glucan synthesis and artificial plaque formation (in vitro sucrose-dependent colonization) by PS14 were significantly enhanced by the addition of Tween 80 at concentrations over 0.00125%. These results suggest that surfactants might vary the cariogenic potential of Strep. mutans even at low concentrations.

Nitric oxide modulates cardiac contractility and oxygen consumption without changing contractile efficiency

Nitric oxide (NO) affects myocardial contractility and myocardial oxygen consumption (MVO2) in vitro. In alpha-chloralose-anesthetized dogs instrumented for the measurements of left ventricular (LV) pressure, LV volume using a conductance catheter, coronary blood flow, and coronary venous oxygen saturation (ScvO2) using a fiber-optic catheter, LV end-systolic pressure-volume relationships (ESPVR) and the relationship between MVO2 and LV pressure-volume area (PVA) were analyzed before and after intravenous infusions of the NO synthase inhibitor NG-monomethyl-L-arginine acetate (L-NMMA; 5 mg/kg, 8 dogs) and the NO substrate L-arginine (600 mg/kg, 7 dogs). L-NMMA increased the slope of the ESPVR (Emax) (P < 0.05) without changing contractile efficiency indicated by the inverse of the slope of the MVO2-PVA line. L-NMMA also increased unloaded MVO2, indicated by the y-axis intercept of the MVO2-PVA line (P < 0.05). In contrast, L-arginine decreased Emax (P < 0.05) while decreasing MVO2 (P < 0.05), and without changing contractile efficiency. The basal oxygen metabolism was not affected by L-NMMA and L-arginine. These data imply that endogenous NO spares MVO2 by reducing oxygen use in excitation-contraction coupling and attenuates cardiac contractility without changing contractile efficiency.

Trabeculectomy with the use of amniotic membrane for uncontrollable glaucoma

Although trabeculectomy is an established surgical technique for glaucoma, in some cases it does not achieve a good filtering effect despite the use of mitomycin-C (MMC). The authors have developed a new surgical technique for uncontrollable glaucoma that uses amniotic membrane to prevent postoperative adhesion of conjunctiva and sclera. They performed trabeculectomy with a limbal-based conjunctival flap using 0.4 mg/ml of MMC for 2 minutes. Amniotic membrane was then placed under the scleral flap and sutured using 10-0 nylon. Among 14 eyes of 13 patients who underwent this procedure, intraocular pressure was controlled to less than 20 mm Hg after surgery in 13 eyes, including 3 eyes that underwent a second surgery with the same technique and 2 eyes that underwent laser trabeculoplasty. The authors' results suggest that this technique is efficacious for the reduction of intraocular pressure in high-risk glaucoma patients.

Transplantation of amniotic membrane and limbal autograft for patients with recurrent pterygium associated with symblepharon

AIM

Treatment of recurrent pterygium associated with symblepharon requires both suppression of fibrosis and reconstruction of limbal barrier. To achieve this, human amniotic membrane was transplanted and limbal autografts performed.

METHODS

Four patients with severe symblepharon resulting from multiple surgeries for pterygium were treated. Human amniotic membrane was obtained at caesarean section and preserved until surgery. After excision of the fibrous tissues, the amniotic membrane was placed on the sclera, and a limbal autograft transplantation was performed using limbal tissues taken from the affected eye.

RESULTS

Recurrence of symblepharon was not observed in any of the patients and significant suppression of the subconjunctival fibrosis was achieved. Ocular movement improved in all cases. Complete remission of pterygium regrowth occurred in three cases, and a slight (about 1 mm) recurrence occurred in one case. The limbal donor site showed the presence of mild depressions without the formation of pseudopterygium.

CONCLUSION

Transplantation of human amniotic membrane with a limbal autograft appears to be a promising surgical treatment for reconstructing the ocular surface in patients with recurrent pterygium associated with symblepharon.

Real-time telemedicine in the clinical assessment of the ocular surface

PURPOSE

To report the feasibility of real-time video and audio transmission of slit-lamp images of the eye using conventional telephone systems.

METHOD

We analyzed the feasibility and benefits of telemedicine in the diagnosis and follow-up of ocular surface disorders in referral patients using a real-time audio-video system that functions through integrated services digital network lines at a transmission speed of 384 kilobytes per second.

RESULTS

Real-time slit-lamp images obtained through integrated services digital network lines offered satisfactory visual resolution of the ocular surface for the diagnosis and follow-up of ocular surface and corneal disease, while simultaneous audio transmission allowed for direct communication with the patient and attending physician when necessary.

CONCLUSION

Telemedicine using conventional telecommunication infrastructures offers sufficient information for the diagnosis and follow-up of ocular surface disorders in referral patients.