CD44s signals the acquisition of the mesenchymal phenotype required for anchorage-independent cell survival in hepatocellular carcinoma

Background:

Circulating tumour cells (CTCs) have an important role in metastatic processes, but details of their basic characteristics remain elusive. We hypothesised that CD44-expressing CTCs show a mesenchymal phenotype and high potential for survival in hepatocellular carcinoma (HCC).

Methods:

Circulating CD44⁺CD90⁺ cells, previously shown to be tumour-initiating cells, were sorted from human blood and their genetic characteristics were compared with those of tumour cells from primary tissues. The mechanism underlying the high survival potential of CD44-expressing cells in the circulatory system was investigated in vitro.

Results:

CD44⁺CD90⁺ cells in the blood acquired epithelial–mesenchymal transition, and CD44 expression remarkably increased from the tissue to the blood. In Li7 and HLE cells, the CD44^high population showed higher anoikis resistance and sphere-forming ability than did the CD44^low population. This difference was found to be attributed to the upregulation of Twist1 and Akt signal in the CD44^high population. Twist1 knockdown showed remarkable reduction in anoikis resistance, sphere formation, and Akt signal in HLE cells. In addition, mesenchymal markers and CD44s expression were downregulated in the Twist1 knockdown.

Conclusions:

CD44s symbolises the acquisition of a mesenchymal phenotype regulating anchorage-independent capacity. CD44s-expressing tumour cells in peripheral blood are clinically important therapeutic targets in HCC.

CD44 variant 9 expression in primary early gastric cancer as a predictive marker for recurrence

BACKGROUND

Multiple early gastric cancers (EGCs) may develop in 6-14% of patients even after achieving curative endoscopic submucosal dissection (ESD); however, a useful biomarker for predicting recurrence is not available. The present study investigated whether the expression of CD44 variant 9 (CD44v9), a functional cancer stem cell marker, in the primary gastric cancer tissue represents an indicator of recurrence.

METHODS

Eighty-eight patients who underwent ESD for EGC from 2008 to 2010 were enrolled and monitored for recurrence for 3 years. The expression levels of CD44v9 in the tissue of initial EGCs were evaluated by immunohistochemistry, and the recurrence rate was compared between CD44v9-positive and CD44v9-negative groups. The mucin phenotype and expression of microRNA-21 (miR-21) and programmed cell death protein 4 (PDCD4) were also analysed.

RESULTS

The recurrence rate of EGC was significantly higher in the CD44v9-positive group than in the CD44v9-negative group (hazard ratio (HR), 21.8; 95% confidence interval (CI), 5.71-83.1). However, mucin phenotypes and the expression of miR-21 and PDCD4 did not predict recurrence after ESD. Meanwhile, grade of gastric atrophy was also identified as a significant marker of multiple recurrence (HR, 4.95; 95% CI, 1.30-18.8).

CONCLUSION

CD44 variant 9 expression represents a potential predictive marker for recurrence in EGC.

Redox regulation in stem-like cancer cells by CD44 variant isoforms

Increasing evidence indicates that several types of solid tumor are hierarchically organized and sustained by a distinct population of cancer stem cells (CSCs). CSCs possess enhanced mechanisms of protection from stress induced by reactive oxygen species (ROS) that render them resistant to chemo- and radiotherapy. Expression of CD44, especially variant isoforms (CD44v) of this major CSC marker, contributes to ROS defense through upregulation of the synthesis of reduced glutathione (GSH), the primary intracellular antioxidant. CD44v interacts with and stabilizes xCT, a subunit of the cystine-glutamate transporter xc(-), and thereby promotes cystine uptake for GSH synthesis. Given that cancer cells are often exposed to high levels of ROS during tumor progression, the ability to avoid the consequences of such exposure is required for cancer cell survival and propagation in vivo. CSCs, in which defense against ROS is enhanced by CD44v are thus thought to drive tumor growth, chemoresistance and metastasis. Therapy targeted to the CD44v-xCT system may therefore impair the ROS defense ability of CSCs and thereby sensitize them to currently available treatments.

Embolization of the Middle Meningeal Artery for Refractory Chronic Subdural Haematoma. Usefulness for Patients under Anticoagulant Therapy

SUMMARY

Endovascular embolization of the middle meningeal artery was performed in two cases of refractory chronic subdural haematoma (CSDH) after repeated burr hole and irrigation surgeries. The embolization prevented expansion of the CSDH in both cases, and the haematoma disappeared completely in one case. The expansion of CSDH is considered to result from repeated bleeding from the macrocapillaries on the haematoma capsule. Embolization of the middle meningeal artery appears to be useful to eliminate the blood supply to this structure.

Gamma knife surgery for brain metastases: indications for and limitations of a local treatment protocol

OBJECTIVE

The purpose of this retrospective study was to evaluate results of a local treatment protocol using gamma knife surgery (GKS) for brain metastases without upfront whole brain radiation therapy (WBRT).

METHODS

Results for 521 consecutive patients satisfying the following 3 criteria were analysed: 1) a maximum of 3 tumours with a diameter of 25 mm or more; 2) no prior WBRT; 3) no surgically in accessible large (>30 mm) tumours. Large tumours were surgically removed and all smaller lesions were treated by GKS without up front WBRT. New lesions, detected with follow-up MRI, were appropriately treated with repeat GKS. Overall survival (OS), neurological survival (NS), qualitative survival (QS) and new lesion-free survival (NLFS) curves were calculated and the prognostic values of covariates were obtained. OS and NS were compared according to tumour number.

RESULTS

In total, 1023 separate sessions were required to treat 4562 lesions. The primary organs were lung in 369 patients, gastro-intestinal tract in 70, breast in 33, urinary tract in 24, and others/unknown in 25. The median OS period was 9.0 months. On multivariate analysis, the significant prognostic factors for OS were found to be extracranial disease (risk factor: active), Karnofsky performance status (KPS) score (<70) and gender (male). NS and QS at one year were 85.6% and 73.0%, respectively. The only significantly poor prognostic factor for NS was carcinomatous meningitis. NLFS at 6 months was 68.9%. For both OS and NS, the differences between a few (</=3) and many (4-10) brain lesions were not significant (OS: p=0.3128, NS: p=0.5509). Patients with numerous (>10) tumours had a significantly poorer prognosis than those with </=10.

CONCLUSION

Our protocol, aggressively applying GKS, provides excellent results in selected patients with </=10 brain lesions and no carcinomatous meningitis.

A new short-acting non-depolarizing muscle relaxant (SZ1677) without cardiovascular side-effects

BACKGROUND

In order to facilitate rapid tracheal intubation, the development of a rapid onset, short duration, non-depolarizing muscle relaxant without cardiovascular side-effects would be a significant accomplishment in the field of anesthesiology. The aim of the present study was to test the action of a new non-depolarizing muscle relaxant (SZ1677) on neuromuscular transmission, muscarinic (M2, M3) receptors and cardiovascular reactions and to compare it with clinically used muscle relaxants.

METHODS

Neuromuscular transmission was studied by recording muscle contractions elicited by indirect electrical stimulation, using (i). in vitro isolated phrenic nerve-hemidiaphragm preparation of mice, rats and guinea pigs and (ii). in vivo sciatic nerve-anterior tibial muscle preparation of anesthetized rats, guinea pigs and cats. Cardiovascular effects of muscle relaxants were evaluated on the grounds of their effects on changes of blood pressure and heart rate induced by electrical stimulation of the right vagal nerve in anesthetized cats. To study postsynaptic antimuscarinic affinity of muscle relaxants on M3 receptors, oxotremorine-induced contractions of longitudinal muscle strip of guinea pig ileum were registered in their presence and absence.

RESULTS

One of more than 120 newly synthesized non-depolarizing muscle relaxants compounds, 1-3[alpha-hydroxy-17beta-acetyloxy-2beta-(1,4-dioxa-8-azaspiro[4,5]dec-8-yl)-5alpha-androstane-16beta-il] -1-(2-propenyl)pyrrolidinium bromide (SZ1677), excelled with its advantageous pharmacological properties: relatively short duration of action, no accumulation and lack of unwanted side-effects. Pharmacodynamic studies show that SZ1677 is a non-depolarizing neuromuscular blocking agent with a relatively short duration and rapid onset of action in a variety of laboratory animal species. It is without cumulative effect, does not reduce blood pressure, and fails to produce tachycardia. Significant cardiac vagal blocking effects were not observed even at concentrations or dosages of 8 times the ED90. This compound, unlike many other muscle relaxants, does not have atropine-like effects on human atrial tissue; it does not increase the release of NA from sympathetic innervation in the heart. In all practical ways, at least from the vantage point of the preclinical study, SZ1677 compares favorably with all presently available short-acting muscle relaxants, including rapacuronium.

CONCLUSION

In experiments, SZ1677 proved to be a short-acting neuromuscular blocking compound having a large safety margin between the doses required to produce neuromuscular block and those likely to lead to cardiovascular side-effects.

Inspiratory pressure-volume curves at different positive end-expiratory pressure levels in patients with ALI/ARDS

BACKGROUND

In lung protective strategy, positive end-expiratory pressure (PEEP) slightly higher than the Pflex (the airway pressure corresponding to the lower inflection point (LIP) on the inspiratory pressure-volume (P-V) curve measured with ZEEP) is generally recommended. However, this method to determine optimal PEEP lacks a theoretical background and there is no clinical report that investigated how the P-V relationship would be with such PEEP. Therefore, we measured inspiratory P-V curves at different PEEP levels to increase our knowledge about the inspiratory P-V curve with PEEP.

METHODS

In eight consecutive patients with ALI/ARDS, inspiratory P-V curves were repeatedly measured at different PEEP levels by low flow inflation technique and LIP was assessed in all inspiratory P-V curves. Afterwards, the minimum PEEP level at which LIP was not identifiable (PEEP(LIP)(-)) was determined and the relationship between Pflex and PEEP(LIP)(-) was investigated.

RESULTS

Pflex and PEEP(LIP)(-) could be determined in all patients. Pflex was 9.4+/-2.0 cmH2O (range: 7 to 12 cmH2O) and PEEP(LIP)(-) was 7.9+/-1.6 cmH2O (range: 5 to 10 cmH2O) (mean+/-SD, P=0.0877). PEEP(LIP)(-) was lower than the Pflex in five patients, and significantly lower than the Pflex + 2 cmH2O (P=0.0024).

CONCLUSION

From the analysis of inspiratory P-V curves at different PEEP levels, PEEP 2 cmH2O higher than the Pflex may not be necessary to prevent cyclic collapse and reopening of alveoli, at least in some ALI/ARDS patients. Further studies are needed to confirm this preliminary result.

The effects of epidural insertion site and surgical procedure on plasma lidocaine concentration

We compared the plasma lidocaine concentrations associated with continuous epidural infusion at different insertion sites in patients during surgery using epidural plus general anesthesia. In Study 1, there were 12 patients in each of four surgical groups in whom blood loss was expected to be <400 mL. The four groups were as follows: the lower extremity, the lower abdomen, the upper abdomen, and the lung. Liver surgery was excluded from Study 1. Study 2 comprised patients undergoing radical hysterectomy or radical prostatectomy (a radical operation group, n = 12) and hepatectomy (a hepatectomy group, n = 12) in whom the expected surgical blood loss was more than 1500 mL. All patients initially received 0.1 mL/kg followed by a continuous infusion of 0.1 mL. kg(-1). h(-1) of 1.5% lidocaine, and plasma concentrations of lidocaine were measured at 15, 30, 60, 90, and 120 min and every 60 min thereafter to 300 min. The plasma lidocaine concentration during surgery did not change regardless of the infusion site or the surgical site, other than the liver. The plasma concentrations of lidocaine in the hepatectomy group increased significantly at 180 min (2.9 +/- 0.6 microg/mL, P < 0.01), 240 min (3.5 +/- 0.7 microg/mL, P < 0.01), and 300 min (3.6 +/- 0.74 microg/mL, P < 0.01) compared with that at 15 min (2.0 +/- 0.3 microg/mL), and these values were significantly larger than those in all other groups.

Does diffusion-weighted magnetic resonance imaging enable detection of early ischemic change following transient cerebral ischemia?

To examine the usefulness of diffusion-weighted imaging for detecting neuronal damage following ischemia, dynamic changes in diffusion-, T1- and T2-weighted images of rats subjected to 10 min of 4-vessel occlusion and of humans who had suffered 10-20 min of cardiac arrest were observed. In rats, no remarkable alteration was observed on day 1. On day 3, however, diffusion-weighted images showed high signal intensity in the hippocampal area, in which the apparent diffusion coefficient was significantly lower than that of the control (760+/-28x10(-6) mm(2)/s in control vs. 480+/-29x10(-6) mm(2)/s on day 3, P<0.0001). Histological observation revealed microvacuolation in 92+/-4% of pyramidal neurons in the CA1 region. On day 7, the hyperintensity in diffusion-weighted images had disappeared and microvacuolation had also disappeared in the CA1 region, but severely disrupted pyramidal neurons containing pyknotic nuclei had appeared in the CA1 region instead. In humans, diffusion-weighted images did not show any apparent abnormality in the cerebral cortex on the day of resuscitation. On day 3, however, diffusion-weighted images consistently showed hyperintensities in the temporal or occipital cortex, and these hyperintensities had disappeared in images obtained on days 7 and 14. From day 14, T1-weighted images showed laminar hyperintensity, suggesting laminar necrosis, along the cortex, where diffusion-weighted images showed high signal intensity on day 3. These results suggested that diffusion-weighted imaging has a potential for detection of the occurrence of microvacuolation and is useful for detecting the progression of ischemic changes in humans following global ischemia.

Dynamic changes of NADH fluorescence images and NADH content during spreading depression in the cerebral cortex of gerbils

To elucidate the changes in the mitochondrial redox state during spreading depression (SD), tissue NADH content was measured in 20 anesthetized gerbils by the enzymatic cycling assay in a small cortical region (0.30+/-0.07 mg) where the direct-current (DC)-potential was measured. Sequential imaging of NADH fluorescence with a CCD camera and continuous monitoring of DC-potential and regional CBF were also performed in another 5 gerbils. Biphasic fluorescence waves propagating at the rate of 3 mm/min were observed using the CCD camera. An initial narrow (1.6+/-0.4 mm) wave, which showed a modest increase in fluorescence (108+/-6.4%), was observed simultaneously with the onset of negative DC-deflection. During depolarization, CBF was unchanged and tissue NADH content increased to 25.3+/-7.9 micromol/kg brain, which was higher than the value in the sham-control (11.0+/-2.5 micromol/kg brain). At 30 s after the deflection, a subsequent wide (7.0+/-2.1 mm) wave, which showed a moderate decrease in fluorescence (87.1+/-5.7%), was observed simultaneously with the increase in CBF and repolarization in DC-potential. Then NADH fluorescence recovered along with normalization of CBF at 152.2+/-38.6 s after the onset of DC-deflection. Tissue NADH concentration sampled at 120 s after the deflection was 11.6+/-4.6 micromol/kg brain. Since NADH fluorescence is absorbed by hemoglobin, the initial increase and subsequent decrease in fluorescence seem to have been induced by increases in NADH content and CBF, respectively. These findings indicate that the mitochondrial redox state transiently inclines to the reduction side synchronous to the onset of DC-deflection and that it normalizes within 120 s after deflection.

[Perioperative change of ionized magnesium concentration--effect of blood transfusion]

In order to evaluate the effect of intra-operative blood transfusion on post-operative decrease of ionized Mg (Mg2+), we performed following studies. 1) We measured ionized Mg (Mg2+), total Mg, ionized Ca (Ca2+), total Ca and citrate before and after operation in 70 patients. 2) We evaluated the effect of citrate on Mg2+ and Ca2+ in vitro. 3) We also measured these values during blood transfusion in 8 patients. There was no significant difference between post-operative Mg2+ of 45 patients without blood transfusion (0.49 +/- 0.07 mmol.l-1, % decrease from pre-operative value was 13.4 +/- 9.2%; mean +/- SD), and that of 25 patients with blood transfusion (0.48 +/- 0.09 mmol.l-1, 17.9 +/- 10.2%). Mean value of post-operative citrate concentration of patients with blood transfusion was 0.15 +/- 0.11 mmol.l-1, and this value decreased Mg2+ about 2% in in vitro study. During blood transfusion, Mg2+ (0.41 +/- 0.05 mmol.l-1) and ionized % (54.5 +/- 8.3%) decreased significantly just like Ca2+ with elevated citrate concentration (0.95 +/- 0.59 mmol.l-1). In conclusion, intra-operative blood transfusion had minor effect on the post-operative decrease of Mg2+, and the major cause was thought to be the dilution of extracellular fluid by Mg-free fluid administered during operation.

Pressure support ventilation augments spontaneous breathing with improved thoracoabdominal synchrony in neonates with congenital heart disease

In neonates, during spontaneous breathing with demand-type continuous positive airway pressure (CPAP), high airway resistance caused by small endotracheal tubes, time delay for triggering, and rapid respiratory frequency may result in patient-ventilator asynchrony. Such asynchrony may alter normal breathing patterns and thoracoabdominal synchrony. We, therefore, studied whether pressure support ventilation (PSV) could augment spontaneous breathing and improve synchrony between the rib cage (RC) and the abdominal (AB) motions in nine postoperative neonates with congenital heart disease. Three successive levels of PSV (0, 5, and 10 cm H2O) were used randomly. With increasing levels of PSV, the tidal volume (VT) increased and the respiratory frequency decreased, associated with an increase in minute ventilation. To assess thoracoabdominal synchrony, maximum compartment amplitude (MCA)/VT (MCA = AB + RC) and the phase delay of the RC-to-AB motion during inspiration (the ratio of the time delay to the inspiratory time) were measured using respiratory inductive plethysmography. When the motions of the RC and AB were out of phase, MCA/VT exceeded 1.0. MCA/VT decreased significantly from 1.3 +/- 0.3 without PSV to 1.0 +/- 0.0 with PSV of 10 cm H2O. The phase delay and paradoxical motion of the RC observed in seven of the nine cases without PSV also disappeared with PSV of 10 cm H2O. In conclusion, PSV can effectively augment spontaneous breathing with better thoracoabdominal synchrony in neonates.

IMPLICATIONS

Assisting spontaneous ventilation in a neonate is often difficult. Because pressure support ventilation facilitates coordination between the patient and ventilator in adults and children, we thought it might be effective in neonates. Our study supports this conclusion.

Management of psychiatric symptoms of Parkinson's disease

Depression and hallucination are the two main psychiatric symptoms in parkinsonian patients. Depressive features in Parkinson patients are very close to those of endogenous depression, except for a relative lack of anxiety, irritability, suicidal ideations, delusions and circadian rhythm. Pharmacotherapy with antidepressants is most reliable in the treatment of parkinsonian depressives, although levodopa or other antiparkinsonian drugs may relieve a depression. Hallucinatory complications of long-term antiparkinsonian treatment appear in two types of symptoms: (1) hallucinosis type-vivid visual hallucination and illusion with clear consciousness and well-preserved orientation, and (2) delirium type-less vivid visual hallucination and illusion with disturbed orientation and confusion. Antipsychotic drugs and 'drug holiday' are recommended for the management of hallucinations as side effects of antiparkinsonian drugs.

[Acid base changes and muscle relaxants]

Previous publications have provided conflicting results concerning the effects of respiratory and metabolic acid base changes on the neuromuscular effects of nondepolarizing muscle relaxants. The varying results can be attributed not only to experimental design or species difference, but also to the accompanying changes in the pharmacokinetics in vivo. Using the phrenic nerve-hemidiaphragm preparation of rats, in which many variables of in vivo studies can be eliminated, respiratory and metabolic acid-base changes were induced by varying carbon dioxide (PCO2) and bicarbonate (HCO3) concentrations in the Krebs' solution and their effects on the potencies of muscle relaxants were compared. Decreasing pH by increasing Pco2 or by decreasing HCO3 increased the potencies of the monoquaternary relaxants (d-tubocurarine, vecuronium and rocuronium), while pH changes did not affect the potencies of the bisquaternary relaxants (metocurine, pancuronium and pipecuronium). Above difference between mono- and bisquaternary relaxants may reflect pH-induced changes in the ionization of the tertiary ammonium and resulting in changes in the sensitivity to the anionic nicotinic receptors. Neostigmine-induced antagonism was not affected by acid-base changes. These results in vitro were compared and correlated with the previous results in vivo.

Effects of adenosine on norepinephrine and acetylcholine release from guinea pig right atrium: role of A1-receptors

The effect of adenosine or its stable analogues (2-chloroadenosine, CADO: 5'-N-ethyl-carboxamidoadenosine, NECA; and N6-cyclopentyladenosine, CPA) and a non-selective A1 and A2-receptor antagonist, 8-phenyltheophylline (8-PT), or an A1-receptor antagonist, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), on the stimulation-evoked release of [3H]norepinephrine ([3H]NE) and [3H]acetylcholine ([3H]ACh) from the isolated guinea pig right atrium was investigated. Adenosine and its stable analogues (CADO, NECA and CPA) inhibited the stimulation-evoked release of [3H]NE in a concentration-dependent manner. The order of potencies was CPA > NECA > CADO > adenosine. CGS 21680 (30 nM), an A2a receptor agonist, failed to affect the release. The inhibitory effect of adenosine and CADO on [3H]NE release was competitively antagonized by 8-PT. DPCPX also prevented the effect of adenosine (Kd = 5.2 nM) and CADO (Kd = 3.3 nM). The Kd value of 8-PT was 0.40 microM for the antagonism of CADO and 0.51 microM for the antagonism of adenosine. When the negative feedback modulation of NE release was inhibited by idazoxan, the inhibitory effect of adenosine and CADO on [3H]NE release was more pronounced. Under this condition DPCPX (10 nM) prevented the inhibitory effect of CADO, indicating that A1-purinoceptors are involved in this action. The release of [3H]NE is tonically modulated by ACh release from the vagal nerve endings, as evidenced by the finding that 4-diphenylacetoxy-N-methyl-piperidine methiodide (4-DAMP), a M3-subtype selective muscarinic receptor antagonist, and atropine significantly enhanced the release of NE. Adenosine, its stable analogues (CADO and NECA), and 8-PT inhibition was eliminated by atropine, adenosine and CADO did not have any effect on [3H]ACh release. Quinpirole, a selective D2-receptor agonist, and neuropeptide Y (NPY) failed to affect the release of ACh. However, atropine and 4-DAMP, a selective M3-receptor antagonist, significantly enhanced the stimulation-evoked release of [3H]ACh. These findings indicate that there are no presynaptic heteroceptors (adenosine, D2, and NPY) on the vagal nerve endings of the guinea pig right atrium. It is concluded that the sympathetic nerve endings of the guinea pig right atrium are equipped with A1-, subclass of purinoceptors and alpha 2B-, and muscarinic (M3)-receptors. Cholinergic vagal nerve endings in the heart are only equipped with muscarinic autoreceptors. Therefore, adenosine liberated during hypoxia inhibits NE release from the cardiac sympathetic nerve and thereby protects against tachyarrhythmia caused by myocardial hypoxia. In contrast, adenosine does not inhibit the vagal innervation of the right atrium.

Presynaptic A1-purinoceptor-mediated inhibitory effects of adenosine and its stable analogues on the mouse hemidiaphragm preparation

1. The effect of adenosine or its stable analogues (2-chloroadenosine, CADO; 5'-N-ethylcarboxamidoadenosine, NECA; and N6-cyclopentyladenosine, CPA) on the release of [3H]-acetylcholine ([3H]-ACh), and on the development of force of contraction evoked by electrical stimulation of the nerve, were studied in the mouse phrenic nerve-hemidiaphragm preparation. Evidence was obtained that the release of ACh is subject to presynaptic modulation through presynaptic A1(P1)-purinoceptors. 2. Adenosine or its stable analogues (CADO, NECA, CPA) inhibited, in a concentration-dependent manner, both the release of ACh and the force of the indirectly elicited contraction of hemidiaphragm preparation, provided in the latter case that the margin of safety was reduced by (+)-tubocurarine or magnesium. The order of potency in reducing ACh release was CPA greater than NECA greater than CADO greater than adenosine with IC50 values of 0.08 +/- 0.01, 0.74 +/- 0.05, 9.05 +/- 0.20, and 410.2 +/- 42.5 mumol/l, respectively. The order of potency in reducing twitch tension was CPA greater than NECA greater than CADO greater than adenosine with IC50 values of 0.11 +/- 0.02, 0.48 +/- 0.03, 2.07 +/- 0.49, and 240.4 +/- 20.0 mumol/l, respectively. 3. 8-Phenyltheophylline (8-PT) antagonized the inhibitory effects of the adenosine receptor agonists on ACh release and twitch tension.(ABSTRACT TRUNCATED AT 250 WORDS)